Prescribers in Plain Sight: Rethinking Psychiatry’s Training and Workforce Assumptions
Psychiatrist, author, advocate.
August 5, 2026
The landscape of psychiatric care has shifted beneath our feet, yet residency training still clings to an older map. Programs continue to imagine a world where the psychiatrist alone sits with each patient, weighs the options, and steers the course of treatment. That tradition endures, but it is no longer the only current running through the field. Across the country, in clinics and hospitals both large and small, a new generation of non-physician clinicians has stepped forward to prescribe psychiatric medications, often in the very places where psychiatrists are hardest to find.
A 2026 JAMA Network Open analysis of Medicare Part D data illustrates the change. Between 2013 and 2023, advanced practice registered nurses and physician assistants increased their share of antipsychotic prescribing from 13.8 percent to 39.6 percent. Meanwhile, psychiatrists' share fell from 48.4 percent to 32.4 percent, and primary care physicians' share declined from 33.0 percent to 23.8 percent. Psychiatrist claims fell by nearly 3 million, while APRN and PA claims rose from 3.1 million to 9.5 million.
This transformation has not come from any single clinician working harder, but from the swelling ranks of new prescribers. The average nurse practitioner or physician assistant still manages a steady caseload, but their numbers have multiplied, filling gaps left by a dwindling supply of psychiatrists. In rural communities, psychiatric mental health nurse practitioners now carry much of the burden, providing more than half of all mental health visits in some regions. By 2020, nurse practitioners were writing more psychiatric medication prescriptions than psychiatrists, a quiet revolution unfolding in exam rooms and community clinics across the nation.
When faced with a shortage of psychiatrists, the instinct is often to call for more training slots, to imagine that with enough new recruits, the old order might be restored. There is wisdom in growing the profession, but this answer alone overlooks the reality already unfolding. The more pressing question is not how to return to the past, but how psychiatrists can best serve in a world where many patients already receive their care from others.
One answer lies in the model of collaborative care. Here, psychiatrists become guides and advisors, working alongside behavioral health managers to review patient registries, identify those who are not improving, and use careful measurement to steer treatment. Rather than replacing the intimacy of direct care, this approach extends the reach of psychiatric consultation to patients who might otherwise remain unseen and untreated.
The training of young psychiatrists has not kept pace. Many residents emerge confident in speaking with primary care teams, but far fewer feel prepared to offer indirect consultation or to practice the disciplined art of measurement-based care. Across North America, only a handful of integrated-care training programs have taken root, and even these are uneven in quality and reach. In the United States, such training remains optional, a missed opportunity to prepare physicians for the world as it is.
This gap is not a small one. Task-sharing succeeds only when it is built on a foundation of ongoing education, structured supervision, and ready access to consultation. The evidence is clear: when primary-level prescribers are supported by psychiatric oversight, outcomes improve, and lives are changed. The lesson is not merely that responsibilities can be handed off, but that a strong and reliable clinical structure must surround them.
This structure becomes even more vital in high-risk prescribing, and few areas carry greater risk than the use of antipsychotics in older adults with dementia. These medications, never approved for dementia-related psychosis and carrying FDA black box warnings for increased mortality, have been linked to serious harms including stroke, falls, and death. Their benefits, when present, are often modest and uncertain. This is precisely the kind of prescribing that demands the supervisory infrastructure residents should be trained to provide: careful case review, ongoing monitoring, clear thresholds for reassessment, and a commitment to deprescribing when the balance of risk and benefit shifts.
The issue is not whether nurse practitioners or physician assistants are capable of prescribing these medications. Prescribing authority has outpaced the systems designed to support it, especially in places where psychiatrists are few. Arguing over this fact will not improve care, but building strong systems of consultation and supervision just might.
The training of new psychiatrists should place indirect consultation, registry review, population-based oversight, and measurement-based care at the heart of clinical education, not on the periphery. Residents must also learn the art of supervision itself: how to review cases with care, recognize risk, offer clear recommendations, set thresholds for direct evaluation, and ensure that treatment plans are being followed.
Faculty must also be prepared for this new era. Many attending psychiatrists learned their craft in a world of direct care and cannot be expected to teach what they have never practiced. Academic centers will need to cultivate expertise in collaborative care, quality improvement, team-based supervision, and registry-guided treatment. Residents should spend real time in primary care clinics, community health centers, rural systems, nursing facilities, and safety-net settings, taking part in caseload review.
Today, most antipsychotic prescriptions in Medicare are written by clinicians who are not psychiatrists. Many patients who receive these medicines may never meet a psychiatrist at all. This is not a lament for what might have been, but a clear-eyed account of what is. The future of psychiatry's influence on quality and safety will rest not only on the patients seen face to face, but on the clinicians and systems that psychiatrists are ready to guide and support. The prescribers are already here. The question is whether psychiatric education will rise to meet them.