Child mental health: More LI pediatricians prescribing medication for psychiatric issues

Dr. Marc Lashley received almost no training in medical school in how to deal with children’s mental health issues. But when he started practicing as a pediatrician, he found there was a critical — and unmet — need because of a shortage of child and adolescent psychiatrists.

With the help of a training program created partly by a Long Island psychiatrist, he started prescribing drugs to treat anxiety and depression in children and adolescents. A decade ago, it made up 2% of his practice. Today, it is 20%.

"It’s given me a tremendous satisfaction," said Lashley, who is based in Valley Stream and Far Rockaway. "There’s nothing like helping somebody who’s undergoing depression, anxiety and not functioning. It’s really the most rewarding part of my practice right now."

Lashley is part of a growing trend in the medical world: pediatricians who are prescribing medication for anxiety, depression, ADHD and other illnesses amid the mental health crisis because of a lack of child and adolescent psychiatrists. Not enough people are going into psychiatry partly because of the long training involved, experts said.

Some pediatricians say they have little choice but to help fill the gap, since it’s extremely difficult for families to find available child and adolescent psychiatrists. Most have monthslong waiting lists or aren’t accepting new patients at all.

Even if families can find an available psychiatrist, most do not accept insurance, leaving families with an out-of-pocket bill that can hit $500 or $800 or more for a monthly visit, medical experts said. And even if a child is going to a therapist, only a doctor can prescribe medication.

"There will never be enough child psychiatrists to take care of the mental health needs" of children and adolescents, said Dr. Victor Fornari, the vice chair of child and adolescent psychiatry for Northwell Health. "Certainly, working with a trusted primary care physician is better than not working with anyone."

Training pediatricians to prescribe

He is one of main creators of Project Teach, a program that has trained 2,000 pediatricians in New York State in how to prescribe medications for depression and other mental health issues. The state-funded project, which operates mostly online, is gaining attention around the country and even overseas as a possible solution to the psychiatrist shortage.

Fornari noted that most psychiatric medicine in the United States and around the world is prescribed by non-psychiatrists, mainly primary care physicians, who are "really in the best position to evaluate and treat these mild to moderate issues" since they know the families and usually accept their insurance.

But he stressed that pediatricians in the program aren't dealing with more advanced mental health issues. If a patient is suicidal or has some other major disorder, a psychiatrist would have to be brought in.

There will never be enough child psychiatrists to take care of the mental health needs of children and adolescents. Certainly, working with a trusted primary care physician is better than not working with anyone.

— Dr. Victor Fornari, the vice chair of child and adolescent psychiatry for Northwell Health

Dr. David Kaye, a professor of psychiatry at the University at Buffalo who helped create Project Teach, said, "Increasingly families look to and feel comfortable with going to their primary care doctors and clinicians for help with these kinds of things. They know their pediatricians ... They trust them."

"If it is seen as part of primary care then people don’t have to feel so ashamed and have a barrier to getting help when it is only available through a psychiatrist for example," he said. "There is still tremendous stigma and there are a lot of barriers to people seeing a psychiatrist."

Not everyone is enthusiastic about pediatricians delving into mental health treatment. Critics contend they lack enough training and are susceptible to making mistakes.

"I don’t think it’s a good idea for pediatricians to treat children without the extensive training that is required," said Dr. Meena Ramani, who is both a pediatrician and psychiatrist based in Nassau County. "The ideal situation for a family and a child is to be treated by the expert."

At a minimum, pediatricians should work in collaboration with a child and adolescent psychiatrist, she said.

Jeffrey Friedman, CEO of the nonprofit Central Nassau Guidance & Counseling Services in Hicksville, said many pediatricians "feel very uncomfortable having to prescribe psychotropic medications to individuals. They’re not doing this day in and day out. They’re not keeping up on the latest trends in the field and are struggling to come up with the most effective treatment for those individuals. It’s not their specialty and they’re not trained in that."

Sometimes when families come to his agency, "our psychiatrist will change those medications because they are not the most effective or efficient treatment for a particular disorder that an individual has," he said.

But Fornari and others say there are few options other than relying on pediatricians and family physicians, and that Project Teach successfully trains non-psychiatrists to take on such work.

"Without this program, these kids don’t get care," he said.

He estimates that 12% of youths nationwide are taking medication for mental health issues, but that 25% could probably benefit from the drugs — if there were enough pediatricians or psychiatrists prescribing them.

A nationwide shortage

The psychiatrist shortage is unlikely to end soon, medical experts said. There are 1,247 child and adolescent psychiatrists in New York State, placing it in the category of "high shortage," according to the American Academy of Child and Adolescent Psychiatry, a nonprofit professional association based in Washington, D.C. Nassau County has 131, while Suffolk has 87, putting them in the high shortage category. Many counties upstate have none, meaning families would have to travel two or three hours to reach one.

Most of the rest of the country is even worse off, with most states classified as "severe shortage," the academy states. Only one has adequate levels — Vermont.

In contrast, New York State has a total of 8,800 pediatricians and family medicine doctors. They could handle many of the lower-level mental health issues of patients, Fornari and Kaye contend. It’s the same situation nationwide: 11,422 child and adolescent psychiatrists, as opposed to 147,860 pediatricians or family medicine doctors, according to the U.S. Bureau of Labor Statistics.

It’s unlikely there will be a big wave of new psychiatrists to make up for the shortage, Fornari said. A maximum of 350 child and adolescent psychiatrists nationwide complete their post-medical school residencies per year, making them eligible to start practicing in the field, he said.

At Zucker School of Medicine at Hofstra/Northwell, he runs one of the largest residency programs in the nation, and it sees only 10 child and adolescent psychiatrists complete their residency per year. Most programs produce even fewer — two or three a year, he said.

The federal government has set the number of residencies at 350 for decades, Fornari said. It does so in this field and others as it tries to gauge how many doctors with specializations the nation needs. And it has the power to do so in part because it helps fund the residency programs.

Yet many years not all of the 350 slots are filled — sometimes the number is as low as 300, Fornari said. He thinks the country needs 1,000 slots, but even if they were established not enough medical school graduates are signing up.

Many doctors don’t want to go into psychiatry because it takes years more of training after medical school compared to other branches of medicine, Ramani said. Pediatricians, for instance, do three years of residency after medical school but child and adolescent psychiatrists must do five to six. It becomes difficult to remain that long in low-paying residency positions because many aspiring doctors already are hundreds of thousands in debt from four years of undergraduate studies and four years of medical school, she said.

The development of telehealth has not solved the psychiatrist shortage either, since they can only see the same limited number of patients per day whether in-person or on a screen, medical experts said. Telehealth simply means a patient does not have to go to a doctor's office — the appointments are not shorter.

Collaborating to meet the need

Mental health problems are on the rise among American children and adolescents, exacerbated by the COVID-19 pandemic, the ubiquity of smartphones and screen time, social media, and increased pressure to perform at school and in sports, according to Fornari and other experts.

Project Teach, founded in 2010 at the request of the New York State Office of Mental Health, is trying to meet the growing need for help.

Participants go through intensive in-person or online training lasting between six and 15 hours, and then have periodic follow-up sessions. Fornari, Kaye and others lead the training. The program is an unusual collaboration among seven medical teaching hubs throughout the state: Northwell’s Zucker, Albert Einstein College of Medicine in the Bronx, the University at Buffalo, the University of Rochester, SUNY Upstate Medical Center, Albany Medical Center and Columbia University Medical Center/NY State Psychiatric Institute.

After taking the classes, or even if they did not, pediatricians or any clinician who treats children have access to a free telephone "warmline" that connects them with a child and adolescent psychiatrist if they need help treating a patient. The "warmline" operates Monday through Friday 9 a.m. to 5 p.m. and usually gets eight or nine calls a day, Kaye said. Typically the psychiatrist calls back within 30 minutes or at a mutually agreed on time.

Project Teach also helps pediatricians find local psychiatrists or therapists if it is determined a patient needs more extensive help.

The program has been replicated in other states, Fornari said.

Texas started its version in late 2019 and it "has just taken off unbelievably," said Joseph Blader, a child and adolescent psychologist who helped launch the program. 

The state-funded program, called Child Psychiatry Access Network (CPAN), gets about 1,000 calls a month on its "warmline," said Blader, a professor of child psychiatry research at the University of Texas at Austin.

Project Teach is even being replicated overseas.

In the past I would make an effort to try to find a psychiatrist" for his patients, "but now I find that’s fool’s gold because you just can’t find one" that’s available or that they can afford.

— Dr. Bruce Gerberg

Fornari and Kaye visited Israel several times to help set up the nonprofit Goshen Behavioral Health Training for Pediatricians. It was launched in late 2023 — just as Israel’s war against Hamas in Gaza broke out. So far, 150 pediatricians and family medicine doctors have been trained, said Dr. Jennie Goldstein, the director of Child & Adolescent Psychiatry at the Shaare Zedek Hospital in Jerusalem, who helped launch the Goshen program.

"It has felt like a revolution," said Goldstein, a Boston native who studied under Fornari on Long Island. "We have been able to allow pediatricians to feel comfortable managing cases that were walking through their doors anyway but they didn’t know how to handle."

One course offered soon after the war began focused on trauma symptoms, she said.

Filling the medication gap

Lashley, the Valley Stream pediatrician, said he joined Project Teach in its first year as he saw growing numbers of children with mental health issues, but whose families could not afford or find a psychiatrist.

"It’s really been transformative," he said. "I think that the Project Teach training is excellent, comprehensive and certainly enough to get a pediatrician up and going and treating."

He said he's treated hundreds of children with basic mental health issues, helping to alleviate the burden on child psychiatrists, who can then handle the more complex cases.

Other doctors "even refer me their patients because they know that I’m competent at doing this and that I’ve gone through the Project Teach training," he added. "There are pediatricians out there who don’t want to treat mental health because they don’t feel comfortable."

Dr. Bruce Gerberg, a pediatrician in Huntington, said the number of patients he prescribes drugs to for mental health issues has gone from two or fewer a month back in 2010 to between 10 and 20 a month now.

He has done some online training in the area, though not through Project Teach.

"In the past I would make an effort to try to find a psychiatrist" for his patients, "but now I find that’s fool’s gold because you just can’t find one" that’s available or that they can afford, he said.

He feels increasingly at ease in his new role.

"So far it’s been great," he said. "As long as I know my limitations and I know when to refer out if it’s gotten too complicated or they require other medications, I feel comfortable doing the basic anxiety, depression kind of stuff."

Dr. Mitchell Abrons, a pediatrician in Rockville Centre, said he has gone from treating one or two patients a week for mental health issues 15 years ago to at least one a day now.

Abrons, who has done some training with Project Teach, said he usually recommends his patients talk to a therapist first to see if that alleviates the problem before he prescribes medication. "Through both mental health counseling and medication, we see a lot of success," he said.