Patrick Kennedy – The Mental Health Reform Blog

Shortage of Child Psychiatrists

Several weeks ago I was incredibly saddened by the news from a colleague and dear friend of mine, also a Duke child psychiatrist, that one of our mentors had passed away in his mid-80’s. He meant so much to me, I wish to mention and memorialize his name in my own little way in this humble esoteric blog. He was Dr. Marc (Marcelino) Amaya (with ‘Amaya y Rosas’ being his full last name).

He was one of the original child psychiatrists in a group that came down to Durham NC from Northeastern training centers to help start the department and to staff it. The other faculty was as were in all major medical centers of the last 50 years, superb instructors and fantastic clinicians that often left us rookies with our veritable mouths open at their insights.

Dr. Amaya started a complete children’s psychiatric hospital I think in the early or mid-1960’s to house what Duke could not offer on its grounds because it was private and not state affiliated and for funding issues. The Children’s Psychiatric Institute (CPI) was a fabulous training center on the level of such other state hospital affiliated and also lesser known than the more celebrated upper crust programs, but every bit as good as any of the Ivy League (Boston, NYC, Philly, etc.) centers such as the late and venerated Dr. Ralph Rabinovich of the University of Michigan at Ann Arbor. CPI has a short term and long term outpatient clinic, a family therapy program that was expanded by this writer and one of the veteran incredibly skilled social workers at CPI, Anne K. Parrish ACSW, LCSW, into a training program for child mental health trainees from Duke and UNC-Chapel Hill medical and graduate schools. Dr. Amaya was a superb supervisor and I always learned untold concepts, techniques, and gems at his feet so to speak. I also accompanied him to the testify in the Golden Days of Psychiatry and Psychology in this country to testify annually before the NC General Assembly (state legislature) as we would advocate for our state funded programs, but also for the private inpatient and outpatient programs at Duke and UNC! So there we would be harassing clinically and statistically the legislators (who in those days seemed to listen better..no matter their party affiliation). It was quite ironic but demonstrated the dedication that Dr. Amaya had to the delivery of mental health services to ALL children of the state and to any agency, institution, training program that was trying to provide such. His program was not his first concern in the statewide scheme of things, it was just another important part of the overall system of resources he foresaw for the state decades before some of them came into existence. He was a short man with a lyrical Hispanic accent that I as a Southwesterner could listen all day long and always feel like, when I was with him, I was a little bit ‘back home’ in the Southwest.”

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The Simplest Mental Health Reform Blueprint

In an unassuming online article published by WDKI television of Kansas, “Mental health reform proposed in Kansas,”there is laid out a summary of the initiative(s) now stirring in Kansas that show the simplest and some of the most needed mental health reform measures needed in this country. The irony is that they are incredibly simple, intuitive and long known as needed by policy wonks in the field and providers of all types in the mental health professions.

They boil down to basically simply and (stupidly enough) restoring some of the most basic lynch pins of our system of mental health care delivery.

Those essential foundations or struts of the superstructures of local or regional mental health care delivery systems of ANY size, consists of two basic things, money (“funding” in the ever dominant bureaucratic talk) and providers. Such a non-complex concept that we are starting to circle around to and rediscover. [Read angry irony in that last sentence please].

The last 20 years have seen state legislatures cut funding for state and local mental health services, fight Medicaid expansion to help provide mental health insurance and thereafter access to the ‘new’ privatized’ models of MH services agencies {they used to be called “mental health centers” in each country]. In most states, the new mental health reforms were SUPPOSED to cover the uninsured but somehow they often did not because of limited funding {read “block funding”]. Block funding as a concept originated mostly under the Nixon administration and since then has been largely used by a political party of a certain flavor tp punish frowned upon governmental services, such as Planned Parenthood, National Public Radio, and other entities, you get the idea. The concept was that funding was not cut off to avoid too much blowback, but given in limited and sometimes ever shrinking amounts with the admonition to choose upon what to spend it, leaving the do-gooders in the agencies to make the cuts and make the less than kind decisions and “be the bad guys.” That way legislators could crow to their constituents that they had not increased spending and had not cut funding [the latter often untrue but who’s quibbling here, this is politics…).

The other major pillar of deconstruction of the old county-based mental health system has been the ever shrinking pool of psychiatrists, counsellors, substance abuse counsellors, psychologists, child therapists of all disciplines and especially outreach workers in the old public health system sense, the “outriders,” who visited homes and if nothing else dropped the essential daily antipsychotic doses into patients’ mouths and made sure they swallowed them. It’s called “compliance.” Training programs until the last 10 years have done nothing but stay static in numbers of graduates or shrink dramatically as my one training program did for years. Some few departments of psychiatry closed or merged such as the famous occurrence at Tufts University Dept. of Psychiatry in Boston decades ago which was essentially saved and bought out by Harvard.

Reading the article makes me realize it has taken 30 years to pummel into the heads of the so-called reformers that three simple needed measures: outpatient services including residential systems of living centers for displaced mentally ill out of destroyed or as they would say in the Peron dictatorship years in Argentina, “disappeared,” hospital beds, and increase the funding and programs for providers, in this case, psychiatric residents. Sen. Chris Murphy’s bill and Former Rep. Patrick Kennedy’s now in effect merged national mental health reform bill does the same things largely except on a national basis

Dr Harold Carmel MD of Duke Psychiatry said now over a decade ago, “it will take us 10 years to get back to where we were 10 years ago.” At least we have real starts now.

The Continuing Serious Shortage of Child Psychiatrists

I first have to make my disclosure statement: I am a child psychiatrist, in addition to being and adult, and geriatric psychiatrist. I trained and was board certified in all three subspecialties but I am a child psychiatrist and that will necessarily makes its way into this post and I wish the reader to know that up front.

The Arab news agency Al-Jazeera had a very recent article that caught my week several days ago. It was entitled: “Shortage of child psychiatrists plagues the US.” It appeared June 25, 2015. It was very fair and well done and I appreciated the factual, accurate and in depth reporting that went into it. But as an American and a child psychiatrist, it stung a little. One of our 30 year old problems that we have unconscionably neglected and is a big part of our present self inflicted, national “mental health crisis” is catching the attention of the foreign press more and more. This hurts. And part of why it hurts is that the venerable, sort of business-y conservative, Wall Street Journal has been reporting on the shortage of child psychiatrist now for well over a decade. If the reader will Google ‘child psychiatrist shortage Wall Street Journal’ you will get a few pages of listings of well done articles published in the past by the Wall Street Journal in past years.

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