Shortage of child psychiatrists plagues the US

When Laura Amann, a freelance writer in Chicago, began looking five years ago for a psychiatrist for her severely depressed 14-year-old daughter, she discovered what many parents have found. There is a shortage of child psychiatrists in the United States.

"There is a workforce shortage. We simply don't have them to meet the need at this point," said Debra Koss, a child and adolescent psychiatrist in a Sparta Township, New Jersey, and a member of the American Academy of Child and Adolescent Psychiatry (AACAP). She added that about about 20 percent of youths are diagnosed with mental illness at some point from ages 13 to 18 and that many families who need a child psychiatrist face long waitlists.

The statistics back her up. For example, last year a study published in the American Psychiatric Association journal Psychiatric Services showed that the average waiting time in major U.S. metropolitan areas to see a child psychiatrist was 25 days for a first visit. Investigators for the study tried to get an appointment with 360 outpatient psychiatrists in Boston, Houston or Chicago and found that after two calls, despite having insurance or saying they would be willing to pay out of pocket, appointments were nailed down with only about 25 percent of the doctors.

According to the AACAP, there are approximately 8,300 practicing child and adolescent psychiatrists in the United States — and over 15 million youths in need of one.

But even without a shortage, it can be difficult to arrange because of the stigma still attached to mental health problems.

"It's not like finding an orthodontist. It's hard to go to a friend or neighbor and say, 'Hey, does your kid have issues? Do you have recommendations for a child psychiatrist?'" said Amann.

She has a 12-year-old son and three older teen daughters, two of whom are seeing a child psychiatrist. Her 19-year-old has been diagnosed with bipolar disorder; her 14-year-old daughter is afflicted with anxiety.

But the professional shortage makes a search for a child psychiatrist particularly distressing. If your child is actively suicidal, the search is relatively straightforward: Take your child to an emergency room. Yet if your child is troubled but not critically suicidal and you're told that your child is going to have to wait three months for an appointment, you may wonder if the wait will mean your kid's problems will just worsen.

That might happen, said Jeffrey Strawn, a child and adolescent psychiatrist and an assistant professor of psychiatry and pediatrics at the University of Cincinnati College of Medicine. "Many of these kiddos, without easier access to treatment, see depression intensify," he said.

While a three-month wait to see a child psychiatrist may not sound like that big of a deal, that's just the beginning of the process, Amann said, explaining that "the medicine usually takes six to eight weeks to become effective … and it might be even longer, since they'll usually start your child off at a low dose."

Even then, that doesn't necessarily mean the end of your child's problems. With her 14-year-old, Amann said, "It took two years to find the right medication."

Why is there a shortage? One would think there would be plenty of child psychiatry graduates. It's a career that's well respected and highly compensated. According to Salary.com, the median expected annual pay for a child psychiatrist in the United States is $183,826.

But a significant barrier into entering the profession is all the education required, said Koss. Most child psychiatrists follow a path involving four years to get an undergraduate degree, followed by four years of medical school, then four years of general psychiatry and finally a two-year fellowship in child psychiatry. A college freshman aspiring to be a child psychiatrist is looking at 14 years of training and likely a mountain of debt.

The way the U.S. health system works may contribute the shortage of child psychiatrists, said Strawn.

During a typical 10-hour workday, he might see 10 to 15 patients a day. He could see more, but a good deal of his time is spent on the phone with insurance companies or coordinating phone calls with numerous people in the patient's life, often a school guidance counselor, teacher or therapist.

"There are so many of these types of calls that aren't addressable when you're in the room with the child, and you end up doing some of those calls after hours. It limits the number of patients you can see in a day and still provide quality care," Strawn said.

"The system is pretty broken, and just hiring more child psychiatrists isn't going to fix it," said Larry Wissow, M.D., a professor with the department of health, behavior and society at the Johns Hopkins Bloomberg School of Public Health. "We're trying to fix a system that shouldn't be fixed. It should be changed."

That is slowly happening, Koss said. One strategy has been a push to create loan forgiveness programs, modeled after something the National Health Service Corps already does with primary care physicians. With such plans, child psychiatrists wouldn't have to pay back many of their loans if they spent time working in underserved areas.

She also said many states have been trying telepsychiatry, in which psychiatrists treat the patients who live in remote, underserved parts of the country through video conferencing. The website for the National Network of Child Psychiatry Access Programs has information on telepsychiatry programs in 30 states and Washington, D.C.

But most promising so far may be the push toward the integrated collaborative care model, Koss said, in which the psychiatrist works in close coordination with the rest of the youth's health care providers. "In that case, child psychiatrists serve as consultants to pediatricians," she said. "We know that all children have primary care physicians and that that becomes a very important and trusted relationship where parents often go for help. So that's a natural fit, to provide pediatricians for the tools and resources they need to help the child."

She added that there are now 34 states in the U.S. that are implementing this model.

Still, these solutions can't come quickly enough for parents like Jill Gawrych, a human resources manager in Milwaukee. She and her husband have four kids, and their oldest has obsessive compulsive disorder. Two years ago, Gawrych said, her then-10-year-old daughter began developing rituals before going to bed, like checking the closet for dead people and praying all the time.

"It wasn't a religious thing. It was more of a mantra. She had to say the right things, and if she didn't, she believed something bad would happen to me," Gawrych said.

More recently, her daughter is obsessed with getting straight A's and has been having panic attacks. "I don't know how to help her," Gawrych said. "She's my oldest. I can't sort out OCD from puberty."

Gawrych fairly quickly was able to find a therapist, who suggested a psychiatrist was in order and recommended some, but none of them panned out. For instance, one had a six-month wait, and another was no longer seeing any new patients. She searched on her own, but finding a child psychiatrist in the area who treats OCD has not been easy.

"We have the means to pay for one. We have the resources. If somebody was out of network, we would go. It's just that almost nothing is available," said Gawrych, who has high hopes that an appointment at a treatment center she has set up for late June may lead somewhere.

Amann said that her family is relocating this summer to Colorado because of a job transfer for her husband. She will have to start the process all over again and find a new psychiatrist for both her daughters.

Five years ago, she was reluctant to ask friends to recommend a child psychiatrist, but she said she no longer worries about the stigma and has already started asking Colorado acquaintances if they know anyone.

"It's way more common than we all realize. So many kids are struggling," Amann said.

At one point, both her daughters were seeing a psychiatrist and therapist once a week. Her co-payments were $25 each, so she was paying $100 a week, plus money for medication. "It adds up to the thousands so fast," she said.

But she is especially grateful for her health insurance, Amann said, "because I'm not sure my daughter would be alive if she didn't have access to proper health care. I don't say that lightly. She has been hospitalized three times. She was on a suicide watch the last time."

As she recognizes, she is one of the lucky ones. Her daughters have received help. In theory, all children should be able to see a psychiatrist, because parents should have insurance coverage for it through the Affordable Care Act or through safety nets such as Medicaid. But not every child psychiatrist accepts Medicaid payments.

There are enough frustrated parents out there that some states have passed controversial laws allowing psychologists, who are not doctors, to get more training to allow them to prescribe medication to patients.

Strawn said he thinks the integrated collaborative care model, with pediatricians receiving guidance from psychiatrists to prescribe medications like antipsychotics, is the way to go. But he said that the system needs to hurry up and get there.

"Unfortunately," he said, "unless something can be done to improve collaborative care, the diagnosis for the shortage looks bleak."