A National Perspective on Children's Mental Health

A National Perspective on Children’s Mental Health

Gregory K. Fritz, MD Professor of Psychiatry and Behavioral Science Warren Alpert Medical School of Brown University Past President, American Academy of Child and Adolescent Psychiatry

Understanding Hampton Roads Series Hampton Roads Community Foundation Norfolk, VA May 15, 2019

Pediatric Psychiatric Disorders are Common • 21% of children and adolescents age 9 – 17 have a diagnosable mental or addictive disorder  at least minimal impairment • 6-9% have a serious disorder causing significant impairment • 50% of lifetime disorders begin by age 14; 75% by age 24

Pediatric Psychiatric Disorders are Expensive

Pediatric Psychiatric Disorders are Expensive

We should be spending EVEN MORE $ on pediatric psychiatric disorders!

80% of the 6% - 9% of children in the U.S. with serious psychiatric disorders receive NO SERVICES! • Uninsured • Minorities • Rural areas (Merikangas et al, 2010)

3.6 – 5.3 million children and adolescents in the U.S. need treatment and are getting none. Per capita savings – but not absolute savings – are possible with improvement to the healthcare system.

Pediatric Psychiatric Disorders Kill Kids: Suicide

Leading Causes of Death in Young People (2016) 10-14 Yrs

15-24 Yrs

25-34 Yrs

Cause 1

Unintentional Injury

Unintentional Injury

Unintentional Injury

Cause 2

Suicide

Suicide

Suicide

Cause 3

Cancer

Homicide

Homicide

Suicide in Young People is on the Rise Rates of Completed Suicide (per 100,000) Age

2008

2017

% Increase

18-19

9.3

14.6

56%

20-21

12.2

16.5

35%

22-23

13.1

17.4

32%

17.0

19.4

14%

…

50-64

Suicide is the 10th leading cause of death overall in the US, one of only 3

causes that are on the rise.

States with Highest Rates of Adolescent Suicide #1 Alaska ( 4x the national average) #2 Wyoming #3 South Dakota #4 Montana #5 Utah ( 2x the national average) Household Guns: 53% in 10 states with highest rates of youth suicide 20% in 10 states with lowest rates of youth suicide Ethnicity: Highest rates of suicide in Native Americans/Alaskan Natives

Very Young Children Attempt Suicide • 1980’s: 5 yo boy was youngest case in medical literature • Statistics on suicide in very young children were absent • >1,300 suicides in children 5-12 from 1999-2015 (CDC)

Why is Pediatric Mental Health Often Ignored in Healthcare Planning?

• Planners go where the money is: – Adult health care = $2.4 Trillion/yr – Pediatric healthcare = $300 Billion/yr

• Children don’t vote • As adults, we like to romanticize childhood as happy, healthy and trouble-free.

– “Infant mental health”?!?

– Depression in children “impossible” 35 years ago – Inadequate pediatric suicide data until 1990’s

Screening Early InterventionPrevention • Conceptually appealing: – Children’s brains and character are malleable – Nature is working with us – Small problems are easier to fix than big, wellestablished problems – Child development is contextually dependent – Modest investment early avoids massive expenditures later

• Near-term data are consistently positive; long term, quantified impacts of prevention are accruing

Effective, Long-Term Prevention of Adult Antisocial Behavior (Dodge, et al. Am J. Psychiatry, 2015)

RCT of 891 kindergarteners at risk for conduct problems (“early starters”) 10 years of intervention Control • Family & peer interactions • Parenting styles • Social, cognitive development • Education & vocational skills • Drug use prevention

Effective, Long-Term Prevention of Adult Antisocial Behavior: Results At age 25 (8 years after the program ended): • Less adult psychopathology • Less substance abuse • Fewer criminal convictions • Less risky sexual behavior • More effective parenting Economics: • Intervention cost $58,000 per subject • Cost of 1 case of chronic adult criminality ≈ $5.3M (cost of 1 case of adult psychopathology – unknown) Dodge, et al. Am J. Psychiatry, Jan 2015

Why Isn’t the Prevention Approach Applied More Widely in Pediatric Mental Health?

• Mental health professionals (unlike pediatricians) lack a “public health mentality.” Our culture and history are focused on the individual, sometimes family.

• Payers demand short-term payoff for new programs.

Prevention requires investment, delayed gratification.

• Relatively thin evidence base – especially cost/benefit studies • Too few child mental health professionals-> lack of access

Lack of Access to Mental Health Services: Consequences • Excessive misery; children unable to reach potential • Learning, behavioral, emotional deficits carried forward to subsequent developmental stages; impairment is cumulative.

• Treatment delayed until severe emergency (suicidal, dangerous, etc.) precipitates high end services

Lack of Access to Mental Health Services: Consequences • Primary care providers: 2/3 report serious difficulties making referrals • 42%  in use of ER to obtain psychiatric services in recent years • Longer waits: impact on other patients • Frustrated ER staff

• Lack of collateral information  inadequate diagnosis • Excessive reliance on medications, sometimes with inadequate monitoring.

Numbers of Physician Specialists 120,000

100,000

80,000

60,000

40,000

20,000

0

Adult Psych

Child Psych

Total Psych

Intern. Med

Family Med

Peds

OB/Gyn

Anesthesia

AAMC – Physician Specialty Databook, 2014

Psychiatrists as % of US Physician Workforce is Decreasing 8 7

PERCENTAGE

6 5 4 3 2 1 0

1970

1980

1990

2000

2010

National Council for Behavioral Health

Child Psychiatry Positions Filled Through NRMD 300 263

258

# of positions filled

250

275

281

276

272

2010

2011

2012

2013

288

289

291

297

2014

2015

2016

2017

251

200

150

100

50

0 2007

2008

2009

YEAR

Age and Gender of Psychiatric Workforce • Age: % aged 55 or older: • General psychiatrists – 60% • Child and Adolescent psychiatrists – 42%

• Gender: % female: • General psychiatrists – 38% • Child and Adolescent psychiatrists – 51%

Our Current Healthcare System Needs Improvement Among 11 developed nations (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the UK), the U.S. ranked: Health system quality: Last System efficiency: Last Access to care: Last Equity:Last Healthy lives: Last Health Expenditures: First Davis et al (2014)

Despite Problems, Optimism is Reasonable 1. Problems are recognized; debate is vigorous (ACA) 2. Stigma of mental illness has decreased • • •

Media are dealing with it Individuals are demanding services Professionals recognize the importance of psychological issues in all of medicine

3. Parity Law exists; government-sanctioned discrimination against psych. disorders is illegal