Long waits for psychiatric help put teens at risk

“When did you start throwing up?”

My 13-year-old patient arrived at our adolescent clinic complaining of “menstrual problems” and was now repeatedly vomiting. A careful history revealed that she had intentionally overdosed, trying to end her life several days ago.

“Thank you for being open with me, I know that can be hard. I do need to tell your mom about your overdose,” I gently reminded her.

“Oh, she already knows, Doc. She just told me to keep throwing up again.” My patient’s mother had grown accustomed to her daughter’s depression and now third suicide attempt. She thought she knew the drill: overdose, throw up the drugs, drink water. Wash, rinse, repeat.

Although I was more than halfway through my pediatric residency at the time and had cared for countless suicidal teenagers, this patient visit has stayed with me. Even her mother had become desensitized to her own child’s suicidality while awaiting a psychiatrist appointment. How could I blame her? Since I started my training in June 2020, I have admitted nearly as many adolescent suicide attempts as asthmatic patients, and asthma is one of the most common reasons for admission to our hospital.

Adolescent depression and suicidality have quickly become the “bread and butter” of pediatrics. Teens without signs of depression or suicidal thoughts or attempts are so rare in our well-visit clinic that they are memorable. I can’t recall a single shift in our emergency room without multiple listings of “intentional overdose” or “behavioral/mental health problem” on the patient tracking board.

I am a pediatrician in an underserved, poverty-stricken community in Philadelphia. But I am not alone in what I’m seeing.

According to the World Health Organization, the fourth leading cause of death in 15- to 29-year-olds is now suicide. In the last decade, the mental health of high school students in the United States has continued to worsen, with 40% of high school students feeling so sad or hopeless that they could not engage in their regular activities for at least two weeks during the previous year. The percentage of high school students who reported making a suicide plan has also increased from 13% in 2011 to 18% in 2021. During COVID-19 lockdowns, from mid-March through mid-October in 2020, the percentage of adolescents across the U.S. who presented to the emergency room for mental health crises increased 31% compared with the same time period in 2019.

The data are clear. We are failing our adolescents.

The current screening, referral, and management process leaves our teens’ mental health issues unrecognized and untreated. Despite the ubiquity of adolescent mental health conditions, less than two-thirds successfully access treatment, and those who do wait an average of 50 days for psychiatrist intake appointments.

But pediatricians are not yet trained to pick up the slack. According to an American Academy of Pediatrics survey, 65% of pediatricians say they feel they lack training in identifying and treating mental health issues, as did more than 50% of pediatric residents. In my own residency program, both residents and attendings often say they feel unequipped to deal with depression and suicidality among our teens. Changes in pediatric training are overdue.

There are legitimate concerns that psychiatrists — not pediatricians — are best qualified to provide proper mental health care to adolescents. This is certainly true for complex diagnoses such as psychosis, schizophrenia, or treatment-resistant depression or suicidality. But with the overwhelming rise of adolescent mental health needs and the scarcity of adolescent psychiatrists in the U.S., the current system must adapt.

It is essential that we incorporate basic mental health care as a core element of pediatric training and practice, so we can fill the gap and provide the care our teens need to survive. Pediatricians have the opportunity to reach patients prior to crises — to stop the cycle of wash, rinse, repeat. Teens’ lives are at stake.

Rose Bayer is finishing her pediatrics residency in Philadelphia and applying for an adolescent medicine fellowship. She continues to pursue her passion and research in adolescent mental health as well as resident wellness and burnout prevention.