Mental healthcare providers are battling an ever-growing psychiatric crisis in pediatric care. This comes amidst an unprecedented youth mental health epidemic that has left millions of teens and young adults both over-medicated and under-resourced. We know that rates of serious mental health issues in young people have been on the rise for over a decade. According to the National Alliance on Mental Health, suicide is now the second leading cause of death for 10-24 year olds, with the surgeon general last year declaring the youth mental health crisis a National Emergency.
The volume and severity of mental health conditions cannot be addressed by the average pediatrician, or in the emergency room. Treatment of issues such as major depression, panic disorders, PTSD, self-harm, and suicidal ideation require comprehensive, personalized solutions. But this is not how our current mental healthcare system is designed.
We are failing our kids.
I’ve had a front seat to this epidemic as a board-certified child and adolescent psychiatrist, and as the Medical Director at Charlie Health, the largest provider of virtual intensive outpatient care for young people in crisis. I’ve treated countless patients that present with psychiatric symptoms to their pediatrician’s office or in crisis at an emergency room and are quickly placed on a staggering number of medications that may actually worsen their mental health. Non-psychotropic interventions are inaccessible, leading too often to “polypharmacy,” the prescription of multiple psychotropic medications for a single patient. This is not a sustainable or effective solution.
Let’s use a twelve-year-old with ADHD–one of the most commonly diagnosed mental health conditions in the country among adolescents–as an example. I’ll refer to them as “Mason.”
Mason is having trouble focusing in school and is having an increasing number of tantrums at home. His parents, lovingly and rightfully concerned, bring up their concerns to the family pediatrician. Mason’s pediatrician diagnoses him with ADHD and writes him a prescription to help with his hyperactivity and anger. At first, Mason seems to respond well to the medication. But a couple of months later, his symptoms begin to worsen. He seems moodier and angrier than ever and frequently talks about feeling worthless. His parents take him back to the pediatrician, and she prescribes an antidepressant in hopes that it will help with his mood swings. Thus begins a cycle of psychotropic experimentation on a twelve-year-old who is just beginning to enter puberty, is still growing and developing, and would most likely benefit from treatment options such as group or skills-based therapy.
This story has become the alarming norm for young people whose pediatricians (to no fault of their own, but rather as a result of systemic issues) are being forced to act as psychiatrists. Why?
To start, there is a critical lack of psychiatrists in the U.S., with more than half of all counties without a single psychiatrist. At the same time, using just one diagnostic example, over 40% of young people who receive medication for an ADHD diagnosis are also prescribed at least one other psychotropic medication. This means that there are more medicines being prescribed to an increasing number of young people by a shrinking pool of psychiatrically-trained providers. Many pediatricians only complete one rotation of psychiatry while in residency, which is about one month’s worth of training. And yet, according to this 2020 study, rates of adolescents being prescribed antidepressants increased nearly 40% in recent years (the rate for adults was an increase of 12%).
In the broader context of the youth mental health crisis, this means that there is a growing number of young people with serious mental health issues who are also on serious psychotropic medicines. Many of these medicines are not approved for youth, and their effect on the still-developing adolescent brain is unknown. This does not mean they should never be prescribed. Of course, there are situations where these medicines are necessary and life-saving. However, the frequency with which they are prescribed is likely a reflection of the lack of access to non-pharmaceutical interventions. Interestingly, studies show that medication alone is not as effective in many mental health conditions such as depression and anxiety. Instead, medication alongside evidence-based therapies is consistently found to be a more effective, sustainable treatment option. Too often, I see youth who have only been able to access medications—no therapy, let alone evidence-based or skills-based therapies such as dialectical behavior therapy (commonly referred to as DBT or DBT skills, which is one of the therapeutic modalities we specialize in at Charlie Health).
We already know that more young people than ever are suicidal. Nearly one in five high school students contemplate suicide each year, and almost one in ten have made a suicide attempt. Young people and families are therefore showing up at emergency rooms in acute crises in droves. According to reporting on the youth mental health crisis by The New York Times, “1,000 young people, and perhaps as many as 5,000, board each night in the nation’s 4,000 emergency departments.” E.R.’s are designed to treat physical emergencies, not mental ones, in most cases.
Further complicating the picture is that these issues do not impact all communities equally. According to The Trevor Project, almost half of LGBTQIA+ young people seriously considered suicide in the past year (compared to 18% of non-LGBTQIA+ teens). On the medication front, low-income teens are more likely to be prescribed antipsychotic drugs than their higher-income peers. This trend is even starker for those on public insurance. 85% of kids on Medicaid who are prescribed antipsychotics are also prescribed a second psychiatric medication, according to this 2014 study. For BIPOC communities, access to any type of mental healthcare is a clear and present public health disparity. As of 2020, young BIPOC people were 14% less likely than their white peers to receive treatment for depression.
The alarming rise of polypharmacy and its strain on well-meaning pediatricians, compounded by the serious lack of efficacy that emergency rooms provide to young people in crisis, underscores the need for care options that are evidence-based and accessible. Some mental health programs offer this type of care but are cost-prohibitive or bogged down by months-long waitlists. We need solutions for teens and families, and we need them now.
The answer that we’ve found at Charlie Health is a virtual model that places personalized, evidence- and skills-based, and affordable care at the core of our program. Our virtual intensive outpatient program combines supported groups, individual therapy, and family therapy to create holistic treatment plans for young people like “Mason.” Our clinical team creates personalized groups that allow young people coming from similar psychiatric and personal backgrounds to heal together. A 16-year-old girl who’s survived sexual trauma and loves video games can be matched with a group of other 16-year-old girls with the same experience and love of video games. They’ll meet three times per week for three hours at a time, creating connections and learning how to heal together.
And to address issues related to equity: we accept all major commercial insurance and Medicaid so that families in crisis are able to focus their attention on supporting their kids, not on worrying about finances. Being virtual also means that we’ve eliminated waitlists. A teen in suburban Philadelphia has the same access to Charlie Health as a teen in rural Idaho. Finally, we’re partnering with pediatricians across these communities to take the burden of psychiatric care off of their shoulders.
Solutions are more than possible—they already exist. We’ve witnessed thousands of young people and families heal at Charlie Health. But it will take a collective effort by providers, insurance payors, and the public to increase awareness, increase access, and ultimately end the youth mental health and suicide epidemic.