No clinician would dispute using the word “crisis” to describe the reality that despite greater public awareness about mental disorders in youth, many young people with severe mental disorders never receive the specialty mental health care they need.
“I think there has been a crisis for some time,” said Robert P. Franks, Ph.D., president and chief executive officer of the Judge Baker Children’s Center (JBCC) in Boston and a member of the American Psychological Association’s Board of Professional Affairs. “Most estimates are that only 20 to 40 percent of kids that need mental health services get them.”
As many as one in five children in the U.S. experience a mental disorder in a given year, according to the Centers for Disease Control and Prevention. The percentage who received treatment in 2008 was 68.9 percent, according to Healthy People 2020, the U.S. Department of Health and Human Services plan launched in 2010 that set health promotion and disease prevention goals for this decade.
One goal is a 10 percent increase in kids receiving treatment by 2020 to 75.8 percent.
So far things look promising. The year 2015 saw the percentage of children who needed mental health services and received them rise to 75.4, according to Substance Abuse and Mental Health Services Administration data.
The figure has been a moving target, rising to 71.6 percent in 2011, dipping to 69.8 in 2012 and then rising again to 70.4 in 2013 and then 70.8 in 2014. (The data show more boys received treatment in 2015, 76.8 percent compared to 73.1 percent. Also, 77.5 percent of white children but only 61.7 percent of black children who needed services were treated).
But the numbers are going in the opposite direction when it comes to reducing the proportion of 12- to 17-year-olds experiencing a major depressive episode in the past year.
Healthy People 2020 sought to reduce the 2008 benchmark of 8.3 youths per 100,000 in this age group to 7.5 by 2020. Instead, the figure was 9.1 in 2012 and continued rising each year to 12.5 in 2015. (A state-level breakdown of this category shows Rhode Island at 13.5 was the only New England state exceeding the national average).
There is also bad news for the goal of reducing suicide attempts by adolescents. The plan sought to decrease attempts from 1.9 per 100,000 in 2009 to a target goal of 1.7. Instead, the rate rose to 2.8 in 2015. (The data is missing reports from more than a dozen states, including Connecticut and Maine).
Franks arrived at Judge Baker in 2014 after serving as vice president of the Child Health & Development Institute in Farmington, Connecticut and director of its Center for Effective Practice, and he knows that numbers involve nuance.
Reducing the Burden on ERs
During the decade he spent working to improve the effectiveness of treatments for children with mental health disorders in Connecticut, he saw how a successful emergency mobile psychiatric services program for kids impacted emergency rooms in the state.
“We had hoped to reduce the burden on our emergency departments,” Frank recalled.
“The great irony was not only did our numbers of contact increase through the emergency mobile psychiatric service system, but at the same time, they also increased in the emergency department. We were actually discovering a new population of kids. Instead of relieving the burden, we were identifying additional children that needed help and services.”
Integrating behavioral health care into primary care settings has helped to link more kids with services as pediatricians now screen for mental health concerns and prescribe stimulants and antidepressants. But that doesn’t mean outpatient specialty mental health clinics see fewer referrals as a result.
“We still have way more referrals than we can handle and we have a desperate need for more support for clinician time,” said Cambridge Health Alliance Child & Adolescent Outpatient Psychiatry Medical Director Nicolas Carson, M.D., FRCPC.
Many of the children he works with in the Massachusetts health system with sites in Cambridge, Somerville and Boston’s metro-north communities have experienced some kind of trauma and he also treats a mix of young patients with autism, ADHD, anxiety and depression.
“Therapy is often the bottleneck,” Carson said. “They need a few months at least to do good work with children.”
Cambridge Health Alliance serves communities where large numbers of immigrants from Brazil, Central America and the Caribbean. The need for interpreter services can slow down an already frustrating wait to see a clinician, Carson said.
“I’d say it’s not uncommon for families to have to wait a few months to be able to get in to see someone, especially if they don’t speak English. Trying to find therapists who speak Portuguese or Spanish or Haitian Creole, it’s much harder to find providers,” Carson added.
Inequities in Care
A health services researcher for the Health Equity Research Lab and the Center for Multicultural Mental Health Research, Carson studies inequities in mental health care and works on solutions to help the mental health of youth and families. He and colleagues have consistently found that minority youth are much less likely to get recognized, referred to and start mental health treatment than whites.
“Once they get into treatment, the rates of use are pretty comparable,” Carson said. “I think that work needs to be done in helping to identify these youth in the community and presenting treatment in a way that works for them.”
The most frequently reported diagnoses for girls aged 17 and younger in 2015 were depressive disorders (22 percent) followed by adjustment disorders (20 percent) and anxiety disorders (18 percent), according to SAMHSA’s “Mental Health Annual Report 2015.”
For boys during the same reporting year, the most prevalent diagnoses were ADD/ADHD (27 percent) followed by adjustment disorders (15 percent) and anxiety disorders (12 percent.)
The good news, both Carson and Franks say, is that there are many high quality interventions that have been demonstrated to work and that more children and families are gaining access to these services.
“I often use the example that earlier in my career, I remember seeing children who’d experienced acute trauma or loss for years sometimes with minimum symptom abatement and now using evidence-based approaches, we can see these kids restored to full functioning in five to six months and we actually see those gains sustained over time,” Franks said.