From Time by Emma Ockerman: Rebecca Gadley’s father searched for months to find a therapist who could treat his teenage daughter for depression in their small Kentucky hometown. The few child psychiatrists within driving distance said she’d be waiting months for an appointment; another refused to accept new patients altogether.
Then, in January of this year, Rebecca’s father finally found someone who could see his daughter every week. Better yet, the treatment could start immediately. There was just one catch: Rebecca and her therapist would be separated by nearly 260 miles. She would be able to hear and see her therapist, but her “telehealth” appointments would mean that she might never get to shake her hand.
“It’s like Skype through a TV,” says Rebecca, now 14. “You get used to it.”
In 2015, the average child and adolescent psychiatrist in Kentucky was 55 years old, and psychiatrists say many in the field are retiring without replacements. Kentucky and most other U.S. states are facing a severe shortage of psychiatrists, according to the American Academy of Child and Adolescent Psychiatry (AACAP). Psychiatrists and mental health advocates say America today needs more than 30,000 child and adolescent psychiatrists, and has only 8,300—and the need appears to keep rising. At Cincinnati Children’s Hospital Medical Center, where Rebecca’s therapist is based, children in psychiatric distress account for more than 7,000 annual emergency room visits per year. Ten years ago, the emergency room saw half as many such visits.
Advocates have long scrambled for solutions to the problem: increase funding for clinics; expand loan-forgiveness programs so medical students might be encouraged to go into child psychiatry; increase the number of psychiatric beds in hospitals; and expand telehealth. More recently, U.S. Rep. Tim Murphy, a Republican from Pennsylvania and a child psychologist himself, introduced the Helping Families in Mental Health Crisis Act, which included funding for collaborative telemental health programs.
“We need three times as many psychiatrists as we have,” says Dr. Gregory Fritz, Rhode Island-based child and adolescent psychiatrist and president of the AACAP. It’s estimated that there are more than 15 million children who could need—and are not getting—treatment for mental health disorders. Experts agree that as more young people emerge in need of psychiatric or psychological care, there is an ever-urgent race to find ways to deliver them the help that they require.
As technology has become cheaper and more reliable, telepsychiatry has emerged as a practical approach to reaching more young people. But it’s not without its detractors. Some advocates disagree on whether appointments like Rebecca’s are as effective as those carried out in-person. Others see telehealth as just one promising piece of what must be a larger, more comprehensive solution.
“It is part of an evolving landscape that has to change to get kids the services they need, and this is one very good part of that,” says Dr. Kathleen Myers, program director for telepsychiatry and behavioral health at Seattle Children’s Hospital. “But if you take a child psychiatrist here and have them practice [telehealth], all you’ve done is redistribute the manpower. We really need more than that.”
An Evolving Model of Care
Telepsychiatry in its crudest form first emerged nearly half a century ago. There are reports from as early as 1955 of the Nebraska Psychiatric Institute using a two-way, closed-circuit television system to collaborate with a state hospital. In the next decade or so, similar setups cropped up at the Dartmouth-Hitchcock Medical Center, Massachusetts General Hospital and others as the technology advanced. Myers has been practicing telemedicine for nearly two decades, in fact, but she’s in the minority.
The kind of treatment Rebecca is receiving is far more modern than what was practiced 50 years ago, of course, providing an almost seamless digital experience—at least for those accustomed to it. Children today are used to interacting with technology, says Dr. Michael Sorter, director of Child and Adolescent Psychiatry at Cincinnati Children’s, and computers and smartphones are where they maintain relationships with friends. Because of that, it might not be so unusual for them to see a doctor the same way. “They seem like they can easily relate to the TV screen,” Sorter says.
Another evolving model for teletherapy is where psychiatrists don’t directly treat patients, but rather provide support for pediatricians and others caring for children who do not have expertise in mental illnesses. Spurred by the National Network of Child Psychiatry Access Programs, which ran a successful pilot in Massachusetts more than a decade ago, state programs are increasingly launching to both relieve some of the patient load child psychiatrists are facing, and to make it easier for doctors who are inexperienced in treating mentally ill children to seek consultation or receive training.
In both telepsychiatry models, however, the distance between the trained expert and the patient has drawn some detractors. A paper published in the American Journal of Psychiatry in 2013 warned that video conferencing could impact the natural conversation and bedside manner that would normally occur between a mental health provider and his or her patient. The appointment might initially feel impersonal, and the psychiatrist might have to make up for that with small talk to encourage “feelings of connectedness in a clinical encounter,” wrote Dr. Jay H. Shore, a psychiatrist in Denver.
And young children can pose particular difficulties. Myers, of Seattle Children’s Hospital, mentions that some may speak quietly, making it hard for the psychiatrist to hear them on the other end. Others say children can be restless or shy during the teleappointments. Connections can cut out, calls can drop and patients and providers can grow confused in the process, though that happens less as technology improves.
Still, despite any potential downsides of teleappointments, the American Psychiatric Association, the American Psychological Association and the American Academy of Pediatrics all acknowledge its prominence and offer resources for patients and providers on how to practice it, while the HRSA’s Office for the Advancement of Telehealth provides federal grant money for programs that support telehealth in rural areas.
Earlier this year, the American Telemedicine Association reported that the number of states requiring that private insurers cover telemedicine just as they would in-person services had doubled in the past four years. Kentucky mandates that telemental health encounters like Rebecca’s be covered through Medicaid and private insurers, according to the American Telemedicine Association, including those appointments through a licensed social worker.
Rebecca’s father, Ron, who works as a machinist for the nearby Warrior Coal mine, had never heard of telepsychiatry before his daughter’s diagnosis of depression. But after struggling to find a local treatment option for her—there are no child psychiatrists in Hopkins County, Ky., where the family lives—he was grateful to learn from a nurse at his workplace that his company’s relationship with Cincinnati Children’s meant Rebecca could receive treatment for free.
“It helped me put a jumbled-up mess into perspective,” Rebecca says. “The therapy put everything everywhere I needed it to be in my life. I’m getting active, I talk to more people, I’m making more friends.”
One Answer to a Growing Problem
Could we be approaching a world where a good deal of adolescent mental health appointments are conducted over video chat? Possibly, says Fritz, the child and adolescent psychiatrist and AACAP president. But that won’t be the cure-all to the crisis of care for children who are mentally ill. He cautions that although telepsychiatry can be an attractive solution for rural children, it doesn’t solve the fact that America desperately needs more child psychiatrists.
Dr. Jennifer McWilliams, child and adolescent psychiatrist at the Children’s Hospital and Medical Center in Omaha, Nebr., concurs. She says about half her patients are now coming to her through telepsychiatry. She notes that “huge swaths” of Nebraska are without any providers at all. “I got into telepsychiatry because it’s one answer to a really, really huge problem. It’s not the answer, it’s just an answer to a huge crisis going on with our mental health care system.”
The legislation introduced by Murphy from Pennsylvania was overwhelmingly approved by the House in early July, with only two Republicans voting against. A similar bill in the Senate, developed by a bipartisan group of senators including Lamar Alexander from Tennessee and Patty Murray from Washington, is out of committee but still awaiting a vote from the full Senate.
Rep. Murphy tells TIME that the lack of psychiatric care for adolescents is particularly troubling because patients entering emergency departments in the midst of a mental health crisis might be heavily sedated or strapped to a bed while they await psychiatric consultation, calling it “pretty Third World in terms of an overcrowded emergency room.” He adds that preventive care through psychiatry and psychology is one way to ensure a patient avoids hospitalization altogether.
“We know now in today’s world that people are very comfortable talking to anybody on a screen,” Murphy adds. “What may have been foreign ten years ago is now common…and now one of those areas in healthcare where a person may be very comfortable.”
Telepsychiatry may also help rewrite some children’s tragic narrative, adds Sorter, the Cincinnati Children’s doctor, by providing access to immediate care so parents don’t give up on trying to find help. One of Sorter’s recent patients suffered from a severe social phobia that caused him to panic if he was separated from his parents. Through telemental health and therapy, the child’s symptoms have eased.
“Now he’s confident, he can separate well, he’s happy,” Sorter says. “That’s one thing about child psychiatry in general, children and family are resilient. This issue of this shortage is critical, because so many kids are needlessly suffering with very painful conditions that are treatable and can improve.”