Adolescent Psychiatric Services: Managing an Increased Demand

Podcast Transcript

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:

More than one in three US high school students experienced persistent feelings of sadness or hopelessness in 2019, according to the Centers for Disease Control and Prevention. And that was before the unprecedented strains of the COVID-19 pandemic.

Since then, rates of behavioral disturbances, mood and anxiety disorders, suicide attempts, suicidal thinking, drug use, and eating disorders have all skyrocketed.

In today's episode, we're discussing how to better serve the growing adolescent population that's in need of psychiatric care. I'm your host, Glen Stevens, neurologist/neurooncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Dr. Joseph Austerman. Dr. Austerman is a psychiatrist and section head of Child and Adolescent Psychiatry in Cleveland Clinics Neurological Institute. Joe, welcome to Neuro Pathways.

Joseph Austerman, DO:

Thanks for having me.

Glen Stevens, DO, PhD:

So Joe, tell me a little bit about yourself. What's your background? How did you get into the area? Just give our audience a little who you are?

Joseph Austerman, DO:

Well, I'm originally from an old steel town near Cincinnati, and I did my undergraduate in medical school at the great Ohio University. So I'm a state born and bred, and I've lived in almost every corner of the state. And I came to the Cleveland Clinic because I was interested in psychiatry and pediatrics and I stuck.

Glen Stevens, DO, PhD:

And how long have you been at the clinic?

Joseph Austerman, DO:

So I started here in 2003.

Glen Stevens, DO, PhD:

Oh, okay.

Joseph Austerman, DO:

So I've been here a little while.

Glen Stevens, DO, PhD:

I was reading recently that they changed the suicide hotline number, but they changed it to a much easier number, which is 9-8-8.

Joseph Austerman, DO:

That is correct. A lot easier to remember.

Glen Stevens, DO, PhD:

And I think that they did that in follow up of the 9-1-1 and thought that that would be a lot easier. Is there anything else to it, why they chose the eight?

Joseph Austerman, DO:

Well, they needed a number that was available and they thought that that would be an easy number. And there were a couple committees that looked into that and chose that number as being the best one to use.

Glen Stevens, DO, PhD:

So just from an education standpoint with your patient population, is this discussed with everybody or not all the patients?

Joseph Austerman, DO:

Of our patients, we are now discussing this number and it's something that we always typically discuss when dealing with our patients and families. But now it's made it a little bit easier. Anytime anybody goes with any paperwork or after visit summaries with us, they have that number. They also have other suicide resources for them available.

Glen Stevens, DO, PhD:

So we touched on it a little bit in the intro, but can you give us a glimpse into the current state of adolescent psychiatric needs?

Joseph Austerman, DO:

So if you look at a historical bent for about 30 years, every year, the rates of teen suicide and mental health utilization was creeping down until 2008. And in that year we saw a reversal of that trend. Then every year since that time, we've seen an increase in utilization of mental health services for teens, and more concerningly, an increase more significant in youth, so children under the age of 13. And that trend persisted up until the COVID pandemic.

Now, if you look at what has been happening in our world in 2008, many people don't like to remember, but we had the housing crash, the subprime loan mortgages, and what we found was the destabilizations of families, the increased stress in our world, affects our kids. And so that translates into this increased utilization of mental health services since that time. But since 2019, that slow trickle has become a tidal wave for us in the mental health world.

Glen Stevens, DO, PhD:

So I'm not a psychiatrist, I'm a neurologist, which is interesting because my board certification says psychiatry and neurology, but I'm certainly not a psychiatrist. But traditionally, how have you managed these patients? How do you see them? How do you manage them? Tell us about your day to day?

Joseph Austerman, DO:

Well, and this is something that is very familiar to most people. You see this in TV and movies. You go to a therapist, you go to a psychiatrist, traditionally you're going into the office and talking to them one-on-one. You develop that relationship with them. And typically in my world, when we start seeing these kids, we see these kids until they're grownups, and then we transition them to adult services if needed. And so they stay with us. And most times, in the traditional model, they tend to see us almost four times more frequently as they see their pediatrician. And that should make sense if you're seeing these kids often during the year.

But what we found was that that model's inadequate. First being, there's always been a shortage of child psychiatrists and therapist. And so there's been this large national dearth of providers. And in that traditional model, even prior to the pandemic, what you saw was kids waiting months, sometimes years, to get in to see a mental health expert. And so that traditional model, once the pandemic hit, no longer really served this nation in any meaningful capacity.

Glen Stevens, DO, PhD:

And in some ways, maybe the Telemedicine was a positive thing. If you're somebody in an underserved area and you did not have access, as you say, it's a limited pool of people, then everybody came on with Telemedicine, the good and the bad of it. But now allowed these individuals, especially as they changed the laws, and you didn't necessarily need a license in a particular state, that you could see any patient practically Telemedicine wise elsewhere, allowed them to have the services. So that would be a very positive.

Joseph Austerman, DO:

That was an extremely positive outcome of this. And a silver lining. It really broke down some barriers to caring for kids. Now, what it also highlighted was that there is an inequity for this because for you to be able to do a virtual visit, you need internet, you need a computer or a cell phone. And what we found where there are some communities, specifically African American and Latino children are at a lower rate of use for or access to internet services.

And so some of these kids were even worse in being underserved because they couldn't come into an office locally because there were COVID restrictions and they couldn't jump online. So while virtual care has really revolutionized how we've been able to provide care and broken down some barriers, it hasn't brought everybody up to that need. And that's where we need to focus.

Glen Stevens, DO, PhD:

Yeah, it's easy to get very insular and think that everybody has access to a computer, internet, those types of things. I'm curious, I think that the benefit of allowing individuals from other states that don't have access to psychiatrists that could then do it, that had internet access as the rules have kind of gone back, what I'm hearing is that, again, if you don't have a relationship with somebody, and you don't have a license in that state, they have to physically come see you. So now we're sort of going back to these individuals that don't have access. How are we going to serve them?

Joseph Austerman, DO:

Well, I think that it is a tricky minefield to navigate. And these kids and their families, we started treating them and now all of a sudden we can't treat them if they're not in this state. And so we're trying to get as many workarounds as possible, but the real action has to come from government action and supporting these laws and continuing to work to decrease barriers. And we're actively working with our states and our federal government to make more common sense legislation around this.

These rules are artificial and we've proven that they don't need to be there. We can take care of these kids. We should be able to. And so really lobbying our government is where we're focusing our energy right now.

Glen Stevens, DO, PhD:

So what's the breakdown of your practice for seeing patients in person versus virtual? I'm just sort of curious how it is at this point in time?

Joseph Austerman, DO:

Prior to 2019, I only saw 10% of my kids virtually. Now our department at large is seeing 70 to 75% of our kids in a virtual space. That's an overwhelming majority number of our kids. And what we've found is kids and families very much like their psychiatric appointments, virtually.

I can't tell you how many times it will jump onto a virtual visit and they'll be in their school parking lot with mom and kid in the car. They can come in, they can go right back to class. It's so much less disruptive to their life than trying to travel 45 minutes, sometimes two hours, to get to my office to see me where we can do largely the same things virtually in psychiatry.

Glen Stevens, DO, PhD:

Have you looked at no-show rates?

Joseph Austerman, DO:

Yes.

Glen Stevens, DO, PhD:

What's that showing you?

Joseph Austerman, DO:

So our no-show rates are minimal at best now, virtually. Again, decreasing those barriers to getting care has been key. And for the majority of the patients that we serve, they do have internet and they are able to log in and it is decreasing those barriers. So we are intensely focusing on those kids that don't and making sure that we do have in-person options and still regional options that these kids can be seen in person.

Glen Stevens, DO, PhD:

So there's always got to be some hidden negatives to doing it, not seeing the patients physically there. What are the negatives to doing it virtually?

Joseph Austerman, DO:

There is something about being in a room with somebody that you just don't capture virtually. The subtle movements, the interactions that they have with their parents, that human interaction is something that, increasingly in our world, we're missing. And that's a completely different talk on how we are becoming more and more divorced due to our technology.

But it is critical connecting with people to at some point be in that room. And that provider patient relationship suffers a little bit, I think, when you're providing all virtual care. We can get the basics done, but there is that little bit of extra benefit of being in person that we're missing.

Glen Stevens, DO, PhD:

So in psychiatry and adolescent psychiatrists, did you guys do shared medical appointments? Or in psychiatry, you don't do that?

Joseph Austerman, DO:

And so that was one of the things that we really transitioned to. And again, this problem existed before the pandemic, but was highlighted, there are not enough providers. And even prior to the pandemic, if you wanted to come see me, you had to wait several months before you could get into my office. And so that's really part of this whole redesign that we looked at our section and said, "How can we see more kids? How can we do it more effectively? And is there an evidence base for that or could we create one?"

And so developing shared medical appointments was part of that package. And being on this podcast right now, I have my nurse practitioner running our shared medical visit as we speak. So whenever you can see nine to 12 patients in the space of one to two, you're going to be able to see more patients and provide more care. And we track these outcomes. And what we've discovered is that kids actually get better a little bit quicker than when they're in individual care.

And part of that is being in that group and getting more information out of that group and not feeling so alone in this space. Kids tend to feel alone when they have negative emotional problems. And seeing other kids struggle with that helps.

Glen Stevens, DO, PhD:

So as they say, "It takes a village." So social workers are involved, psychologists are involved. How are they finding the virtual aspects of it for their practice?

Joseph Austerman, DO:

So I think that they are in the same boat as we are, as psychiatrist, a little bit more. And when I'm looking at prescribing medication, diagnosing symptoms, that virtual care I can suffice. I think that when you're doing more of the therapy aspect of that, and that communication, what I've universally heard from the therapist that I know, the social workers, is that it becomes a little tougher. They prefer the in person, they prefer that aspect of being there. It's doable. And there are benefits, again, significant benefits to virtual care, but it's not a panacea, it's not going to be all that. So always that hybrid model and being able to offer both options is key.

Glen Stevens, DO, PhD:

There's probably a sweet spot depending on what type of practice you run. Some it's a lower percentage, some probably a higher percentage. But I think that for my own practice, everybody was doing virtual visits before the pandemic, but as you discussed, it was a low percentage. We're maybe doing 10% or maybe even less. And it's just made everybody more flexible.

And I think that the same in our practice in the brain tumor field, we just have learned and evolved in terms of when it makes sense and when it doesn't make sense and when patients need to be seen and virtually is fine for those patients. I know that you've done some in high school type practice. Tell us a bit about that?

Joseph Austerman, DO:

Well, and again, we're in the business of trying to lead healthcare and our mandate is to see how we can bring healthcare to the patient and really remove ourselves from that model of the patients come to a center. How can we break down barriers and get care to the kids that need it the most?

So we've talked a lot about virtual care, but one of the programs that we started even prior to the pandemic was, "Well, kids are in school. That's their job. That's where they're at. Can we provide care in that space? Can we remove some of these barriers?" And so we partnered with Cleveland Clinic Community Care, which includes family and internal medicine along with general pediatrics, who built a physical space in a local high school that provides sports physicals, routine medical care. But a big component of that was mental health care.

And so these kids don't have to leave school. And what we found was that really significantly positively impacted kids. They were able to get to care when they needed it. So it prevented crises. So when they had a bad day, they could get to a clinic right on site. It reduced no-show rates significantly, even prior to virtual care. The providers were able to get these kids in a captured setting. And so we look at it as a preventive care model.

But also one of the redesigns of mental health care is understanding that we as psychiatrist or psychologists aren't working in silos. We can help others provide mental health care and wraparound services. That includes teachers, janitor, school counselors. And so we expanded our team and so we could look, and the teachers and the school personnel knew these kids much better than we were. And what we found is that they were identifying kids. They would not have gotten care, they would've just suffered. But the teacher recognized something and said, "Hey, why don't you do this? Why don't you go see a psychiatrist?" And that breakdown of barriers has been world changing. And so we are really focusing our efforts now.

Now we have limited providers, so we are integrating into some schools, but now providing virtual care to some schools. So we're, again, that hybrid model to help increase access and continue to build this team around these kids. As you said before, "It takes a village."

Glen Stevens, DO, PhD:

And who's mostly staffing that? Is that PAs, NPs, physicians, psychologists? All the above?

Joseph Austerman, DO:

All of the above. Again...

Glen Stevens, DO, PhD:

All hands on deck.

Joseph Austerman, DO:

All hands on deck for this. And it's really that team based approach that we're really looking for. When we look at this, everybody has a specific role. The psychiatrist, what we feel that we do the best in is diagnosing, initiating a treatment plan, and really tackling these crisis to stabilization. But working with therapists, working with social workers to connect these kids with other things they may need.

They may need internet services. So we connect them with our social workers who can work with the cities and state to get kids services. If they're in a food deprived area or a food desert, they can connect them with food services. And it's really about looking at these kids holistically and each part of these cogs doing their job in a team like fashion to help these kids grow in a healthy environment and mental attitude.

Glen Stevens, DO, PhD:

So we all sort of look at our practices and trying to figure out where it's going to go in the future. But at least from my practice, I see virtual visits as being a long term thing. And ultimately, I think at this point we see the majority of our patients in the brain tumor field, because most patients need MRIs, although they can do it closer to home and we have access to the films. Where do you see your psychiatric practice go?

Joseph Austerman, DO:

I think I see it similarly. And so what we are going to be doing is continuing this virtual space. I think there will be a threshold where the technology barriers become less and less, and then you diminish those in person needs, but continue to have the benefit of virtual care working in large teams with these kids, not only the medical team, but the community teams.

And so that's really where we're putting our energy into because understanding there's never going to be enough psychiatrists, there's never going to be enough therapists, and it's about doing what we do well and providing that cog in the whole wheel of serving these kids. And so that we're not doing it alone. And we have these teams. I think that's where we're going in the future and utilizing technology as much as we can to do so.

As we get better, there will be better technology to be able to diagnose, to be able to look at these kids, genetic testing, imaging testing, to be able to develop better prescriptive plans, better utilize therapy plans. And app based space. So one of the things that we do is we partner with mobile apps that can help provide therapy at all times of day or stress reduction techniques. And so that augments our ability to treat these kids and get them to a place of health.

Glen Stevens, DO, PhD:

One of the things that we see in brain tumor is that if a patient has been had a pediatric tumor and they've been followed by the pediatric neuro oncologist for some period of time, they have a really difficult time moving on from the pediatrician.

Sometimes we'll see pediatric brain tumor patients being followed that are in their 30s. How is that in psychiatry field? I would imagine there's some of the same types of problems?

Joseph Austerman, DO:

Exact same type of problem. Once our patients know us and we know them, one of the big stress points that we have is being able to transition them not only from their side, but our side. These kids have grown up with us, we've got them to a healthy place. We want to see them continue to grow up. So it's hard for us to turn kids over.

And so we really try to partner with our primary care and our adult providers and being able to safely and slowly transition these kids to adult services. One of the programs that we have is our passport program where starting at age 13, the kids get a virtual passport where we start to check off things. Do you know your diagnosis at 16? Can you tell me what medications you take? Can you tell me who your therapist is? What do you do in an emergency? And as they progress to that age 18, 19, then we feel like they have a good knowledge of what they're being treated with, how their treatment's going. And then we're focusing on getting them warm handoffs to other providers."Hey, I know this psychiatrist I'm going to be referring you to." And so we partner with our adult colleagues to get them transitioned to that stage. And sometimes we co-treat them for a little bit with this, until they're ready to make that step. That's a significant stress for us though.

Glen Stevens, DO, PhD:

So we discussed the gravity of this situation in the last six months or so is it plateauing? Are the problems continuing to escalate? Are they slowly getting better? We don't have the data. Anything you can tell us about that?

Joseph Austerman, DO:

What we saw with this, really this tsunami of mental health crises that we saw during the pandemic, we began, as soon as the restrictions were lifted, we saw a brief reprieve. Because a lot of these kids that weren't being socialized because they were being quarantined and having that normal peer-to-peer interaction at school and being at school, we found that they were a little socially delayed coming back into school. But for the most part, people were really happy. And so we saw a brief dip.

But now we're starting to see the other side of that dip where anxiety rates, depression rates are again starting to escalate. And what we know from local epidemics in the past, for example, Ebola epidemics, some epidemics in Southern Europe where we've looked at this long term, what we found was the mental health crisis persisted for 10 to 20 years after the actual epidemic.

And so when the physical safety risk abated the mental health crisis didn't, and we expect that globally to continue. So we expect that there are going to be long term ramifications of this that we're going to have to deal with, and hopefully we're designing a better program to deal with it going forward.

Glen Stevens, DO, PhD:

So it sounds like you can't retire at any time in the future?

Joseph Austerman, DO:

In the future, I hope maybe they'll make a digital version of me.

Glen Stevens, DO, PhD:

So we mentioned shared medical appointments, but any additional thoughts on how care will continue to evolve for this growing population? Are there any new models out there?

Joseph Austerman, DO:

So here at the Cleveland Clinic, we're developing a new model of psychiatric care for kids. And it's really focused on taking kids in crises and moving them to a place of stabilization in a teams based approach.

Again, we want to get these kids as quickly as possible, sometimes we can't. And so we have our school-based preventive model and our general longitudinal clinics, but really developing disease-specific programs. And this is all based on what we saw the data driving. So when kids come to us, we looked back and said, "What are they coming to us for?" Anxiety, depression are the two main drivers. And so we developed specific programs to help get them from a place of crisis to stabilization within six months and working with our primary care team to take that care on so that we can continue to get these kids and get them in quickly.

And the quicker we can get them in, the quicker we can stabilize them and get them back to their local team. And so developing multidisciplinary programs around these kids focused on stabilization actually gets them better quicker. And we have a lower need for ongoing care in the future. So that's really where we're revising our model and utilizing both the bigger team of professionals, utilizing social media, and app-based programs and technology and virtual care.

And it's really the leveraging of all these services packaged into specific programs that I think is going to drive care in the future and get more kids seen quickly.

Glen Stevens, DO, PhD:

I guess the problem with social media is maintaining them on the correct social media?

Joseph Austerman, DO:

Yes.

Glen Stevens, DO, PhD:

Not getting all their psychiatric care from TikTok.

Joseph Austerman, DO:

Exactly. We want it to be professionally based social media and not peers or influencers.

Glen Stevens, DO, PhD:

And as we're getting towards the end comments about drug use changes?

Joseph Austerman, DO:

And so just like with primary mental health, we saw an increase. We've seen a skyrocketing rate of substance abuse. And interestingly that substance abuse tends to be around the patient. It's actually adults that have seen a bigger increase of substance abuse.

The problem being is that has led to increased destabilization of the family unit. It's led to a significant increase in domestic violence, and then that feeds into pediatric mental healthcare.

Prior to the pandemic, and still now, we're seeing some of the lowest rates of substance abuse in kids and younger teens. It's that family unit that has turned to drugs and alcohol, but that has significantly negatively impacted kids.

Glen Stevens, DO, PhD:

So any parting insights you might share with our listeners who are facing the same challenges in their practice?

Joseph Austerman, DO:

So when you have patients and you're dealing with this, don't be afraid to ask them the questions. Don't be afraid to ask them if they are hurting, if they are depressed or anxious. There is help. There is connected care that we can provide rapidly and that they can be connected to our services with a touch of a button and we take it over, but we work as a partnership.

We will stabilize them, we will get them back better, and get them back to you in your care as quickly as we can. But there are support networks that are there and available for kids.

Glen Stevens, DO, PhD:

Yeah, I think that's a great point. I think some people are scared that if we say it, if we put a name to it, then it'll make it worse. Where it's really the opposite and we have to say it. We have to acknowledge it, and then we can move forward and we can find an avenue for treatment for it.

Joseph Austerman, DO:

Exactly.

Glen Stevens, DO, PhD:

So I love that point that you made. Well, Joseph, we appreciate all that you and your colleagues are doing for these patients. It sounds like you have job security for the future, unfortunately. Thank you for joining me for today's podcast.

Joseph Austerman, DO:

Thanks for having me. It was a pleasure.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.