The School of Nursing at UNC-Chapel Hill is increasing the scarce supply of mental health providers by retraining nurses to diagnose and treat psychiatric illness.

What's more, the program recruits at least half its students from North Carolina counties with the greatest shortfall of providers. That means new providers often return to practice where they are most needed.

UNC-CH is one of a handful of universities nationally that trains registered nurses to be psychiatric nurse practitioners. Here, and across the country, such professionals are emerging as critical players in efforts to address a growing shortage of psychiatrists.

Seventeen of North Carolina's 100 counties have no psychiatrist, and 27 others have significant shortages, according to the Cecil G. Sheps Center for Health Services Research at UNC-CH.

Because of the shortages, many patients with mental illness, particularly in rural parts of the state, go undiagnosed or untreated. Some seek help from primary care doctors who typically lack the specialized training to provide optimal care. In the worst situations, untreated patients wander the streets, land in hospital emergency rooms or end up in jail.

"You have terrible access across the state," said Dr. Marvin Swartz, chief of the division of social and community psychiatry at Duke University Medical Center in Durham. "It's a very challenging situation." Duke is also trying to address the shortage, by training physician assistants in a one-year fellowship program that provides advanced training in psychiatric care. Upon completion, physician assistants will be able to function as primary mental health care providers.

Swartz and others say mental health reforms adopted by the state in 2001 only exacerbated problems by closing down county-run psychiatric programs. In theory, private providers were to step in to care for patients. Most counties are still waiting for that to happen. Others have overpaid for services that benefit easy-to-treat people, leaving profoundly sick patients with little care.

UNC-CH's psychiatric nurse practitioner program helps by producing highly skilled clinicians who can assess and diagnose psychiatric illness and treat it with both psychotherapy and medication. In North Carolina, psychiatric nurse practitioners are the only nonphysician mental health providers who can prescribe powerful anti-psychotic drugs. State law does require them to work in collaboration with a physician, though the doctor need not be on site.

Employers call with offers

Abree Ryans of Jacksonville graduated from UNC-CH's program in December to find employers clamoring for her expertise.

"For the first time in my nursing career, I have not had to look for a job -- people are calling me," said Ryans. "I have turned down at least 10 job offers."

Ryans, a former psychiatric nurse, has accepted a part-time position at a private mental health services practice in Jacksonville, which is an underserved area. She will perform psychological assessments and manage patients' medications. She is considering a second position with a provider in Wilmington.

"I'm excited and raring to go," said Ryans, who loved her work as a nurse but felt too limited in what she could do for her patients. "Now I am going to be able to help people so much more."

UNC-CH has had a psychiatric nurse practitioner program since 2002. But enrollment didn't take off until the next year, when the School of Nursing received state and federal grants to target nurses already living and working in underserved areas across North Carolina. The program also seeks to enroll nurses who are racial minorities or come from poor backgrounds.

Students entering the program may have a two-year or four-year nursing degree, or they may already have a master's degree in nursing. Depending on the level of training coming in, it takes one to three years to complete the degree.

Nurses recruited through the grant-funded program, called Nurses Enhancing Mental Health Options for the Underserved in North Carolina, receive resources such as a free laptop computer. Tuition assistance is also available in exchange for a commitment to work in an underserved area.

To make attending school as easy as possible, UNC-CH modeled the psychiatric nurse practitioner program after executive degree programs that require only weekly or monthly visits to campus. It also incorporated courses taught via teleconference. That has enabled nurses from remote parts of the state to work toward degrees while continuing to work in their home communities.

A desperate need

"I probably wouldn't be able to do this without distance learning," said Kim Bronson of Garland, a small town in Sampson County about a two-hour drive from Chapel Hill.

Bronson, a single mother, works full time as a substance abuse nurse while also attending the psychiatric nurse practitioner program. She hopes to stay in Sampson County after she completes her training. Her dream is to open a substance abuse treatment center there or in nearby Robeson County. Both counties have a desperate need, she said.

"A lot of people don't know where to go or what to do to access services," Bronson said. "The emergency departments are inundated with psychiatric patients."

Since 2003, enrollment in the UNC-CH program has grown from two students to more than 50. Fewer than six have completed their psychiatric nurse practitioner degrees to date, but at least 14 more are expected to graduate this summer.

"We started slow, and we started small, so the numbers are not that impressive," said Linda Beeber, a professor of nursing at UNC-CH and founder of the psychiatric nurse practitioner program. "But give us a couple of years. It's certainly not the answer to the whole problem, but it's one proactive thing that nursing can offer."