Pediatrician Karen Rhea said she found it “gut-wrenching” to see young people in psychiatric crisis: a teen who overdosed, the one with mental illness who landed in jail, the high school senior who tried to kill herself by crashing her car. With a population of about 20,000 then, Franklin, Tenn., where she practiced, had no child and adolescent psychiatrists, so Rhea spent long hours searching for inpatient care, phoning judges, looking for mental-health specialists in Nashville 20 miles away.
Sometimes her efforts made a difference. The suicide survivor thrived in therapy. She wrote a note to Rhea, thanking her for saving her life.
Eventually, Rhea became convinced she could better serve patients as a child and adolescent psychiatrist and returned to medical school. Now she is chief medical officer of Centerstone, one of the largest community mental health providers in Tennessee.
But some things have not changed.
Three decades after she left pediatrics, not a single state has what professional groups deem a sufficient number of child psychiatrists.
In her home town of Holladay, Tenn., a rural community, Rhea says the nearest child and adolescent psychiatrist would be about 50 miles away.
And limited access to mental health care has far-reaching consequences.
The longer that psychiatric illness or family dysfunction goes on, the more difficult it is for the child to succeed, Rhea said. Untreated problems can lead to difficulties in school, and that, she said, hurts self-esteem, limits social skills, hinders relationships and creates the view in a family that the child is badly behaved instead of having an illness.
“We’re looking at small people,” Rhea said, pointing out that special training in pharmacotherapy is required because children experience more side effects than adults and because drugs metabolize differently at younger ages. “We have the patience to make small adjustments in medication.”
Mental disorders often start young. The median age for the onset of anxiety and impulse control disorders is 11 and substance abuse, age 20, according to a 2005 study. Lack of treatment can mean difficulties in adulthood. Major depressive disorders, for example, can result in absence from work and poor productivity.
The shortage of child and adolescent psychiatrists is profound, said Scott Shipman, a professor of pediatrics at the Dartmouth Institute for Health Policy and Clinical Practice. There is an estimated one psychiatrist per 1,807 children who need services in the United States.
A new report by Mental Health America, an advocacy group, found that rates of depression among young people rose from 8.5 percent to 11.1 percent from 2011 to 2014 and that 80 percent of youth with severe depression receive no treatment or insufficient treatment.
Getting an appointment can be difficult and discouraging, sometimes taking five weeks or more in the area outside Nashville, said Beth Hail, Centerstone regional vice president. School counselors and psychologists, once a safety net for identifying and helping troubled children, are stretched, Bob Vero, chief executive of Centerstone, said. These school workers are expected to focus on scheduling, college applications and testing, leaving less time for emotional and developmental needs. Pediatricians and family physicians find themselves forced to practice beyond their comfort zone and their training.
In 2001, the American Academy of Child and Adolescent Psychiatrists organized a task force to find ways to increase the number of people in the field. The panel found training programs and resident numbers stagnant or declining at the same time that need was growing. These experts focused on intensifying recruitment to build the numbers.
“We put a massive effort into it,” said Gregory Fritz, president of AACAP and co-chair of the task force. In the end, the task force did increase numbers a fraction and encouraged the founding of 10 new training programs. However, Fritz said, “all of our successes need to be multiplied by 10 or 20 to even make a dent.”
The results were discouraging, he said. “I don’t know which is harder to change — the federal government or the medical community.”
There are two common ways to train for child and adolescent psychiatry, or CAP, and each takes a significant amount of time. After medical school, a candidate studies four years of general psychiatry and moves on to a two-year fellowship in child and adolescent psychiatry. The second option is called the fast track. It takes five years instead of six.
“What I firmly believe is that when we have such a huge national need, we ought to make all sorts of different paths,” Fritz said, expressing frustration that after years of work, more programs that tap medical students who want to work with kids were not embraced.
But even if there were more medical students eager to devote an extra five or six years to training, limited money for fellowships and CAP’s exclusion from loan forgiveness programs have stymied growth. The Balanced Budget Act of 1997 set a limit on the number of federally funded residency slots and cut funding for subspecialities such as CAP. The 10 new training programs added as a result of the task force’s efforts were all paid for by hospitals rather than with federal funds. Even well-established and competitive programs such as the University of Maryland’s offer only seven fellowships a year.
One factor related to the shortage goes back to the very nature of helping children. It is a lot of social work, according to Jess Shatkin, vice chair for education at the Child Study Center at NYU Langone Medical Center. Child psychiatrists speak with parents, teachers, siblings, coaches and others involved in a child’s life, to get a full understanding. “One case can suck up a lot of time,” he said.
Candidates who express interest when they enter residency in general psychiatry sometimes reconsider when faced with adding two more years of training, delaying entry into a career with a paycheck and taking on more debt, all at an age when they may be considering starting their own families.
And general psychiatry, looked to as the pipeline for CAP candidates, also has a shortage. One reason for that is reimbursement amounts for mental-health services and the lingering stigma about its value, said Carol Bernstein, an associate professor of psychiatry and director of residency training at NYU School of Medicine.
Lacking sufficient progress with the task force’s strategy, leaders in the profession turned back to pediatricians.
“If you ask families where do you want to get their mental-health care, they say their pediatrician’s office. They love their pediatricians and they trust their pediatricians,” Fritz said. Pediatricians also have the benefit of a longitudinal view of children, seeing them over the course of their development. And there are a lot of these physicians. Pediatrics is the third-largest specialty in the United States, with more than 50,000 doctors.
The goal is for primary-care doctors to take on minor mental-health problems in consultation with a child psychiatrist. The important corollary, Fritz said, is that these problems are minor because they are getting addressed earlier.
In some cases, a psychiatrist or psychologist is embedded in a primary-care practice, where he or she can do hallway consultations or engage in what is known as a warm handoff. “The pediatrician walks two doors down the hall and introduces the patient,” Fritz said.
In Tennessee, Centerstone has three clinics located in primary-care offices and has introduced videoconferencing to provide mental-health care remotely. But the clinics’ doctors have also had to adjust their model of care, relying on advanced-practice nurses under the supervision of physicians. Only three of Centerstone’s 70 medical staff members are child and adolescent psychiatrists.
Another model that started in Massachusetts and is now used by more than 30 states involves having regional call centers for primary-care physicians to get a real-time consultation with a child and adolescent psychiatrist.
NYU’s Bernstein says integrated care is the wave of the future, not only for CAP but for general psychiatry as well.
Fortunately, there are still young doctors who have been moved, as Rhea was, by CAP’s potential. Fayrisa Greenwald is one. She was working in an outpatient pediatric practice and found it very difficult to find a psychiatrist when a child needed one.
Now she’s a second-year resident in general psychiatry at NYU and will be applying for a fellowship in child and adolescent psychiatry. “I feel that by intervening early,” she said, “I can potentially change the trajectory of their entire life course.”