A Crisis in Child Psychiatric Service Delivery: Why Hasn't the Piper Been Paid?

Abstract

Address reprint requests and correspondence to David A. Mrazek, MD, FRCPsych, Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: mrazek.david @mayo.edu). In Ecclesiastes, it is written that there is a time to keep silent and a time to speak. I have been asked to speak about the state of psychiatric services for children. What needs to be said is difficult. Over the past decade, expenditures dedicated to the provision of mental health services for children have been reduced dramatically. This was a shortsighted policy during a period of considerable prosperity. The negative consequences of these restrictions in provision of services are measurable. While I have spent much of my career as a clinical researcher, it is my long experience caring for troubled children that allows me to speak with some authority about providing psychiatric care to children. Child psychiatrists are permitted and expected to enter into the inner world of their young patients. This entitlement comes with the responsibility of sharing their patients’ most intensely guarded secrets and deepest fears. It is a world to which few adults gain even minimal admission. Over the past generation there have been many advances in our ability to treat mental illness, most vividly shown by the prolific creation of psychotropic medications. The Food and Drug Administration has approved 21 antidepressants. An issue more critical for children is the emergence of evidence-based reports demonstrating efficacy of preventive interventions. Olds et al reported on an impressive home visitor intervention study that quantified beneficial effects for both young mothers and their children. Many years later, children whose families received intervention were less delinquent and had fewer problems associated with alcohol. Furthermore, the mothers who received this home visiting intervention were less likely to be abusive or neglectful. Evidence now shows that early intervention can actually decrease the expression of depressive illness. A study that targeted teenagers with early symptoms of depression and provided them with group treatment showed that the rate of onset of depressive illness could be nearly cut in half. In light of our advances in providing improved treatments, a report on the mental health of children in the United States should be encouraging. Unfortunately, there A Crisis in Child Psychiatric Service Delivery: Why Hasn’t the Piper Been Paid?