From 2012 to 2016, 47 Hawaii youths ages 10 to 19 killed themselves.

A shortage of mental health providers is one of the obstacles to providing mental health care to youths, to the point that extreme cases sometimes get sent to the mainland. Currently, 14 Hawaii youths are at specialized treatment facilities thousands of miles from home.

“Honestly, I don’t think that there will ever come a day where we will not have to use the resources of other states as a last resort,” said Lynn Fallin, deputy director of the Behavioral Health Services Administration at the Department of Health.

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According to a 2015 report by the Substance Abuse and Mental Health Services Administration, only 30 percent of adolescents ages 12 to 17 were treated for their depression in Hawaii.

The limited access is one result of Hawaii’s overall shortage of health care professionals. According to the University of Hawaii annual systems report to the 2017 Legislature, the state is short about 500 physicians overall, and specifically is in need of 15 more psychiatrists.

“That workforce shortage is a challenge for the behavioral health field as well,” Fallin said.

Prevention Versus Reaction

Advocacy groups like Mental Health America of Hawaii say it’s crucial to assess and help youths in the early stages of mental health problems, and that not enough resources are devoted to that. In Hawaii, the leading cause of death for youths is suicide.

“We’re trying to shift the focus from reaction to prevention in our schools,” said Mara Pike, community outreach manager of MHA Hawaii. “Unfortunately, it’s primarily volunteers doing the work of suicide prevention in this state.”

Early mental health treatment involves a combination of awareness, counseling and training techniques employed to reduce incidents of self harm, injury and intensified mental health problems.

While state entities like the Child and Adolescent Mental Health Division provide care for youths with severe needs on Medicaid, community health centers and other organizations do a lot of the heavy lifting on the early treatment of mental health issues and suicide prevention.

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Currently there are about 2,500 youths enrolled in the state’s mental health services program because of their eligibility for low-income Medquest status, with a few hundred making use of the services provided by CAMHD, which include intensive in-home care services that allow youths to be treated by mental health professionals in familiar surroundings.

“You want to impact the kids in an environment that’s as close to reality as possible,” said Dr. Stanton Michels, division chief administrator of CAMHD. “We don’t want to institutionalize them.”

Children and teens who aren’t eligible for Medquest due to their family’s income status, can either be referred to a mental health professional by their health care provider, or seek help from a school counselor.

But those counselors tend to have overwhelming caseloads and end up referring parents to outside mental health care services — stretching resources that are already in short supply.

According to Troy Loker, president of the Hawaii Association of School Psychologists, school counselors generally provide the first level of support for students, but their involvement is usually limited to dealing with short-term incidents.

“My understanding is that school staff is pretty open with parents, that ‘I don’t have the time,’ but there are other sources they could use,” Pike said.

The school district can also use school-based behavioral health specialists, whose primary responsibility is to provide support to counselors and assess the mental health needs of students. But there are only 20 certified behavioral analysts on staff and another 20 are contracted to the state, according to the Department of Education,

Hawaii’s Caring Communities Initiative for Youth Suicide Prevention, operated out of the University of Hawaii, works with community groups to raise awareness about teen suicide and provides suicide prevention training across the state.

“We know from the work that we’re doing, that the youth in rural communities have to wait a very long time to get treatment,” said Deborah Goebert, director of the initiative. “The last time a new (advanced practice registered nurse) that was accepting both adults and adolescents came in, they had to stop taking in new patients after two weeks.”

Goebert said the nurse was accepting mental health care patients, and the speed with which her workload filled up is a prime example of the need for mental health care professionals.

A Gap In School-Provided Care

In 1994 the Felix Consent decree was approved by a federal court, mandating that mental health and educational services in Hawaii be improved to meet federal standards and giving the state a 2001 deadline to do so. In 2002, the Department of Education was found to be in “substantial compliance,” meaning the requirements for staff and services had been met.

From that point, federal oversight was dropped and the DOE took over the responsibility of monitoring compliance with the standards.

“When we had the Department of Education working with the Department of Health more, it was more efficient with a lot more kids getting help,” Goebert said. “When the federal consent decree ended, there was no incentive to do that anymore.”

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One area where the DOE falls short is in the small size of its school psychology staff. The federal recommended ratio, according to the National Association of School Psychologists, is one school psychologist per 500 to 700 students. In the Honolulu District in southeast Oahu however, there are about two school psychologists per complex.

A complex is a high school and its neighboring middle and elementary schools. In the Kaimuki complex for example, there are about 4,108 students, meaning two school psychologists would be responsible for more than 2,000 students apiece.

“There’s a shortage of us in the state so we usually have to spend a heavier amount of time on special education assessments,” said Loker. “This takes away from time we can use to deliver more comprehensive mental health services.”

Right now four of the 12 school psychologist positions in the DOE’s Honolulu District are vacant, and Loker said Hawaii’s lack of a training program for school psychology only makes matters worse.

“If we had time to put more of our efforts into mental health promotion and prevention, we could reduce the number of crises and chronic mental health problems that happen,” Loker said.

Reaching Out To Rural Areas

In 2006, Hawaii’s Caring Communities Initiative for Youth Suicide Prevention and the state Child and Adolescent Mental Health Division started providing telepsychiatry services to youths in Hawaii’s rural communities in an effort to increase mental health care access.

“If you were living in Kau (in rural Hawaii County) where they don’t necessarily have the care you need, you could Skype someone in Honolulu and it would be hopefully as beneficial as if they were sitting on the couch with them in their office,” said Kelley Withy, the lead doctor in charge of UH’s John A. Burns School of Medicine’s Hawaii Physician Workforce Assessment.

Since its inception, the availability of telepsychiatry has expanded statewide.

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In April 2016 the Legislature passed a resolution that recommended the Prevent Suicide Hawaii Task Force, a group of several mental health organizations across the state, create a “strategic plan to reduce suicides in Hawaii” by at least 25 percent by 2025. The task force is expected to present the plan during the 2018 legislative session.

“A lot of the work being done in the plan is already being done on a smaller scale,” Pike said. “The goal is to ensure that every community has (mental health) groups, providers and services available.”

Last year was also when House Bill 2357 was passed, decreasing the age of consent for adolescent mental health services from 18 to 14. This meant that teens who wanted mental health treatment could get it without notifying their parents.

That’s important because, according to the Interagency Working Group On Youth Programs, some teenagers forgo treatment because they don’t want their parents to know that the problem exists.

“Part of improving things is making sure that the public is educated about when to seek care for their child,” said Trisha Kajimura, executive director of MHA Hawaii.