Over the weekend, I received calls from two old friends, both requesting advice about how to navigate the mental health care system during a crisis with their child. One child is preschool aged and has been “tantruming” for 75% of his waking hours for most of the past year, and now has been getting suddenly worse. He screams and writhes around on the floor most of the time. The other is a teen who cut herself with a razor and told her parents she hears voices and wants to die. These are serious situations in need of psychiatric opinions.
Their families live in different states and have different resources, but they ended up having very similar experiences when trying to get mental health services for their children. After exhausting the knowledge and resources of primary care providers, they needed a specialist. But then neither family could get an appointment with a psychiatrist, even with the assistance of their primary doctor. They offered to pay out of pocket, or do anything necessary to facilitate getting the child seen, and both families were told that nothing was available for many weeks.
They faced the impossibly difficult decision of considering hospitalizing the child just to get the expert opinion. One family opted for hospitalization, where their child was locked in (and they were locked out), and although the child was placed on psychiatric drugs to stabilize symptoms, the parents still never directly spoke with a psychiatrist to hear advice or even education about what brought on the symptoms in the first place. They left the hospital without securing an outpatient appointment, and just hours after they got the child home, it was clear that the treatment wasn’t working and there was no one to call.
“Why has it become so impossible to access mental health care services?” was the question both families asked.
I wish I fully understood the answer to that question. It seems many factors have contributed to the growing state of impossible access to psychiatric services. Foremost among them, there just aren’t enough psychiatrists. Filling psychiatric residencies is nearly impossible; it’s not a prestigious or high paying medical specialty. And then as the public raises awareness and encourages those in need to seek out psychiatric help, the need is increasing and no new providers are available to meet the increased need.
I don’t see access to care in psychiatry being resolved by training more doctors. My own premed, medical school, and then residency training spanned (a standard) twelve years. We can’t wait more than a decade for a solution. Physician’s assistants (PA’s) and psychiatric nurse practitioners (NP’s) can be trained more quickly and can therefor meet some of that need, but even then, psychiatrists have a great deal more specialized training and seeing a PA or an NP isn’t always interchangeable. Even primary care physicians, trained in a wide array of medical care, often say they lack specialized knowledge to feel competent in treating serious mental disorders.
I have concluded that psychiatry is going to have to change. Psychiatric physicians are going to have to alter the age old model for delivering mental health care. We cannot just work faster and see patients in 3-minute time slots to fill this need. We are going to have to be innovative and work in teams with our fellow professionals (PA’s, NP’s, and primary care doctors). Not every family has the ability to call a psychiatrist friend for advice, but everyone deserves basic access. Psychiatry is going to have to find a way to address the need.
Here are ways to expand access now:
1. Psychiatrists can provide case consultation services to primary care physicians to help them stabilize and manage complex cases.
2. Psychiatrists can offer one time clinical “second opinion consultation ” services to aid in diagnosis and treatment planning, and them allow other professionals to manage care long term.
3. Psychiatrists can work closely with well-trained physician extenders in their outpatient clinics.
4. Psychiatrists can offer educational and support services to the public, and to other providers.
5. Psychiatrists can coordinate medication refill services for stable patients with primary care, so that unstable patients can be seen in open/available time slots in the psychiatric clinic.
There are probably many other ways to expand access as well. Share your suggestions in the comments section below.