Shortage of Child and Adolescent Psychiatrists in Texas
The Journal - March 2010
Tex Med . 2010;106(3):e1.
By Emilie A. Becker MD; Brian King, BA; Alan Shafer, PhD; and Christopher R. Thomas, MD
Dr Becker, psychiatrist, Mental Health Substance Abuse Division; Mr King, program director, Health Professions Resource Center; and Dr Shafer, research specialist, Strategic Decision Support, Texas Department of State Health Services, Austin, Texas; Dr Thomas, Robert L. Stubblefield Professor of Child Psychiatry, Department of Psychiatry and Behavioral Sciences, The University of Texas Medical Branch at Galveston. Send correspondence to Emilie A. Becker, MD, Texas Department of State Health Services, Mental Health Substance Abuse Division, Mail Code 2013, PO Box 149347, Austin, TX 78751; e-mail: emilie.becker[at]dshs[dot]state[dot]tx[dot]us.
This study was conducted to determine how the current shortage of Texas child and adolescent psychiatrists (CAPs) impacts the delivery of mental health care services to indigent Texas youth. First, Texas Medical Board data detailed how many counties had CAPs and how many did not. Second, statewide Medicaid data revealed the number of prescriptions for psychotropics written for Medicaid youth by CAPs and non-CAPs. Third, Local Mental Health Authority (LMHA) encounter data of youth seen by a CAP were analyzed. Fourth, state census data gave the location and characteristics of youth by county. Eighty percent of counties in Texas, predominantly rural, do not have a CAP. Non-CAPs wrote 66% of psychotropic medication prescriptions written for Medicaid youth. Those in nonmetropolitan areas were more likely to see a non-CAP than were Medicaid youth in metropolitan areas. For youth seen by an LMHA, those in rural poor counties were less likely to see a CAP than were those in urban counties. The shortage of CAPs in Texas results in an unequal distribution of psychiatric care for those receiving Medicaid prescriptions or services through LMHAs, especially in rural areas. Suggestions to correct this shortage are made.
Texas' shortage of child and adolescent psychiatrists (CAPs) mirrors that in the rest of the country. Since the early 1980s, studies have repeatedly shown a gap between population growth and the supply of child and adolescent psychiatrists (CAPs).1-4 Following are some of the most commonly cited reasons for this shortage:
- Fewer training programs exist, graduating fewer CAPs.5
- Low exposure to CAP during medical school training and delayed exposure during general psychiatry residency decreases the numbers who choose CAP.6
- CAP training, an extra 2 years, does not substantially increase wage-earning capacity over that of general psychiatrists. 7
- Fewer international medical graduates are available for any specialty because of the combination of more strictly enforced immigration laws along with increased examinations.5
- More psychiatric residents choose careers in the newly created specialties in geriatrics, forensics, psychosomatics, and addictions.
- Texas has an overall physician shortage.8
The Texas Department of State Health Services provides outpatient services throughout the state via 38 Local Mental Health Authorities (LMHAs) that cover the 254 counties in the state. The statewide safety net for the mentally ill, the LMHAs serve a widely varying number of counties, geographic areas, and populations. For example, the Texas Panhandle Mental Health Mental Retardation (MHMR) catchment area includes 21 counties that span 21,000 square miles, and their physicians saw 531 youths in 2007. Harris County MHMR (Houston) covers a single county of 2000 square miles, throughout which doctors saw 4212 youths in 2007. The LMHA in Dallas differs from the rest of the state, contracting with a managed care organization and other private providers for mental health care.
This study was a retrospective analysis of available state data to support the hypothesis that a shortage of CAPs exists and that shortage affects the care given to Texas indigent youth.
Description of Data Sources
Data were gathered from the following sources:
- A current list of practicing CAPs provided by the Texas Medical Board. The database comprises all medical licensure issued in the State of Texas. Texas verifies identity, age, medical school education, and examination scores. Graduate medical education and board certification are not verified, but false information can lead to disciplinary action. Physicians choose whether to list psychiatry, child and adolescent psychiatry, or pediatric psychiatry as either their first or secondary specialty.
- Psychotropic prescriptions written for Medicaid youth from the Texas Health and Human Services Commission for state fiscal year 2006.
- Children's mental health service encounters in which care is delivered by physicians at Texas LMHAs for 2007. The original data analysis included the number of service encounters according to LMHA and identification of each physician server. Each LMHA was then asked to list each physician's name by server identification; the training of each physician was subsequently verified on the Texas Medical Board Web site by the authors or by the LMHAs on the Texas Medical Board Web site. Three of the 38 LMHAs chose to do the latter. Data were obtained from all the LMHAs.
- Census data on children and Texas come from the Population Projections for Texas developed by the Texas State Data Center at The University of Texas at San Antonio.
Results Availability of Texas CAPs
In Texas in 2007, the Texas Medical Board listed 587 licensed psychiatrists with child, adolescent, or pediatric psychiatry as a self-reported primary or secondary specialty. Of these, 408 were engaged in direct patient care (ie, neither retired, doing research/administrative work, working with the military, nor a resident or fellow). This final number is slightly inaccurate because a closer review of the findings revealed that not all of the psychiatrists who completed a 2-year child and adolescent fellowship or a pediatrics residency listed themselves as specialists in child and adolescent psychiatry. And the reverse was also true: that doctors might list themselves as specialists in CAP but not list their fellowship or board certification. But the variance appeared relatively small, accounting for less than 5% of the 408 psychiatrists. In all but one case, the psychiatrists listed their practice address rather than a mailing address.
As Figure 1 shows, of the 254 counties in Texas, 50 counties (20%) had a CAP and 204 (80%) did not. Only 3.2% of the CAPs practiced in rural counties. The map reveals that the density of CAPS correlates with urban areas and the interstate highways that connect them. In particular, many CAPs seem to work along the Interstate 35 corridor that connects Dallas-Fort Worth, Austin, and San Antonio, and the Interstate 10 highway between San Antonio and Houston.
The number of children (those younger than 19 years) in Texas was 6,730,737 in 2007. 9 Thus, Texas has 6.7 CAPs for every 100,000 children.
By sex, 248 of the 408 CAPs were men (61%), and 160 were women (39%). The racial or ethnic breakdown was 239 white (59%), 21 black (5%), 58 Hispanic (14%), 73 Asian (18%), 2 Native American/Alaskan (<1%), and 15 unknown (4%). In 2007, the Texas population from birth to age 18 years included 2,612,669 whites (38.8%), 822,056 blacks (12.2%), 3,054,219 Hispanics (45.4%), and 241,793 others (3.6%). 9
Psychotropic Prescriptions by Texas CAPS
Texas Medicaid children and adolescents by definition are either living in poverty (based on poverty income levels) or are wards of the state. In December 2007, the children on Medicaid numbered 2,607,281 (about 38% of children in Texas).10 In state fiscal year 2006, a total of 1,514,136 single prescriptions for psychotropics (as listed in the Drug Formulary of the Texas Department of State Health Services) were issued to 256,315 Medicaid youths younger than 18 years ( Table 1 [ PDF ]). Thus, 9.8% of Medicaid youth received a single prescription for a psychotropic drug. Of these prescriptions, CAPs wrote 510,995 (34%), and other specialists (eg, general psychiatrists, pediatricians, and family physicians) wrote 1,003,141 (66%). Possibly, some of the medications listed as psychotropics might have been used for medical purposes (ie, Depakote for seizures or Vistaril for skin conditions), but diagnoses were not available for analysis; however, these prescriptions appeared to be exceptions rather than the rule, and the bulk of psychotropics are prescribed by physicians other than CAPs.
The 408 practicing CAPs in Texas were matched by license number to the Texas Health and Human Services Commission Medicaid Provider ID file. Of these 408 CAPs, a subset of 336 prescribed psychotropic drugs to Medicaid children during state fiscal year 2006. These 336 CAPs prescribed an average of 1520 prescriptions (SD = 2424) to 171 Medicaid children (SD = 250), for a total of 510,995 prescriptions. In contrast, the 15,433 non-CAP Medicaid prescribers prescribed an average of 65 prescriptions (SD = 346) to 19 Medicaid children (SD = 76), for a total of 1,003,141 prescriptions.
The non-CAP Medicaid prescriber group was further examined by specialty. Eighty-two percent of prescriptions written by non-CAP Medicaid prescribers were accounted for by four self-reported primary specialties: pediatrics (32% of non-CAP prescriptions), general psychiatry (29% of non-CAP prescriptions), family practice (13% of non-CAP prescriptions), and child neurology (8% of non-CAP prescriptions).
Further analysis of the 15,433 non-CAP prescribers showed that 817 general Medicaid psychiatrists (who accounted for 29% of non-CAP prescriptions) prescribed an average of 360 prescriptions per doctor to 47 clients for a total of 294,555 prescriptions. The remaining 14,616 non-CAP, nonpsychiatrists only prescribed an average of 48 prescriptions per doctor to 17 clients for a total of 708,586 prescriptions. In sum, while as a group the nonpsychiatrists wrote most of the prescriptions for psychotropics to Texas Medicaid youth, individually each nonpsychiatrist prescribed fewer medications and saw fewer children on average than either psychiatrists or CAPs.
More CAP prescriptions were written in metropolitan counties and more non-CAP prescriptions were written in nonmetropolitan counties (chi-square = 6,140, P <.001). Specifically, more prescriptions written by CAPs were observed (439,398) in metropolitan counties than were expected (422,115), and fewer were observed in nonmetropolitan counties (71,597) than were expected (88,800). For non-CAPs, fewer prescriptions were observed (811,376) in metropolitan counties than were expected (828,659), and more were observed in nonmetropolitan counties (191,765) than were expected (174,482).
Service Encounters by Texas CAPs
In 2007, the 38 LMHAs reported 103,034 physician service encounters for child mental health service. Of these, 77,034 (75%) service encounters were delivered by a CAP. The rest were seen by non-CAPs, most of whom were adult psychiatrists.
Of the 51,764 physician service encounters at 10 urban LMHAs, a total of 42,615 (82%) were delivered by CAPs ( Figure 2 [ PDF ]). In contrast, of the 51,270 physician service encounters at 28 rural LMHAs, only 34,419 (67%) account for care delivered by CAPs, a statistically significant difference (chi-square = 3,151, P <.001).
Subsequently, LMHAs were classified also according to the average per capita personal income for their catchment counties by using a median split. Half of the LMHAs served counties where the average per capita income was greater than $30,137; these were categorized as high per capita income LMHAs, and the other half were classified as low per capita income LMHAs. Figure 3 [ PDF ] shows that at 56,650 (82%) of the 68,605 physician service encounters at high per capita income LMHAs, the care was delivered by CAPs. In contrast, of the 34,429 physician service encounters at low per capita income LMHAs, only 20,474 (60%) involved care delivered by CAPs, a statistically significant difference (chi-square(1) = 6,414, P <.001).
Finally, LMHAs were categorized according to the percentage of their catchment population that was Hispanic or Black or both. A median split was used to classify LMHAs serving a low minority population versus a high minority population. Half the LMHAs served counties where the minority population was less than 37%; they were categorized as low minority population LMHAs, and the other half were categorized as high minority population LMHAs. Figure 4 [ PDF ] shows that at 25,761 (72%) of the 35,694 physician service encounters at low minority LMHAs, the care was delivered by CAPs. Similarly, of the 67,340 physician service encounters at high minority population LMHAs, the care was delivered by CAPs in 51,273 (76%). This statistically significant difference (chi-square = 194, P <.001) appears to be related to the distribution of minorities, who are disproportionately located in urban areas. Minorities in rural areas had the same lower percentage chance of seeing a CAP as did their nonminority peers.
Minorities are disproportionately underrepresented in the number of child psychiatrists.13 Given that Hispanic teens are now the majority in Texas, the small number of Hispanic psychiatrists is particularly striking. The 2001 Surgeon General's report found that although mental disorders are prevalent within minority populations in the United States, minorities are less likely to seek care, and the care they do receive is often of a lower quality than care provided to nonminorities. 14 Having more minority psychiatrists would help destigmatize mental illness for minorities and improve that barrier to accessing care.
In general, Texas Medicaid children and adolescents appear to frequently get at least a single prescription for a psychotropic drug from either a primary care doctor or a general psychiatrist. However, when the emotional problems become more severe, these patients seem to receive specialty help, as reflected by the increased number of prescriptions per patient by a CAP.
Few would disagree that the number of CAPs needs to match the population growth in Texas. How to best address this issue, however, creates much debate. The supply of CAPs is primarily determined by recruitment into training, number of training positions, and retention of graduates in practice. The following are some suggestions to consider:
- Increase the number of medical students.
- Increase recruitment into child and adolescent psychiatry.
- Increase funding for the number of training positions in CAP.
- Waive the debt faced by graduating CAPs through loan-forgiveness programs.
- Study CAP access to show it improves patient outcome and reduces overall health care costs.
- Place CAP fellows in rural areas for periods of their training.
- Increase psychiatric reimbursement rates for child and adolescent patients.
- Streamline psychiatric training to reduce the total number of years required to become a CAP.
Given that the number of CAPs is unlikely to increase to sufficient numbers, additional suggestions to maximize access are to use telepsychiatry to deliver care by urban CAPs. Advanced practice registered nurses and physician assistants with training in child and adolescent mental health can also fill the unmet need. Lastly, integrating CAPs into pediatric and primary care clinics leverages CAP access. Meanwhile, Texas suffers from a shortage of CAPs. Changes are needed to improve treatment for the vulnerable population of the young mentally ill.
- Child Psychiatry: A Plan for the Coming Decade . Washington, DC: American Academy of Child and Adolescent Psychiatry; 1983.
- Council on Graduate Medical Education. Re-Examination of the Academy of Physician Supply Made in 1980 by the Graduate Medical Education National Advisory Committee (GMENAC), for Selected Specialties Bureau of Health Professions in Support of Activities of the Council on Graduate Medical Education. Cambridge, MA: ABT Associates; 1990.
- Graduate Medical Education National Advisory Committee. Report to the Secretary, Vol 1-7 . Washington, DC: US Dept of Health and Human Services; 1980. DHHS Publication No. HRA 18-651-657.
- Texas Dept State Health Professions Resource Center. Highlights of the Supply of Mental Health Professionals in Texas. Austin, TX: Texas Department State Health Services; 2006. Publication No. 25-12347.
- Kim WJ. Child and adolescent psychiatry workforce: a critical shortage and national challenge. Acad Psychiatry. 2003;27(4):277-282.
- Fritz GK. Where have all the child psychiatrists gone? Brown University Child and Adolescent Behavior Letter . 2002;18(3):8.
- Allied Physicians. U.S. Physician Salaries - Ongoing Salary Survey. 2006. http://www.allied-physicians.com/salary_surveys/physician-salaries.htm . Accessed October 28, 2008.
- Ortolon K. Still not enough: Texas faces physician shortage despite growing workforce . Tex Med . 2008;104(6);41-44.
- Texas State Data Center and Office of the State Demographer, The University of Texas at San Antonio. Population projections for Texas; 2006.
- Texas Health and Human Services Commission. Point in time count: Medicaid enrollment by month; 2008. http://www.hhsc.state.tx.us/research/MedicaidEnrollment/PIT_monthly.html . Accessed October 28, 2008.
- Levin A. Rural counties suffer from child psychiatry shortage. Psychiatric News . 2006;41(14):4.
- Thomas CR, Holzer CE. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry . 2006;45(9):1023-1031.
- Stubbe DE, Thomas WJ. A survey of early-career child and adolescent psychiatrists: professional activities and perceptions. J Am Acad Child Adolesc Psychiatry . 2002;41(2):123-130.
- Mental Health: Culture, Race and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. U.S. Department Health and Human Services. http://download.ncadi.samhsa.gov/ken/pdf/SMA-01-3613/sma-01-3613A.pdf [ PDF ]. Accessed October 28, 2008.
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