Essex County Board of Supervisors
ELIZABETHTOWN — Essex County has been without a full-time medical director and staff psychiatrist since the mental health department’s medical director, Dr. Kausar Chaudhry, resigned last December.
Chaudhry was a staff psychiatrist who served as the department’s medical director.
Patients are still receiving care, said Mental Health Services Director Stephen Valley, and residents are not being discharged.
“When a patient comes, they have a primary counselor who works with them,” explained Valley. “Some, not all, also see a prescriber. The vast majority are still coming to the clinic and receiving their counseling services.”
Lorna Jewell, the office’s psychiatric nurse practitioner — a registered nurse with additional training in psychology who is allowed to write prescriptions — has increased her workload from one to two days per week, said Valley, and is handling many of Dr. Chaudhry’s former patients.
Jewell cannot accommodate all of them, however, so the balance has been transferred to local primary care physicians for the purpose of prescribing their psychotropic medications.
“The general consensus for good treatment in mental health treatment is to combine therapy with medication,” said Valley, whose office is designed to provide, according to their mission statement, county residents with opportunities to improve their psychological well-being through therapeutic partnerships with mental health professionals.
County residents tend to require the same mental health services as the rest of the nation: treatment for mood disorders and depression are common, said Valley, and tend to be comorbid with substance abuse problems.
But shuttling them over to primary care physicians, while not detrimental to the patient, is just a quick fix to the staffing problem and isn’t a permanent solution to patient care, say officials.
“While a primary care physician can write a prescription, they don’t have the training to really offer counseling,” said Valley. “If you have a heart problem, you go to the cardiologist. Raising the bar for primary physicians to care for those who don’t have a psychiatrist available concerns me greatly.”
“It’s a big issue throughout the county,” said Elizabethtown Community Hospital (ECH) representative Jane Hooper. “Our emergency room is seeing increases in patients who need that type of care and it’s very challenging for our staff.”
Ultimately, according to ECH medical director Dr. Rob DeMuro, these patients require counseling and services from a medical professional skilled in that particular specialty.
“Physicians are always there to assist; but patients really require specialty care, something in addition to what their general practitioner can provide.”
The average number of people actively receiving treatment from the Essex County Mental Health Department at any given time is about 450, or about 1.2 percent of the county’s population.
Valley’s office treated more than 1,300 people in 2013, most of whom were seen in three visits or less.
The department’s staff includes 10 masters-level counselors, two care managers, two supervising clinicians, an assistant director and the director.
The psychiatrist shortage has been a longstanding issue nationwide.
While the U.S. population grew 4.7 percent between 2005 and 2010, the number of psychiatrists shrunk slightly from 38,578 to 38,289, according to the Association of American Medical Colleges.
According to a report issued last year by the US Department of Health and Human Services, almost 91 million adults lived in areas where shortages of mental health professionals made obtaining treatment difficult.
A report to Congress later that year said 55 percent of the nation’s 3,100 counties have no practicing psychiatrists, psychologists or social workers, the result of a perfect storm of budget cuts, doctors leaving the profession and a lack of young med school graduates eager to enter the field.
The reason for the shortages fall under three main hypotheses, said Dr. Kevin M. Antshel, Associate Professor of Psychology and Director of Clinical Training at Syracuse University.
The first, he said, is because psychiatry generally isn’t a popular medical profession.
“The common view among med students is that’s where the weak students go, which will lead to a shortage,” he said.
The second is because psychiatry as a profession is associated with high levels of burnout.
“It’s a difficult population to work with chronically,” Antshel said.
Lastly, young, freshly-minted psychiatrists tend not to be attracted to rural areas.
“That’s not a problem in Manhattan where you might have trouble finding an internist, for example,” said Antshel. “Psychiatrists tend to gravitate to metropolitan areas.”
“Despite how beautiful the North Country is, it’s hard to attract professionals here,” he said. “For a lot of doctors we have in this area, psychiatry seems to be an aging speciality. At the same time, the culture of mental health treatment has gone mainstream and it’s becoming more acceptable to seek out help for those problems.”
Fifty-seven percent of practicing psychiatrists are at least 55 years old, established, approaching retirement and more selective in who they take on, primarily patients who can afford to pay out of pocket.
Valley also said psychiatry is not as lucrative compared to its fellow studies and doctors can make more money as, say, orthopedic surgeons.
The mean income for psychiatrists — $186,000 a year — ranked 19th out of 25 medical specialties, and rose only one percent in 2012.
While a full-time medical director and psychiatrist is not a county-mandated position, said county manager Daniel Palmer, the county does have to adhere to state law and provide a medical director for a medical clinic and must provide a certain level of mental health services to the citizens required to receive those services from other county departments — like the District Attorney’s Office, for example, or Social Services.
Each county is structured differently when it comes to how they approach mental health.
Hamilton County, for example, doesn’t have a full-time psychiatrist or medical director, said Robert Kleppang, Hamilton County’s Director of Community Services.
“A psychiatrist comes in for one day every two weeks and that meets our needs in terms of adult care — we’re not heavily populated, we have less than 5,000 residents, so this system works for us.”
Kleppang noted, however, that the county is struggling to find a child psychiatrist.
“The larger issue is recruitment,” he said. “not so much the ability to fund.”
Franklin County, which has a population of about 10 times greater than Hamilton, doesn’t have a full-time director or psychiatrist, either, instead referring psychiatric patients to North Star Behavioral Care, a network of private behavioral health providers in Northern New York.
Clinton County (population 81,654) has a mixture of both private and public mental services — non-profits are paired with a county-run clinic — while Washington and Warren County have consolidated services in order to serve a combined population of about 130,000.
“It’s going to be a real challenge moving forward,” said Valley. “We’re providing the best services we can under the circumstances.”
Following national trends in health care, the county is in the process of expanding their telepsychiatry services.
“We use that to provide psychiatric consultations to support the primary physicians who are prescribing meds,” said Valley.
The search for Dr. Chaudhry’s replacement is ongoing. Taking the search national, advertisements have been placed on the American Psychiatric Association’s website. Valley is also contacting med schools with psychiatric residency programs to scout out new talent.
“We’re trying to find out if someone’s coming out of residency this spring to see if they’re interested in community mental health in a rural setting,” Valley said. “We’ve got a good quality of life here in the North County and hope we can find someone soon.”