Virginia’s Mental Health Reform Effort

In a recent editorial, the Virginia News & Advance newspaper published on May 29, 2016, entitled “Trying to Remake State’s Mental Health System,” Virginia’s commendable mental health reform efforts were enumerated in a concise fashion. Virginia’s efforts are somewhat unique in the country’s landscape concerning this issue which now dominating many American state legislatures.

Virginia’s efforts, similar to a few others states’ efforts, have been singularly prompted by a highly publicized tragedy, that of the death of a young adult, Gus Deeds. What is very different is that his father is a mental health professional, and a Virginia state legislator.

This young man while psychotic  tried to stab the father, Craige Deeds. He was held in a local hospital emergency room for several days while awaiting a referral and placement in either a private or public state psychiatric hospital. There was no bed to be had and he was released a few days later. Shortly thereafter, he suicided. His father, state senator Deeds Ph.D. has made this a personal and public service legislative cause and mission to author and see enacted to address the deficits in Virginia’s mental health system to prevent another tragedy.

State Senator Deeds’ efforts have been very well placed and appropriate. However, even he has had difficulty in seeing this well crafted and reasonable legislation passed as the above-cited editorial, unfortunately points out. This is emblematic of many state’s efforts. The limiting factors are budgetary and many state legislatures, governors, and legislators are finding it very hard to find and devote the long needed monies to mental health reform. Some states have made creditable progress such as my home and practice state of North Carolina. But it remains quite hard to address the funding issues in many states that have permitted the development of state mental health system crises that we see presently almost everywhere. One can only hope that these difficulties can be overcome as efforts continue.

 

Colorado Has Same State Wide Problem

A very recent article, Colorado Still Lacks Inpatient Psychiatric Care by Ms. Elizabeth Drew published May 10, 2016 documents the same kinds of problems with psychiatric acute inpatient treatment resources that many other states have faced around the USA for the last 15 to 20 years.

Ms. Drew highlights the backdrop that started the mental health reform effort in Colorado so suddenly and starkly. Colorado suffered the misfortune to have the two double tragedies of mass shootings, the Columbine High School tragedy a number of years ago and the more recent Aurora CO theater shootings of 2012 committed by the then clearly psychotic James Holmes, whose trial riveted the nation. The James Holmes shooting caused a huge outcry from the public in that state for major and thoroughgoing changes in mental health services’ delivery.

Colorado has closed two state hospitals due to aging facilities being shut down and not being replaced. Colorado ranks now well below the current statistical average of 14 or so (13.9 in the previous blog posting’s article) per 100,000 beds for public inpatient psychiatric care in the state. Like many other states, its public mental health system has suffered greatly in the past two decades with inadequate funding and lack of growth of services commensurate with its higher than national average population growth. And like many other states, tragedies have begun to ramp up in severity, frequency and publicity as the “chickens have come home to roost.”

This article describes the very ambitious and quite rapid changes in point of fact, that Colorado put into place just last year, only about three years or so after the Aurora theater shooting. A massive state-wide system of acute outpatient crisis centers and much more rapid access to mental health contact, screenings and referrals to treatment resources was put in place. This clearly had a positive effect. Admirably, Colorado has begun a serious open effort to evaluate only one year into the operation of its new system. The results have been mixed and no matter what criticisms or kudos one may choose to endorse. Colorado, in my opinion as a long-time observer of mental health reform efforts nationwide, had commendable courage to permit and undertake this open review process. This review effort, documented in Ms. Drew’s article appears to show two results if I may condense and categorize them: 1) positive results in the delivery of acute mostly outpatient services, and 2) the common bugaboo of the yet unaddressed shortage of acute inpatient hospital beds seen now almost everywhere. Ms. Drew succinctly summarizes the reasons for this as relating to loss and closure of state hospital psychiatric beds and facilities, and,  inadequate funding at the state and federal levels of the riddle of the expense of inpatient psychiatric hospital based treatment. [In a coming post I will try my psychiatric hand at explaining why inpatient psychiatric treatment is always expensive].

In  coming posts,  I will try my psychiatric hand at enumerating other issues common to all states beyond hospital beds that make the current mental health delivery crisis so severe. These issues will include the shortage of mental health professionals especially psychiatrists and the history of some more discrete and largely unknown to the public, mental health training fund losses that have caused our current severe practitioner shortages.

 

Criminal Discharges When There Is No Outpatient Infrastructure

This subject and set of events is dated, and I offer my apologies to the reader. But this offering will serve to remind what can go wrong when in the course of the mental health reform process, things can go very wrong when the health care sector succumbs to criminal insufficiencies in their immediate continuum of care system, gives in ethically to a dishonest set of circumstances, does not fight back and falls back upon devising equally criminal ways of coping and inventiveness instead of advocating at any cost for their powerless patients who are dependent upon them for everything and anything they need to start over and begin the recovery process outside life in the  hospital.

Over two years ago the Los Angles Times reported on a story that I thought I would never see again in my practicing lifetime, that of “dumping patients.” I practiced in Arizonaover 15 years ago and saw the now extinct Charter hospitals do this when a patient’s health insurances would be exhausted after a month or long stay in the free-standing hospital and then be “discharged to the street” literally and abruptly. I was witness to this process as our hosptal system having a rather compassionate approach to psychiatric care would willingly accept these unfortunate and truly traumatized persons when their desperate families brought to our admission doorsteps, those of the Camelback hospitals, once a group of psychiatric hospitals in the Phoenix and Scottsdale areas, started in the 1940’s and in the days of affordable psychiatric healthcare, a nationally recognized system for its superb quality of care. These dumped persons from  the for-profit hospitals, still suffering acute symptoms such as severe unremitting depressions, suicidal impulses or pressing urges and thoughts, would be admitted no questions asked–at a loss to the hospital and to us attendings who took them on as inpatients, not expecting to be paid at all, and saw this as part of our responsibilities and part of universe of care we should offer out of our senses of service and ethics. I saw no practitioner at the Camelback system of hospitals ever turn down such a patient or take on their care resentfully.

The process of discharge in modern inpatients psychiatric care literally begins with a day or two of admission, not so that we can hurry up the process, but so that we can get a head start in lining up the needed outpatient resources, financial support, sometimes a place to live for a homeless person, sometimes family resources for a homeless minor, but always for a “best fit” between the patient and the all important team of team of therapist and psychiatrist. Often during the patient’s inpatient “do-over,” we would have the prospective therapist and future psychiatric come to visit the patient in person to have a get-acquainted session to make sure there was a good personality fit and rapport among them all, thereby giving often these persons brutalized by the “for profit” systems genuine hope that after discharge, whenver all arrived at a consensus decision made together, there would be the help ready in place to support them, giving them genuine hope instead of another trauma.

The article I came across recently in my constantly Google searchbot curating system for developments and trends inthe massive nationwide effort at changing our mental health care delivery system for all for the better was in the Los Angeles Times, entitled “S.F. sues to recoup costs for patients ‘dumped’ by Nevada hospital,” published ‘way back” in September 10, 2013. Its dated historical time of occurrence does not make it any less timely and happens to follow up on my previous post, which documented the emerging and alleged corruption of a privatized (read also for profit but sanctioned by the state who handled over inpatient psychiatric care to a national money making hospital system, to deliver service and make profit like the experiment with privatization of state prison systems who crowed about saving money to state legislatures, and of course pocketing the difference.) Well that did not go so well in a number of instances and the practice is still be re-examined in states who went in this direction.

The LA Times article though documented simply horrendous new heights of patient care callousness in patients at hospitals in Nevada, at discharge, from the Rawson-Neal Psychiatric Hospital in Las Vegas, often by bus with no resources, not provision at all for any outpatient care or personnel to San Francisco. The investigation by the newspaper the Sacremento Bee, started small but uncovered a scam/scandal of monstrous proportions and scale. It was found that about FIFTEEN HUNDRED patients had been shipped off to cities and towns in California over the previous five years. The investigation at that time was headed up by San Francisco City Attorney Dennis Herrera.

Those days were a unique confluence of corporate greed, and the growing appearance in the 1980’s of the seeds of the crisis we now face: the national shortage of adequate outpatient resources to replace which that hospital, especially the state public psychiatric hospitals could furnish even if at times, it bordered on “institutionalization.”

The solution is obvious and in everyone’s sight and radar. Outpatient resources and its infrastructure must be constructed nationwide, and governors and the no more taxes ideology of the present day and last 0 years must confront the reality that this costs money. Period. Good luck all you politicians trapped by your ideologies that do not square with reality. You need a paradigm shift in the biggest way and it will painful for your as you have to rethink your dearly held assumptions and shibboleths.

 

 

Oklahoma Joins List of “Distressed” Mental Health States

Approximately 3 weeks ago I read one of the most distressing that most informative articles I have seen in over 20 years. It was published in the Oklahoma City newspaper on January 2, 2015 and written by Jaclyn Cosgrove. It was entitled “‘Epidemic ignored’: Oklahoma treats its mental health system without care.” It was described as: “a yearlong investigation into Oklahoma’s mental health system.’

It had the usual now almost obligatory saddened startling photographs of dilapidated antiquated hospital facilities with patients in threadbare clothing without shoes crowded into dining halls or sitting hopelessly in empty hallways.

Much more startling to me the reader of such articles now spanning nearly 30 years since I have made it special interest of mine, were reading quotes from legislators, treatment advocates, and mental health professionals from time periods ranging from 40 to 100 years ago. The statements that were discovered and published in this article were quite riveting and unsettling because they could have been uttered in the last few years and without there being identified in the context of the years long past when they were first uttered, I would’ve had no idea if these were statements made by people long deceased. It was like reading the history of our present dilemma in mental health care system delivery and its failures nationwide, that existed in a parallel almost identical universe of similar mistakes, failures to adequately fund mental health programs, many of whom had forms and objectives and methods similar to the “new” massive programmatic renovations proposed in almost all states in this country today

For instance in 1895 the governor at that time of Oklahoma William C Renfro began proposing a novel idea that residents should be treated for their mental illness closer to their homes. This arose out of the unbelievable practice in that time in Oklahoma when the territory was sending mentally ill residents away by train to the state of Illinois. A second example is the fact that this newspaper article reported, “almost 80 years ago, the national mental hospital survey committee published a report that noted that air Oklahoma would save money if it invested in its mental health system.’ Whatever the future may bring,’ the report concluded,’ Oklahoma cannot look on itself with pride until provision is made for adequate care of its mentally helpless citizens. The year of that statement was 1937. It was recognized even then that the few state-funded inpatient hospitals then supported by the state of Oklahoma were only the first part of the treatment continuum that had to include community placement for the chronically mentally ill
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One of the fundamental hypotheses of this newspaper article was that Oklahoma has been far behind in most other states in this country in providing mental health services. For instance the news purple article noted that in the year is surrounding World War II, Oklahoma had one of the worst doctor to patient ratios ranking it number 43 in the United States for care of the mentally ill. One other telling statistic was cited that each of the doctors at Central State Hospital in approximately 1947 had a caseload of 700 people, one of the highest psychiatric physician caseloads in the United States. It also had one nurse for every 45 patients in the hospital. The problems with safety of the psychiatric hospitals and facilities began very early in the history of treatment of the mentally ill in Oklahoma. For instance Western State Hospital at Fort Supply was overcrowded by nearly 500 patients and had building buildings which had already by the 1880s been repeatedly condemned by fire marshals as fire hazards and there were only four doctors to treat 1603 patients and no nurses or social worker

This is the historical backdrop to the looming mental health serivce crisis in Oklahoma today. This beginning examination of the mental health crisis in Oklahoma will be examined further in the coming weeks in a series of posts that will sketch the usual elements that have already beeen seen to operate in so many other states the last 20 years. These all too well known factors include: economic shortfalls in the state’s budget that suddenly jeopardize everything except football program at the state universities, poor foresight and plannnining, shortage of mental health professionals and delaying for still years the easy to have been seen to explore still further the outpatient agenices, facilities, physicial plants and staff cohorts of the world of public outpatient mental health services.

Further I will go on to document in following posts the same kind of story in another state with very unique twists and hardships of its own in meeting lesser mental health care needs in that state, Alaska which is slowly grinding toward a large crisis of its own.

 

 

 

Private Psychiatric Sector is Re-Awakening

One of the unspoken “white elephant in the room’ disturbing trends in the long slow 20 year disintegration of intensive, vitally needed, inpatient, hospital based psychiatric care delivery system has been the inexorable closure of beds everywhere. I do not honestly know that statistics of the percentage of private psychiatric beds that have closed since the early 1990’s when the trend accelerated, but it has been very substantial.

As they say in trite stories designed to bore the listener, “it all began in…”  the early 1990’s when the bandit organization called Charter Hospitals [read the book BEDLAM by New York Times long time investigative reporter who is still writing, Mr. Joe Sharkey, for an expose of how a few national private for profit psychiatric mills like Charter operated in those days. Instead of “pump and dump,” those outfits operated on the financial principal of “vacuum and dump,” meaning keep the patient inpatient till their insurance benefits ran out, and then arrange a discharge–quickly. Charter went bankrupt as most of us ethical practitioners knew it eventually would in the early 1990’s. In the few other locales that I have practiced, other than Durham NC and western North Carolina, I always knew the refrain “never have Charter on your CV.” Among ethical practitioners it was a blight. I recall a  personal incident where in one pra1930e Southwestern resident sister, did much more than I could to help them, I was approach my first week in my relocated and family driven need to work there, by a Charter “professional relations representative.” He came at the end of my long working days in the evening hours and was obviously irritated at having to wait so long as he was not accustomed to shrinks who worked past 6 p.m. I was puzzled as he carried a brand new bag of a complete set of golf clubs.{Disclaimer: I do NOT play golf]. He started his preamble and then launched into his pitch that I would be deserving of a shady sounding financial arrangement if I referred inpatients to the two then local Charter facilities. I would also be given an all expenses cruise for my wife and myself and have my staff credentials all done in a week or so. As it dawned on me nature of the arrangements being offered me and their inherent dishonesty, my Texas temper began to boil. Knowing me from years of analysis I knew I had to keep it under control or I would repeat my father’s mining engineering WWII approach to leadership in the mines he oversaw when I was growing up: throw the guy THROUGH the wall [my father was a true giant of of a man and one of the true “Four Horseman of Texas” high school football named after the Four Horseman of Notre Dame. I remember exercizing every bit of self control I ad and coldly as possibly with the most moral opprobrium, I could muster, telling him in civil but no uncertain terms to “get out” and take his bribes with him. I remember he was flabbergasted, never expecting than any greedy practitioner would turn down such a wonderful offer. As a final addendum, there was a salary offer couched in all this that would supplemented by an undisclosed sum with every referral. Such were the operations of Charter and at least some other national psychiatric chains, such as “NME” written about by Joe Sharkey.

But the bad news about Charter cratering all in a week or two in the 1991 or so [that year may wrong] was than a few thousand private psychiatric beds were lost the country over. And that started the trend of private psychiatric beds closing and private units downsizing all over the country as the reimbursements from private insurance companies cratered also. And that is the largely forgotten co-contributing cause to our present day mental health care crisis.

My next blog post in a week or two, I hope will address that legislation moving through Congress that will seek t redress the coverage inequities that still plague private hospitals who still, God Bless Their Souls, who operate inpatient psychiatric units. They ALL do so at a loss. Like a loss leader at a grocery store except in health care you cannot refer every psych inpatient for expensive surgery and make up the loss like you can at the steak counter in a grocery store. These hospitals do so out a sense of mission to the communities and because nobody else will.

But finally the psychiatric, bean counter, local legislative world is waking up partly due to the overcrowding of jails everywhere with the severely mentally ill who cost gobs of money to house, care for and treat well enough to retain accreditation of correctional review bodies, the rise of the mentally ill homeless even in small towns, as they said in the old movie “The Music Man,” ‘right here in River City! And the never ending now weekly spate of mass shootings at least enough of which are perpetrated by a particular brand of mentally ill for the most part that is fast becoming the shameful distinguishing news feature of American around the world. But debate is for another post…

A recent article, “Centra applies to add beds to psychiatric unit at Virgina Baptist,” in Lynchburg VA, published at NewsAdvance.com, is a good example of a relatively novel and much needed trend in the slow turn-around in the re-construction of mental health care in this country. Centra Health, a private hospital holding corporation is doing what I hope and assume is a brave thing, entering into the world of inpatient psychiatric care, likely in the hopes of better things, i.e., financial support, to come. Wake up Congress, this effort starting to happen elsewhere is bourne of desperation as states and local regional health care entities try to start filling a gap that is now upon us that imperils us and patients in many ways. I am not a dyed in the wool free market Republican but this is an example the market doing the right thing, seeing a need, and entering to fill it. But it needs support at a large level. And attention legislators: IT IS GOING TO COST REAL MONEY.

Centra hopes to add 8 to its existing psychiatric 37 beds which is impressive. It is clear from the article they saw the need locally and responded.

And why did this happen? Ask State Senator Craige Deeds now well known to the nation as one of our most well placed mental health advocates, whose son Gus suffered the ultimate price of unavailability of local mental health care too late, suicide, after having stabbing his father nearly two years and highlighting in a personally tragic way our current mental health care delivery crisis plight.

The answer is simply that states across the country since the 1990’s have sought to save monies in the multiple economic bubble  busts, and recession, by slashing mental health budgets, closing state hospital psychiatric beds and neglecting the decades long disparities in mental health insurance reimbursement that have drive the private psychiatric care sector into a shadow of its former self nationally. My own training university, a powerhouse and truly deserving prestigious care and research organization, now has far fewer private inpatient psychiatric beds than when I trained there in the 1970’s and depends upon a local private hospital with a far larger private psychiatric inpatient service to meet those needs. Most of the university’s now few inpatient psychiatric beds are funded by research grants and funds that is the reality facing many such prestigious university medical centers that one would assume are rich and powerful beyond belief. Not so anymore.

More to come on this topic soon.

 

Shift of Mental Health Care to Jails

Once again the author finds himself balefully writing about the continuing appalling trends in mental health inpatient care nationally. However, I am moved to do only when I see a very good reference that I feel the reader interested in this vital topic, should be alerted to.

A recent article in the news blog, Vindy.com of November 24th, 2015 showed that it does not take a nationally prestigious paper or news sources to put out a superb summary and analysis of a subject pertinent to this topic. In an article entitled, “Mental health care in Ohio shifts from hospitals to jails,” written by Peter H. Milliken [milliken@vindy.com] in Youngstown Ohio, the issues were as clearly spelled out as I have ever seen.

That author started that “”in the past five decades, state-run psychiatric hospitals have been phased out with funds shifted into each community cereate outpatient care and support services for those afflicted with any of a number of mental illnesses.” He adds tellingly: “As in all complicated cases, the result has been a complicated stream of causes and effects,” and I would add ‘unintended effects’ that have marked ill conceived mental health reform efforts nationwide over the last 15-20 years. The three basic mistakes were 1) way too rapid closing of albeit aging state mental health hospitals and beds, 2) grossly inadequate replacement of those inpatient beds, the thinking being in the minds of frankly ignorant and misinformed ideology on the part of state level mental health planners and legislators, that the beds were not needed and should be “liberated” [my term] bourne out of the “de-institutionalization” misguided ideology arising in the 1950’s and 1960’s, and 3) the totally insufficient of funds to cover the community based needs as a result of the closure of inpatient, BOTH public and private.

The author gives an example of a state hospital closing 19 years before, the Woodside Hospital, and its surrounding county gradually absorbing what sounds like an inordinate number of extreme mental patients who had no place else to go. He states tellingly, “We’re in a crisis for state hospitals,…we have days when there are no hospital beds for our clients,” quoting Duane Piccririlli, executive director of Mahoning County, whose jail had to pick up the slack.

The article goes on to describe what happened in stark broad overview terms. The state of Ohio previously had 19 state hospitals but now has only six. Patient shifting as it is sometimes, called has occurred in  a massive way from non-existent state hospital beds to jail beds. And it costs the state more in most studies to house such patients in jails than even so called “expensive” or “labor intensive care,” and the care if far poorer and more and more marked by preventable tragedies.

 

 

More States Paying the Price of Cuts

One of the sadly recurring, and enduring themes of so-called “mental health reform” in this country,  is the inevitability of a number of problems as state hospital beds are foolishly cut in this country and staff positions are cut as well.

Continue reading “More States Paying the Price of Cuts”

The Difficulties of Funding Improved Delivery of Mental Health Care

Today, September 22, 2015, the Raleigh News and Observer newspaper revealed and published some very disheartening and totally surprising news that illustrates yet another dilemma in the ever more difficult tasks in improving mental health care public services in this state, and, likely reflects the kinds of dilemmas that other states are and will be struggling with in facing up to their obligations in this area. The article is entitled: “NC budget cuts $110 million from regional mental health,” and can be read here.

Continue reading “The Difficulties of Funding Improved Delivery of Mental Health Care”

Contrarian Thoughts on the State Mental Hospital System: We Still Need Them

The state hospital system in this country began as an attempt in various of the early 13 colonies and later the early states as humane, for the most part, attempts to house the mentally ill. Williamsburg VA, now the site of Eastern Virginia State Hospital and a  similar facility established by the Quakers in Philadelphia were two of the earliest efforts. There was no effective treatment until the advent of ECT (electroconvulsive therapy in the 1940’s and 1050’s with its own then shortcomings and crude, barbaric techniques till refined later, and the advent of psychiatric medications starting with Thorazine, Valium Elavil etc., in the 1950’s.

By this time even the best efforts of Clifford Beers a man who had recurrent psychotic mental illness and wrote in the early 1900’s the first widely read autobiographical account of his onw psychosis which was a national sensation as it described basically for the first time for the public, the pain of being mentally ill, and Dorothea Dix the great crusader for the mentally ill the lattter half of the 1800’s, fell short of preventing the average state hospital from turning into a facility for containment, incarcertion, etc., of the mentally ill. The famous book ASYLUM was published in the fifties and cranked up the debate over “institutionalization” and debasing treatment of the patients in the average state hospital. This fueled, the movement to get patients out of state hospitals, then beginning to be thought of as cruel institutions and less as places of possible treatment or early rehabilitation. This book came on the national scene at the “right” time, caught the attention of the public, politicians, advocates and helped to state the partial dismantling of state hospitals nearly every where. Bed numbers were reduced from averages of a few thousand beds per hospital, as many state hospitals were indeed massive. Smaller was thought to be better and bed numbers through the second half of the 20th century over time came down to the hundreds. And this does not include the dozens of institutions that were outright closed, because of revelations of abuse, mistreatment, no treatment, subhuman conditions, and “warehousing.” The Comprehensive Mental Health Center Act of 1963 was enacted as one of the last major pieces of legislation of the JFK Presidency. Smaller treatment-oriented facilities were to be built all over the country by the hundreds, often to be linked up with major medical centers. One of the earliest community psychiatric hospitals so built was Marshall I. Pickens Hospital in Greenville SC next to Greenville Memorial Hospital. They both still exist today; GMH is the major teaching hospital because of its size and faculty, of the University of South Carolina at Columbia. The opening of Marshall Pickens Hospital was graced by the presence of no less than Hubert Humphrey in the early years of Lyndon Johnson’s administration after the assassination of President Kennedy.

Continue reading “Contrarian Thoughts on the State Mental Hospital System: We Still Need Them”

Maldistribution and Shortage of Psychiatrists and Child Psychiatrists

This is a reprise of a recent post on my other site “Pen and Psychiatrist.” I apologize to the the reader if you have already read this topic at the other site which deals in more cultural and social issues. But after I posted that entry not too long ago, I realized it more properly belonged on this site, since it deals with one aspect of the mental health reform puzzle in this country.

In my previous life some two decades ago as a young Turk clinical teaching and supervising faculty of psychiatric and child psychiatric residents and fellows in training at Duke Medical Center, I became interested in “manpower” (the vernacular then) or more properly speaking practitioner distribution and training issues of psychiatrists. This was in the so called Golden Age of mental health practice, even though the service delivery system in all disciplines, had serious issues, I and many many others could see the troublesome issue of maldistribution of mental health care professionals that was emerging three decades ago and worsening  year by year. Basically what was evolving was a situation in which desirable places to live, urban areas with urban amenities such as the symphonies, ballet and performing arts companies, university centers, and above all many colleagues around for support and lively continuing education meetings of regional psychology, social work and psychiatry societies, kept graduates of advanced training programs in the regions in which they trained. So over time, it evolved that areas like Boston/Cambridge MA, Raleigh-Durham-Chapel Hill NC (the Triangle Area), Ann Arbor MI, Dartmouth, New York City especially Manhattan, Stony Brooke, Long Island, Houston, Los Angeles, San Francisco, Seattle, Eugene OR, San Diego, Davis CA, Charleston SC, Atlanta GA, Birmingham AL, Albuquerque, Tucson AZ, and many other urban areas became the landing places where psychiatrists trained and often stayed to practice, in the university medical center cities. A good friend and colleague, now passed on Bruce Neeley MD of Duke and Emery, used to give lectures to residents nearing the penultimate stages of their training careers and were a year away from the decision of where to settle to practice. By then the 1980’s the trend had become set in concrete, only a minority of graduating psychiatrists left the training centers and set up practice in under-served areas.

Bruce Neeley and I separately in turn would give almost off the records seminars to the ‘senior residents,’ telling them in so many words, almost like the famous newspaper editor of the 1800’s, “Go West Young Psychiatrist,” In North Carolina we first meant go literally to western North Carolina which I knew very well because of my wife’s origin from Cherokee NC. But we also meant “get out of the urban centers, there are too many of us here already.”

WNC then and sadly still is vastly under-served by psychiatry with a chronic shortage that is almost criminal. I can count on the fingers of one hand the number of child psychiatrists in practice west of Asheville and that is a lot of territory. I used to tell senior residents to “Get out of the RTP [Research Triangle Park, another term used to denote the entire Raleigh-Durham-Chapel Hill area since each of those cities incredibly are only 8 to 15 miles from each other!

Continue reading “Maldistribution and Shortage of Psychiatrists and Child Psychiatrists”