Monday, February 27, 2006

Underserved in America

Sometimes, I get too wrapped up in big issues, such as universal health coverage, or in minutiae, such as neurochemistry, and lose sight of the middle picture.  In the service of my endless pursuit for balance, I am going to look at a couple of the mid-scale issues in health care today.

The Los Angeles Times today has an article about the state of mental health care for children and adolescents in the USA.  A while back, I wrote that the undersupply of qualified mental health care professionals serving children is a national disgrace.  The LAT confirms that this has not changed.
Young and alone
With only 7,500 child psychiatrists in the U.S., millions who need treatment are left desperate for care.
By Shari Roan, Times Staff Writer
February 27 2006

[...] When they need help the most, some families find, they're on their own.

"It would be the equivalent of your child getting a concussion, in pain, vomiting, and not being able to get any medical help," says Sandra Betler, an Orange County woman whose daughter began cutting herself and talking of suicide last spring but who couldn't find a doctor to see her child. "You think they're going to die at any time."

About 15 million U.S. children ages 9 to 17 are thought to have a serious mental or addictive disorder — such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), eating disorders, early onset schizophrenia or bipolar disorder. [...]

But only about 7,500 child psychiatrists are currently practicing in the United States — and only 300 new child and adolescent psychiatrists complete training each year. The profession — the only board-certified medical specialty that trains physicians to treat mental disorders in children and teens — is experiencing one of the most severe labor shortages among all medical specialties.

Those doctors who are available are often concentrated in urban areas, leaving some rural counties without a single child psychiatrist.

"Every child psychiatrist in the country has a waiting list," says Fritz, an expert on the workforce shortage. "I've never talked to one who didn't. Many will not even put people on a waiting list because it's too long and ridiculous." [...]
This situation is made worse by the fact that some psychiatrists finish their residency, do a fellowship in child psychiatry, then go into practice in which they see only adults.  I've never been sure why that is, and it would be presumptuous of my to make some kind of negative judgment about that, but it is important to realize that not all of the 300 new child psychiatrists each year will actually see children.

Personally, I would guess that one of the reasons that some child psychiatrists do not see children, is the same reason that I chose to not do a child fellowship.  That is, in addition to the USA having a shortage of child psychiatrists, there also is a shortage of nonmedical child service providers: therapist, social workers, child protection workers, foster care homes, special education teachers, etc.  I thought is would be endlessly disheartening to try to function in that system.  

As an aside, I would like to point out that there is no easy answer to this.  Increasing the supply of child psychiatrists without also increasing the supply of the other child workers would necessarily lead to an overemphasis on medication treatment, to the exclusion of psychosocial interventions.  It is pretty obvious that if a kid is neglected or abused at home, underserved in school, hungry, and otherwise disadvantaged, putting the kid on a medication is not going to do a whole lot of good.  

The whole topic is depressing.  Sometimes, though, there are some points of light amid the gloom.  

This week happens to be National Eating Disorder Awareness Week. (HT: Dr. Serani).  Eating Disorders often start in childhood or adolescence, and as a result, tend to be underrecognized and undertreated.   The "awareness week" activities can help.  Every once in a while, people participate in these kinds of activities, and as a result, end up going ahead and seeking a proper evaluation.  Sometimes they don't seek help right away, but end up doing so after a few days or weeks.  

In cases of eating disorders, quicker treatment can make a big difference.  Some persons with eating disorders develop serious medical complications.  The risk increases with time.  Therefore, quicker treatment can mean fewer complications.  

Another benefit from awareness week events is that they can help educate the general public.  This may reduce stigma, which is always a good thing.  It also may help persons who know persons with eating disorders to become more understanding.  One of the problems that faces a person with an eating disorder is the sense of isolation -- even alienation -- that can accompany the disorder.  The more people understand the problem, the better.