The mental health workforce crisis: a policy report

Demand for mental health care is outrunning the people trained to provide it, in Switzerland as everywhere. The gap will not be closed at one policy level; it needs three at once.

The shape of the problem

Every health system now says the same sentence about mental health: demand is rising faster than the capacity to meet it. The sentence is true, but it understates the problem, because the shortfall in mental health care is not new and was never small. The landmark analysis of community epidemiology found that even in systems with established services, most people with a diagnosable mental disorder receive no treatment at all: the median treatment gap across studies was 56% for depression, 58% for generalised anxiety and 78% for alcohol use disorders (Kohn et al., 2004). That was the baseline before the recent surge in presentations, particularly among adolescents and young adults, that clinicians across Europe now describe from the floor.

Nor is the workforce side likely to close the gap on its own trajectory. The WHO's most recent projections put the global shortage of health workers at roughly 10 million by 2030 (Boniol et al., 2022), and mental health professions sit among the thinnest slices of that workforce in nearly every country's statistics. A system that plans on recruiting its way out of the mental health gap is planning to import staff that, in aggregate, do not exist.

Switzerland is a well-resourced system by any international comparison, with one of Europe's densest psychiatrist populations. The Swiss problem is therefore not headline scarcity. It is distribution and flow: care concentrated in urban self-pay practice while need grows in adolescent services, addiction services and rural cantons; a training pipeline that moves more slowly than demand; and a reimbursement architecture that quietly steers practitioners away from exactly the populations with the greatest need. A shortfall of this shape cannot be fixed with a single instrument, which is why a decade of single-instrument responses has not fixed it.

The three structural drivers

The training pipeline is long and rigid. Specialist psychiatry training takes upwards of six years after medical school, so any decision to expand capacity taken today changes the workforce in the next decade, not this one. On the psychology side, the constraint is not graduate supply but the supervised-practice bottleneck: master's programmes produce candidates faster than the supervised-hours regime converts them into practitioners entitled to treat patients under the mandatory insurance system. A pipeline whose slowest segment sits after graduation is a pipeline that wastes its own intake.

Scope of practice reform is half-finished. Switzerland made a genuinely significant move in July 2022, when the prescription model replaced the old delegation model: psychologist psychotherapists became able to bill mandatory health insurance directly on medical prescription, rather than working under a psychiatrist's delegation (Swiss Federal Council, 2021). The direction is right. But a scope reform is only as real as its administrative completion, and the transition has left practical frictions, in recognition, in supervision requirements, in the referral pathway, that keep qualified practitioners from taking the patients the reform was designed to reach. A right that cannot be exercised at scale is a press release.

Reimbursement steers the wrong way. Tariff positions for psychiatric and psychotherapeutic care have not kept pace with the economics of practice, and the predictable migration follows: toward urban self-pay work and away from the cantons, the age groups and the clinical segments where the need is concentrated. No individual practitioner is behaving badly; each is responding rationally to the price signal the system chose to send. If the system dislikes the resulting distribution, it must change the signal, not lament the response.

A three-level response

The policy conclusion follows from the structure: the levers must be pulled together, because each one alone leaks.

Pipeline. Expand specialist training capacity now, accepting that the payoff is a decade out, and attack the faster bottleneck in parallel: fund supervised-practice posts for psychotherapy candidates at scale, with explicit priority for under-served cantons and for adolescent and addiction services. The cheapest additional practitioner is the qualified graduate currently idling in the supervision queue.

Scope. Finish the 2022 reform. Complete the administrative integration of psychologist psychotherapists into the mandatory insurance system, clarify referral and oversight pathways, and measure the reform by the only number that matters: additional patients in treatment, by canton and by segment.

Reimbursement. Index tariff positions for mental health care to observed access, waiting times by region and segment, rather than to historical schedules, and introduce explicit supplements for rural, adolescent and addiction practice. Money is the one lever that redistributes a workforce without coercion, and the current settings redistribute it toward the places that need it least.

None of these moves works alone. Pipeline expansion without reimbursement reform trains practitioners for the urban self-pay market. Scope reform without supervised-practice funding entitles people who cannot qualify. Reimbursement reform without pipeline growth bids up a fixed supply. The minimum institutional vehicle is a standing federal-cantonal coordination mandate with a multi-year horizon and a published progress report, so that the three levers are moved by one hand and the public can see whether they are moving.

The measure of success

The temptation in workforce policy is to measure inputs: training places funded, tariff positions adjusted, practitioners registered. The honest measure is the treatment gap itself, the share of people with a diagnosable condition who receive competent care within a reasonable time, tracked by canton, by age group and by condition. That number made the case for action (Kohn et al., 2004); the same number should judge it. A mental health workforce policy that cannot say, within two years, whether the gap it exists to close is closing, is not yet a policy. It is an intention.

References

1. Boniol, M., Kunjumen, T., Nair, T.S., Siyam, A., Campbell, J. and Diallo, K. (2022) 'The global health workforce stock and distribution in 2020 and 2030: a threat to equity and universal health coverage?', BMJ Global Health, 7(6), e009316. https://doi.org/10.1136/bmjgh-2022-009316
2. Kohn, R., Saxena, S., Levav, I. and Saraceno, B. (2004) 'The treatment gap in mental health care', Bulletin of the World Health Organization, 82(11), pp. 858-866.
3. Swiss Federal Council (2021) Änderung der Verordnung über die Krankenversicherung (KVV) und der Krankenpflege-Leistungsverordnung (KLV): Neuregelung der psychologischen Psychotherapie. Bern: Der Bundesrat (in force 1 July 2022).