June 25, 2018
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Crisis time: How Maine can help remedy its child psychiatrist shortage

The MetroHealth System | The MetroHealth System
The MetroHealth System | The MetroHealth System

Time after time, children and teenagers end up in pediatricians’ offices not with broken bones or the flu, but with extreme anxiety or depression.

Adolescents with mental health conditions are typically seen in primary care more than any other setting, even though primary care physicians are not fully trained to diagnose or treat mental illness, according to the U.S. Agency for Healthcare Research and Quality.

Still, it’s up to that doctor to know what to do: Does the child need psychiatric care? How can immediate help be provided?

Then the bigger question arises: If the child needs continuing care from a psychiatrist, is one available nearby — and soon? Especially in rural Maine, the answer often is no, and the consequences are dire.

The lack of child psychiatrists is a national problem — for areas with both large and small populations — especially considering that an estimated half of all lifetime cases of mental illness begin before age 14. But rural places struggle the most: It can take months for a young person to get to see a child psychiatrist. Too often, help comes too late.

In the same way that individuals can work to overcome a mental health diagnosis, though, Maine can and should work to remedy the shortage of child psychiatrists. Failing to properly diagnose or treat children with mental illness creates more developmental and learning hurdles for them and can cause wider harm to society.

Addressing the shortage will, essentially, require greater collaboration between medical fields.

One response to the lack of psychiatric care for children and adolescents has succeeded — allowing pediatricians to consult with child psychiatrists by phone when they have patients who need mental health help.

Massachusetts started the first such program in the country: the Massachusetts Child Psychiatry Access Project. When primary care clinicians have concerns about a patient with a possible mental health diagnosis, they contact the program and receive a return call from a psychiatrist, usually within half an hour. The psychiatrist can then either answer the primary care doctor’s questions over the phone, refer the doctor and family to other resources or set up a way to see the patient face-to-face.

The Massachusetts program is fully funded by the state and provides coverage for roughly 96 percent of children needing care. Maine has a similar initiative called the Child Psychiatry Access Program, but it operates only in the southern part of the state, was started with grant money and continues with funding from a philanthropist, which will end. The program works with eight practices and provides coverage for about 38,000 children and adolescents.

The program could be doing much more, especially in Central and Northern Maine where the need is great. And the benefits multiply: As primary care doctors use the services, they become more knowledgeable about how to handle patients needing mental health help.

Even though this is the ideal time to stabilize the program’s funding — considering the need and that rewards come with time — the Maine Legislature appears unlikely to provide the $650,000 needed per year to turn it into a statewide offering.

There are other options, though. Insurance companies, for example, could help by covering the cost of the phone consultations — if the Legislature mandates it. Coverage has been provided in other states, such as Delaware.

There are more ways, too, to build the number of psychiatrists and primary care doctors with mental health knowledge — in Maine and elsewhere. For instance, loan forgiveness programs can be expanded for psychiatrists who work in underserved areas. More mental health professionals could be trained to work in primary care settings.

Practices in more remote areas can develop “telepsychiatry” options. And, as the country shifts toward the model of accountable care organizations, medical residents can gain expertise in more collaborative ways, such as through the pairing of those studying psychiatry and pediatric primary care.

Parents too often struggle to find help for their child. Primary care physicians too often encounter those with mental health conditions and don’t know what to do. As a result, depression or other illnesses go undiagnosed or untreated, inappropriate drugs are prescribed with little follow-up, or mental health problems lead later to chronic disease symptoms. There are ways for Maine to reach more people in need. But doing so will require greater collaboration and political will.

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