Delaware Struggles to Remedy Serious Psychiatrist Shortage

A massive child-molestation case and a spate of high school suicides in southern Delaware led to calls for more mental health services in the area, but attempts by the psychiatric community and state health officials to respond have produced only mixed results.

Delaware has just three counties, and the two southernmost—Kent and Sussex—are also the most rural. The two counties were rocked by the arrest in 2009 and eventual conviction of pediatrician Earl Bradley, M.D., of seaside Lewes, on charges of assault, rape, and sexual exploitation of at least 100 children in his care.

Then, from January 11 to March 22, 2012, eight young people aged 13 to 21 died by suicide in the two counties, twice the average annual number reported in previous years.

The suicides prompted a study by the Centers for Disease Control and Prevention (CDC), which found that over a slightly longer time—January 1 to May 4, 2012—there were 11 deaths by suicide in Kent and Sussex counties. The CDC found that all decedents had two to five risk factors such as mental health problems, parent-child conflicts, legal issues, relationship problems, or substance use.

The CDC recommended several prevention strategies, including training to identify at-risk youth and guide them to services; development of youth programs; monitoring trends in youth suicidal behaviors; reviewing evidence-based suicide prevention strategies; and continued implementation of CDC media guidelines for reporting on suicide.

Meantime, the Bradley case led the state legislature to authorize a study of mental health needs in Kent and Sussex counties. The study called for improved training for child mental health professionals in the two counties, better case-management services, and a review of the adequacy of child mental health coverage under public and private insurance plans.

The study noted that all of Sussex and part of Kent County did not meet federal standards for a variety of mental health professionals, including psychiatrists.

“There is no one full time at the hospitals in Kent and Sussex and no inpatient units,” said Carol Tavani, M.D., president of the Delaware Psychiatric Society, in an interview. “That’s a real crying need.”

Beebe Health Care in Lewes closed its inpatient psychiatric unit at least 10 years ago and has relied for the last two years on telepsychiatry to evaluate patients in the hospital’s emergency department or for consultation for medical patients with psychiatric comorbidities, said Loretta Ostrosky, R.N., M.S.N., director of patient care services. Patients in crisis can be referred to private nonprofit agencies, while involuntary commitments are processed through the state, which assigns patients to hospitals elsewhere.

There are real socioeconomic divisions in the county. The eastern edge, along the Atlantic coast, is home to a string of bustling and often posh resort towns. Inland, though, lie flat farming country and small towns.

The legislative group set a high bar for the psychiatrists they hoped the state would hire. They wanted psychiatrists “willing to practice in a consultative role, with family doctors and pediatricians, rather than providing all services in a one-on-one fashion,” clinicians who would not only work in the rural west of the county but also be available nights and weekends—and speak Spanish. The latter reflects an increasing population of immigrants drawn to agricultural and food-processing work in the county.

Tavani sees a number of complicating factors in western Sussex, where socioeconomic measures are lower than on the coast. They hold true for most other rural areas in the United States as well.

“There’s a relative lack of awareness about psychiatric issues and that help exists for [patients seeking it], she said. “Fewer people have insurance or it’s hard to find someone to take Medicaid. There is also a lot of stigma attached to psychiatric issues, and so we have to educate the public.”

Despite intensive recruiting efforts, no psychiatrists have signed up so far, although a loan-repayment program has attracted a “significant” number of nurse practitioners and social workers to Kent and Sussex, said Jill Rogers, M.S.N., executive director of the Delaware Health Care Commission.

The state does provide some funds for hiring mental health counselors in schools and for mental health first aid training statewide. Another program trains school personnel to recognize depression.

One child psychiatrist, Mark Borer, M.D., splits his time between his mid-state Dover office and trips to behavioral health contractors around the state, including at Georgetown, in Sussex County, where he consults with primary care physicians and psychiatric nurse practitioners.

Lack of incentives may not account for the continuing deficit in Kent and Sussex, suggested psychiatrist Gerald Gallucci, M.D., M.H.S., medical director in the office of the secretary of the Delaware Department of Health and Social Services.

“Delaware has no medical school,” said Gallucci in an interview with Psychiatric News. “And the only residency program is at the Delaware State Hospital in New Castle, near Wilmington.”

That hospital has just 14 slots and is not based at an academic medical center. Residencies typically send their graduates into the local medical system, so the state lacks that feeder system. Gallucci has created some educational connections with Thomas Jefferson University in Philadelphia and Johns Hopkins in Baltimore, which he hopes will eventually bear fruit.

So far, though, loan-forgiveness programs plus the blandishments of country or seaside living have not been enough to solve the psychiatry shortage in Kent and Sussex counties.

“I used to joke that maybe we should give candidates a few weeks in a beach house to see if they’d make up their minds,” said James Lafferty, B.S., executive of Mental Health America in Delaware, an advocacy group. “Maybe we should give it a try.” ■