Long-term shortage of child psychiatrists inflicts toll nationwide

NEW YORK -- In state after state, bleak statistics and grim anecdotes lead to the same diagnosis: America suffers from a serious, long-term shortage of child psychiatrists that is taking a toll on young people, their parents and their doctors.

Wyoming is down to two child psychiatrists; another left last year. In Augusta, Ga., Dr. Sarah Sexton tells would-be new patients she might be able to see them in July. Elsewhere, doctors take no new patients at all.

"There is no state where it is not a problem -- none," said Dr. Gregory Fritz, director of child psychiatry at Brown Medical School in Providence, R.I. "We see it in the emergency ward every night, where problems have gotten out of hand over time due to lack of intervention, and progress to a point where a kid is suicidal or dangerous."

Worsening consequences

The shortage has been noticed within the profession for years, but psychiatrists say the consequences are worsening as the stigma of mental health problems recedes and more families seek help for their children, including prescriptions for psychiatric drugs.

Demand for such drugs is intense, and the shortage of psychiatrists "forces kids to see other practitioners for medication management who might not have the training or experience to appropriately treat them," the National Conference of State Legislatures warned in a report last month.

The shortage is attributed to two main factors: the extra two years of training required for child psychiatrists, on top of four years of medical school and three years of general psychiatry; and a reimbursement rate that doesn't reflect the extra time required for a psychiatrist to interview parents, teachers and others familiar with a child's behavior.

"You always have to deal with a parent or caretaker -- it doubles the interview time," Fritz said. "But the reimbursement rate is the same as if you're evaluating an adult."

7,000 in the field

The main organization representing the profession is the American Academy of Child and Adolescent Psychiatrists (AACAP), which gauges the number of practitioners in the field at about 7,000. The U.S. Bureau of Health Professions projects there will be about 8,300 child psychiatrists in 2020, only two-thirds of the estimated 12,600 needed.

The shortage already is staggering. The Center for Mental Health Services estimates that at least 5 percent of America's children and adolescents have acute mental health disorders.

Yet a study commissioned by the AACAP in 2003 found there was, on average, only one child psychiatrist for every 15,000 youths under 18 -- in theory, producing a burdensome caseload of 750 seriously disturbed children per doctor. West Virginia had 1.3 child psychiatrists per 100,000 young people.

Because of the shortage, pediatricians, family doctors and child psychologists have been filling the void, though their training is far less thorough. Several states are encouraging tele-psychiatry in which physicians in underserved rural areas can consult long distance with urban- or university-based child psychiatrists.

"We have to use our expertise in as broad a way as possible, to help the physicians actually providing the care," said Dr. Steve Cuffe of the University of South Carolina.

Often, according to the National Alliance on Mental Illness, parents unable to find or afford private psychiatric care are told the only way to get needed treatment is to relinquish custody of their child to the state.

Compounding the problem is the surging use of drugs for children with attention deficit disorder or other behavioral problems. One recent study estimated that 2.5 million children a year are taking such drugs; Fritz said most are prescribed by pediatricians and other non-psychiatrists.

"They're probably overused, and often without appropriate assessment and monitoring," he said. "If there were more child psychiatrists, they wouldn't be used as casually as they are."

Several steps have been proposed to ease the shortage, though none are expected to produce swift changes. One concept is to either shorten the five-year psychiatry program or enable students interested in child psychiatry to begin working with children sooner in their training.

Another step was taken last week when the House of Representatives approved an amendment that makes students preparing for work in youth mental health eligible for loan forgiveness. But the measure's Senate prospects are uncertain, and a broader bill addressing the psychiatrist shortage has languished in committee for two years.

"Everyone knows there's a shortage of nurses, of science teachers," said Michael Zamore, an aide to amendment sponsor Rep. Patrick Kennedy, D-R.I. "When it comes to mental health, it's hidden in the closet."