Where have all the psychiatrists gone?

By Michelle Crouch

The Charlotte Ledger/ NC Health News

When a South Charlotte mom was looking for a psychiatrist to prescribe medication for her teenage daughter’s depression last year, she described sitting with her phone and going down the list of doctors listed as in network with her insurance company.

Some weren’t taking new patients. Others never returned her messages. And a few said their first appointment was months away. 

After more than 25 calls, she finally found a practice able to schedule an appointment for her daughter that month. 

“It’s frightening because I was so in fear for my daughter,” said the mom, who asked to remain anonymous to protect her daughter’s privacy. “I needed the process to start as soon as possible, and the constant answer was wait, wait and wait.” 

In the midst of an undeniable teen mental health crisis — with soaring rates of anxiety, depression and suicide — a dramatic shortage of psychiatrists in North Carolina and across the country is making it harder for children to get the treatment they need before they go into crisis.  

The problem stems largely from an aging workforce and the relatively low pay psychiatrists receive — far less than other doctors. It’s contributing to the surge of adolescents with mental health problems landing in hospital emergency rooms, where they sometimes wait for days or weeks for an available bed at an inpatient psychiatric facility. 

“People just have to wait too long to see a psychiatrist,” said Kelly Crosbie, director of the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services. “Children are ending up in the emergency room because they weren’t able to see a psychiatrist either in a timely fashion – or at all. And that’s not just in rural areas. We’re seeing it across the state.”

‘Severe shortage’ of child psychiatrists

Psychologists, licensed counselors and other behavioral health providers are also in short supply, but psychiatrists — who are medical doctors — can prescribe medicine. They are also the most qualified to diagnose complex problems and tailor psychiatric medications to stabilize a mental health condition. 

If the patient is under age 18, what they really require is a child and adolescent psychiatrist — a doctor who specializes in children’s mental health. North Carolina has only 354 of them across the state, about 15 per 100,000 children — a rate that puts the state at a “severe shortage,” according to the American Academy of Child & Adolescent Psychiatry. 

Credit: American Academy of Child & Adolescent Psychiatry

The psychiatrist shortage isn’t new, but it has been exacerbated by an explosion in demand from kids with mental health problems coming out of the pandemic. Forty-three percent of high school students in North Carolina reported feeling sad or hopeless in 2021, up from 29 percent in 2017. And more than one in five seriously considered suicide, according to the 2021 Youth Risk Behavior Survey. 

Alyson Kuroski-Mazzei, CEO and chief medical officer at HopeWay Psychiatry & Associates in Charlotte, said the practice has been overwhelmed with calls since the pandemic. 

“We can’t keep up,” she said. “The number of calls has skyrocketed to the point where we are hiring more admissions staff to help decrease the call log.”  

No choice but to go to the E.R.

Amanda McGough, a psychologist who works with teenagers at Find your Base in Charlotte, said when a client can’t get an appointment with a psychiatrist, sometimes she doesn’t have a choice but to recommend they head to the E.R. 

“Sometimes, pediatricians can bridge the gap,” she said. “But as things get complicated, if there is more going on and multiple layers present, or if your symptoms are negatively impacting your life in more significant ways, you need a psychiatrist. That’s a time as a therapist when I’ll say, ‘Let’s have you go to the E.R., be assessed by a psychiatrist and see if it’s appropriate to start medication now.’”

The lack of psychiatrists isn’t just sending kids to the E.R. It’s also part of the reason they get stuck there, waiting for a spot at an inpatient psychiatric facility.

The state can’t retain enough psychiatrists and other behavioral health workers to fully staff those facilities, so beds are sitting empty, Crosbie said.

“When we can’t fill [staffing] vacancies, we’ve got to actually close beds,” she said. 

In August, about a third of the state’s psychiatric beds weren’t being used because of staff shortages, according to the state Department of Health and Human Services. 

Some counties have no psychiatrists

In rural parts of North Carolina, the situation is even more dire. Twenty-two North Carolina counties have no psychiatrists who list those locations for their primary practice. Sixty-eight counties lack a child psychiatrist, according to the UNC Sheps Center health professions data system. 

“We’ve got so many people in rural North Carolina that don’t have access to anyone,” said state Sen. Jim Burgin (R-Angier), chair of the Senate health and health appropriations committees. “I get calls from people every week. One of the big problems is, we can’t get kids assessed so we can go ahead and start treating them. By not doing that, their cases get much more complicated.”  

Burgin has introduced several measures at the General Assembly to address the shortage in recent years. This legislative session, he hopes to get approval for his idea to fund a program to cover a significant chunk of a new psychiatrist’s medical school debt if they commit to work in a rural North Carolina county for five years. 

He said he is optimistic that money for the program will be included in this year’s state budget, which is expected to be finalized this month. 

Why aren’t there more psychiatrists?

Psychiatry has long been one of the lowest-paid medical specialties. 

Although federal law technically requires mental health care to be paid on par with other types of health care, studies show psychiatrists receive significantly lower reimbursement rates from insurers than doctors who focus on physical health, said Robin Huffman, executive director of the North Carolina Psychiatric Association. 

Moreover, North Carolina has not increased Medicaid rates for psychiatric care since 2012, giving psychiatrists little incentive to enroll. (Boosting the rate is another change some lawmakers hope will be in the final state budget.)

In August, NCDHHS Secretary Kody Kinsley said that 40 percent of psychiatrists in North Carolina are “cash only,” meaning they don’t accept private or government insurance.  

“It is not just that we don’t have enough psychiatrists, it is that we have a lot of psychiatrists that are not engaging in the public system for behavioral health,” he said.

And it’s not just Medicaid and Medicare rates for mental health treatment that need to increase, Kinsley said.

He cited recent data showing that private insurance pays for behavioral health services at a rate that’s only 70 percent of what the government’s Medicare pays for the same care. He also noted that for physical health care, private insurance pays better than the Medicare rate.

“You get what you pay for,” he concluded.

Brianna Lombardi, director of the Behavioral Health Workforce Research Center at the UNC School of Medicine, said transitioning to self-pay allows psychiatrists to charge a rate closer to what they think their time is worth. 

In addition, she said, “everyone is burnt out and stressed, and (opting out of insurance) is one less administrative burden for them.”

With many psychiatrists charging hourly fees ranging from $100 to $300, the shift puts this specialized care further out of reach for many families. 

More training for less money

For child psychiatrists, the financial incentives are dispiriting. The specialty requires at least one extra year of training, yet in many cases, the pay is lower than that of general psychiatrists, according to Gary Maslow, a child and adolescent psychiatrist and a pediatrician at Duke University Hospital.

The reasons behind that are manifold. It’s partly because facilities that focus on kids generally don’t pay as well as those that treat adults, Maslow said. And children often get paid for by Medicaid, the state and federally backed health program that covers more than half of North Carolina’s children. Medicaid makes it so the pay is markedly less for the same work compared to adult psychiatry, Maslow said.

It’s also because treating a child is more complex and time-consuming than treating an adult — while in many cases, the reimbursement rate is the same, said John Nicholls, a child and adolescent psychiatrist who is medical director for psychiatry at the Mountain Area Health Education Center in Asheville. 

For example, he said, a typical new patient intake for a child might include seeing the parents and the child together, seeing the child alone, seeing the parents alone and then bringing everyone together, Nicholls said. “Contrast that with assessing an adult,” he said, “when you’re often only speaking to that one person. In child psychiatry, we always treat a family system.” 

Pediatricians, primary care doctors fill the gap

With psychiatrists so hard to access, many parents turn to pediatricians or primary care providers to prescribe psychiatric medications for their children.

A 2018 analysis by Duke University researchers found that only 14 percent of North Carolina children on Medicaid receiving psychiatric prescriptions were being treated by a child psychiatrist. Others had their medications prescribed by family practice doctors, pediatricians, adult psychiatrists, physician’s assistants or advanced practice nurses.

That can lead to some adolescents with mental health problems getting the wrong diagnosis or treatments, said Maslow, whose team conducted the research. 

“If someone with no training in pediatrics takes what they know about adults and applies it to children, you can end up with a misdiagnosis or inappropriate treatment,” he said. “We see it all the time. Then there’s the opportunity cost: if more kids actually had access to the right diagnostics and the right treatment, they could get better.” 

Crosbie and Maslow pointed to several initiatives the state has launched to provide more support to providers who are filling the gap:

• Hotline for doctors: The North Carolina Psychiatry Access Line (NC-PAL) is a phone number that pediatricians and other health care providers can call to consult with a child psychiatrist in real time. More than 1,000 providers called the number last year. 

• Weekend trainings: DHHS offers weekend-long programs in behavioral health for primary care providers through a program called REACH PPP. “It doesn’t make you a child psychiatrist, but it makes you much better equipped and informed and competent,” Crosbie said. “We’re trying to extend the workforce.”

• Collaborative care model: DHHS encourages psychiatrists and primary care doctors to work together through a model called “collaborative care,” in which an off-site psychiatric consultant regularly reviews patient files and provides advice to a primary care office. It’s an evidence-based way to improve access to care, Crosbie said, and in 2022 N.C. Medicaid agreed to cover it. 

More psychiatrists in the pipeline

In some good news, a growing number of medical students at the national level are matching into psychiatry residency programs. And North Carolina has doubled its number of psychiatry residency programs in recent years, with new programs at MAHEC, Cape Fear Valley, Atrium Health, Cone Health and Novant Health.

“What we’ve discovered is, if we can keep medical students here in North Carolina for their residency, we stand a far greater chance of keeping them here practicing in the future,” Huffman said. 

The program in Charlotte, through Atrium Health and Wake Forest University, launched in 2017. It currently accepts five residents a year, but the hospital plans to grow the program to at least 24 residents and add fellowships, including a child-and-adolescent one, according to James Rachal, chair of the department of psychiatry for Wake Forest University–Charlotte region. 

In an email response to questions, Rachal said the program aims to increase access to care because Mecklenburg County has only 38 percent of the psychiatric prescribers needed to serve the region, and many don’t take Medicare, Medicaid or private insurance as payment. 

The South Charlotte mom who called the 25 psychiatrists knows that firsthand. She said when she sat in the waiting room while her daughter saw the doctor, she was often reminded of how lucky she was. 

“I would see panicked parents come in and get turned away. They would beg at the front desk for an appointment,” the mom said. “I would sit there and just think to myself, we really need more resources.” 

This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting focused on the Charlotte area. For more information, or to support this effort with a tax-free gift, click here.

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