Options are limited for treating mental illness in teens, children

Aug. 02--Sometimes Dr. Timothy Newton wishes he had a "phone-a-friend" option.

The 32-year-old family practice physician works out of a clinic in Cherokee, a northwest Oklahoma town of about 1,600 people.

About one-fifth of the children that he sees have a mental health issue, whether it be depression, attention deficit hyperactivity disorder (ADHD), anxiety or a mixture of all three.

Newton wants, at times, to pick up the phone and call a child and adolescent psychiatrist for advice on a prescription, but that's not yet an option in Oklahoma.

"The hardest thing is when I get to a point where I feel uncomfortable giving kids heavier doses of medications or changing medications multiple times," Newton said. "And I start to feel uncomfortable, and it's hard to find somebody to send them to to get that taken care of."

Newton is right. In Oklahoma, and throughout the rest of the U.S., there is a large shortage of child and adolescent psychiatrists.

That means children and their families often wait weeks, if not months, to see a child and adolescent psychiatrist.

State health leaders estimate that there are about 60 child and adolescent psychiatrists in Oklahoma, but only about half are actually seeing patients.

General psychiatrists also see children, but Oklahoma also has a shortage of these practitioners and a large adult population that needs their care, too.

In 2012, Oklahoma had child and adolescent psychiatrists practicing in only nine counties: Cherokee, Cleveland, Comanche, Delaware, Kay, Logan, Oklahoma, Tulsa and Woodward counties, according to an American Academy of Child and Adolescent Psychiatry analysis.

Meanwhile, Oklahoma has a high prevalence of mental illness among children, mixed with low access to care, according to Mental Health America.

The state ranks No. 38 in the U.S. for the rate of children with emotional behavioral developmental issues, according to the mental health advocacy nonprofit. And 68,000 of those children are uninsured, leaving Oklahoma with one of the highest number of uninsured kids in the country.

"Especially in Oklahoma, they have had to play a strong role in both diagnosis and medicating kids," said Dr. Sara Coffey, a Tulsa child and adolescent psychiatrist. "I think it's been hard, though, because they don't have the luxury we do in adolescent and child psychiatry to invest in a thorough (evaluation) of children."

More collaboration?

One proposed solution: more collaboration between child and adolescent psychiatrists, pediatricians and family practice physicians. Especially in rural Oklahoma, pediatricians and family doctors are and have been, for years, on the frontlines treating mental health, advocates say.

Mental illnesses could be described as diseases of the young, although a person is often well into adulthood before they're diagnosed.

About half of all lifetime cases of mental illness begin by age 14, according to the National Institute of Mental Health. And although there are effective treatments for children, there are long delays, sometimes decades, between when a child first shows symptoms and when they seek and receive treatment, according to the institute.

Left untreated, people with psychiatric disorders can suffer more frequent and severe episodes, and are more likely to become resistant to treatment.

And research has shown that children untreated for these disorders are more likely to fail in school, have a child as a teenager, have a hard time finding a job and face marital instability.

These children could potentially improve -- if they had access to consistent, quality mental health care.

The majority of Coffey's time is filled each week with seeing about 50 patients, if not more, ages 3 to 18, at three clinics across Tulsa.

Coffey, an assistant psychiatry professor at the University of Oklahoma School of Community Medicine in Tulsa, oftentimes sees children whose previous physicians have tried multiple medications to manage their ADHD.

And those medications failed, in part, because along with ADHD, the child has anxiety and severe trauma.

"Certain kids are more complicated and need a specialist to do a more thorough evaluation to help kind of manage them through," Coffey said.

That's the role that child and adolescent psychiatrists play. Coffey can spend an hour, if not longer, evaluating a child, whereas a family practice physician gets reimbursed by an insurance company for a 15-minute visit.

Coffey wanted to be a child and adolescent psychiatrist after watching her mother, Diane, give her heart into her job as a social worker. And Coffey, before medical school, even worked as a case aide at the Oklahoma Department of Human Services, driving kids around the state for family visits.

Coffey did her four-year residency training in Chicago through an adult psychiatry program. Then she went to Harvard for a two-year child psychiatry fellowship. And then she came back home to Oklahoma.

In Tulsa, she stays busy, seeing children not only from that metro area, but also from Wagoner, Skiatook and Tahlequah.

"At our clinic, we're not able to take new referrals from outside of the OU Pediatrics, so I think that's notable, but right now, we're still seeing at least one to two new referrals a day from our OU pediatricians, and I'd say probably four to six weeks is our wait time right now," Coffey said. "And that's just serving our internal community."

Coffey helped start the college's child and adolescent psychiatry fellowship program, a two-year training program that physicians attend after finishing medical school and their residency program.

The goal is to turn out two fellowship-trained child psychiatrists each year.

In July, Dr. Sarah Flanders started as one of the program's first two fellows.

Flanders, 30, went to medical school at Tulane University in New Orleans. She met her husband there, and they moved to Oklahoma to be closer to his family.

Three days each week, Flanders works at Parkside Hospital, a psychiatric hospital and clinic in Tulsa. She also works at another a clinic for part of the week.

During her residency, Flanders received some training in child psychiatry, but she didn't feel it was enough to understand the scope of what she might see as a practicing physician.

"And maybe some people would do great with that little of training, but I felt comfortable getting more," Flanders said.

After her fellowship, Flanders isn't sure whether she will stay in Oklahoma.

"I think there's a strong possibility I'll stay in Oklahoma, but that's a ways away, and I can't say for sure," Flanders said.

And Coffey points out: Even colleges adding fellowship programs can't fully address the psychiatry shortage.

"There's never going to be enough child psychiatry anywhere," Coffey said. "There just isn't -- because there's so much need."

Different pay model?

Instead, there's a push nationally to find different health care models that make it easier for child psychiatrists, pediatricians and family practice physicians to work together.

For one, the Affordable Care Act incentivizes this type of collaboration through Accountable Care Organizations, when a group of doctors, hospitals and other health care providers work together voluntarily to provide patient care.

And under the federal health reform law, mental health is required to be covered in the health insurance coverage available through the federally run marketplace.

"So it really makes it almost the law -- except, of course, it takes a long time for the Affordable Care Act to get anywhere, so it's just beginning, but anyhow, it's in there," said Dr. Gregory Fritz, president-elect of the American Academy of Child and Adolescent Psychiatry.

Fritz led the organization's charge to increase the number of psychiatrists treating children. The goal was to increase the workforce by 10 percent over a 10-year period.

But those efforts largely, and unfortunately, didn't work, he said.

"We're still trying to entice people to the field, but that isn't going to be the solution," Fritz said.

Surveys show that, when a family cannot get help or doesn't know where to get their child help with mental health issues, they want to go to their pediatrician, rather than specialists they don't know, Fritz said.

Some states have tried experimenting with creating a telephone network that physicians can use.

For example, the Massachusetts Child Psychiatry Access Project is a regional system of children's mental health consultation teams that help primary care physicians serving children with mental health conditions, according to a Massachusetts legislative analysis.

Under this model, six regional teams of mental health professionals provide information to primary care physicians who call. The program is paid for largely through state funding. At least 20 states have emulated the program.

Other states have seen mental health professionals embedded in pediatric practices, and they offer "curbside consultations," meeting informally in their practice to quickly discuss a child's case.

But insurance companies haven't jumped on that bandwagon. Generally speaking, physicians aren't reimbursed for a "curbside consultation."

Fritz said a fee-for-service model, the current health care model in the U.S., is the opposite system for funding these types of integrated care models.

"What would work much better is if there were pediatrician practices or accountable care organizations that had a capitated agreement to take care of 5,000 people or 50,000 people, and the insurance company gave them per member, per month payments," Fritz said. " ... If that system were in place, a capitated or value-based system, as opposed to a fee-for-service volume-based system, this integrated care would save money hand over fist."

For now, in Cherokee, Newton's options remain largely the same: referring a child to Alva for a telemedicine visit with a psychiatrist, a practice he isn't fond of, or an in-person visit with a psychiatrist in Enid.

The clinic hopes to receive federal grant money to add more mental health staff. Presently, a counselor is at the clinic one day a week.

But counseling can be a hard sell to parents who want answers and a diagnosis for their child, Newton said.

And for that, it's always a wait, sometimes two or three months to see a psychiatrist.

"And some of these kids need help a little more urgently," Newton said. "They might end up hurting someone or themselves. It's almost like we have to wait until they're suicidal or endangering other people. ... Sometimes, the wait is so long, we're just waiting for them to lash out before we can get help, and it would be much better to be proactive."

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