Lanai resident Uri Cabatu is a single mother of a 14-year-old boy with autism and attention deficit hyperactivity disorder.

Her son takes psychiatric medications to control his outbursts, tantrums and other challenging behaviors and to improve focus. There’s no psychiatrist on Lanai, so Cabatu relies on telehealth appointments with a provider in Honolulu to keep her son’s prescriptions up to date.

But the provider won’t refill a medication without seeing the boy on screen, and busy schedules make that hard to pull off, which has resulted in medication delays.

“Sometimes he skips medications for two, three days, up to a week,” said Cabatu, who works as a home health care aide. “It’s very difficult.”

When her son goes off his medication, his behaviors can rapidly deteriorate and stress within the family can spike, affecting everyone’s mental health and emotional wellbeing.

Valerie Janikowksi, a registered nurse on Lanai and Cabatu’s employer, knows the struggle well. Her 18-year-old son also has ADHD and requires medication. He was diagnosed at age 4 by a psychiatrist in Honolulu. Telehealth was just starting to emerge in Hawaii in 2010 so the family flew to Honolulu for appointments, a cumbersome, time-consuming and expensive process.

“It was exhausting,” Janikowski recalled.

Although telemedicine eased some of that strain for families like Cabatu’s and Janikowksi’s, it’s no panacea, especially for children who find it hard to bond or express their feelings with a health professional on a screen.

But with a severe shortage of pediatric psychiatrists in Hawaii, combined with growing demand for mental health services fueled by the pandemic, social media, bullying and other factors, many Hawaii families are desperate to find whatever help they can get.

In the best of times, navigating medical bureaucracy can be a head-pounding experience. But hunting for a child psychiatrist or therapist on the neighbor islands can often seem downright fruitless.

“I have people who are waiting up to nine months for an appointment,” said Mark Ansel, a Big Island therapist with a doctorate in social work.

The dearth of providers and the consequences from that shortage are borne out by data from the University of Hawaii Manoa, community surveys and interviews with mental health providers, patient liaisons and families.

Despite the grim statistics, some hope may be coming. Efforts are underway to ease some of the strain by getting more people trained as mental health providers. That would include everyone from masters-level community therapists to advanced nurse practitioners and physicians with degrees in psychiatry.

Limited Resources

It’s a bleak picture across the neighbor islands.

Maui had two full-time and three part-time child psychiatrists last year. Kauai had one full-time pediatric psychiatrist and one who works part-time.

In 2022, the Big Island had one full-time child psychiatrist, who is currently not accepting new patients, and two part-time ones. There are none on Lanai or Molokai.

That’s according to data compiled by Dr. Kelley Withy, a professor at the UH John A. Burns School of Medicine who produces the annual Hawaii Physician Workforce Assessment.

Why the neighbor islands lack psychiatrists and why so many of those in practice are nearing or at retirement age stems from a variety of factors.

There’s Hawaii’s astronomical cost of living for one. Combine that with the high cost of rented office space, lower reimbursement rates for insurance programs like Medicaid and Medicare, lack of professional networking opportunities, and the isolation of rural, island living and you find a situation that deters doctors.

Hawaii is also one of just two states that collects a general excise tax on medical services, an added disincentive for physicians, especially those who are treating Medicare patients who are among those most vulnerable.

“You’re not going to get young practitioners here who are going to want to pay for the costs of medical school, establish a family, buy a house and build a practice. They can’t afford to,” said Dr. Michael Farnsworth, a psychiatrist on the Big Island.

“Older psychiatrists like me can come and semi-retire. But we’re only going to be around for a short period of time,” he said. 

Farnsworth treats children who are 14 years and older at Kipuka o ke Ola Native Hawaiian Rural Health Clinic in Waimea.

Long Waiting Lists

It’s not just child psychiatrists who are in short supply. It’s mental health practitioners in general. Clinical social workers, marriage and family therapists, licensed professional counselors and psychologists are few in number compared to demand. Most have long waiting lists.

On Hawaii island, the ratio of clients to therapists is roughly 320-to-1, according to John Souza, a marriage and family therapist in Hilo.

It’s worse for therapists who specialize in working with children, and even greater for those living in rural communities, said Souza, a doctoral-level therapist who is past president of the Hawaiian Islands Association for Marriage and Family Therapy.

Hawaii is only meeting about 14% of its need for mental health services and the statistics are worse for children, he said.

The shortage of psychiatrists and other mental health workers is one facet of a larger issue with Hawaii’s well-documented paucity of doctors and mid-level health care providers.

A survey released last July of more than 3,500 community members and health care professionals in Hawaii found that psychiatry and mental health counseling are the two medical specialties most sought after. More than three-quarters of the health care providers who responded said the greatest demand for patient referrals was, by far, for mental health counseling and psychiatry.

The nonprofit Community First Hawaii conducted the survey in partnership with the Hawaii State Rural Health Association, Department of Health, Hawaii Health Systems Corp., Hawaii Medical Association, HMSA and Pacific Basin Telehealth Resource Center.

The survey included gut-wrenching stories from respondents.

“My teenager attempted suicide during the pandemic and ended up warehoused in an ER for six days due to a shortage of pediatric psych beds — at the time, there were 15 kids being held in ERs across the state waiting for beds to open up,” wrote an anonymous survey participant.

It’s especially tough on the neighbor islands for kids who need inpatient psychiatric care. Due to the lack of residential facilities for keiki in crisis, the children often have to be flown to Oahu or the mainland for treatment.

Although the medical transport staff are highly trained and compassionate, it can be traumatizing for a child to be airlifted off their home island and sent to Kahi Mohala, an 88-bed center in Ewa Beach on the west side of Oahu, the only in-patient facility in Hawaii that will treat children.

Requests to tour Kahi Mohala or interview the administrator were both denied.

Demand At All-Time Highs

As neighbor island residents struggle with the shortage of mental health providers, there’s no immediate relief in sight.

In fact, the need for mental health care is growing acute, particularly among adolescent girls.

According to the American Psychological Association, mental illness and the demand for psychological services are at all-time highs.

The U.S. Surgeon General issued a youth mental health advisory in 2021, saying national surveys at that time showed alarming increases in the rates of depression, anxiety and suicidal ideation among young people.

More recently, the Centers for Disease Control and Prevention released a Youth Risk Behavior Survey that said teen girls are experiencing record high levels of violence, sadness and suicide risk. Children in the LGBTQ+ community are faring even worse.

Nearly 1 in 3 teen girls have seriously considered suicide, up nearly 60% from a decade ago, according to the report. Nearly 3 in 5 teen girls felt persistently sad or hopeless in 2021, double that of boys.

With such dire statistics, many in the mental health profession are wondering what they can do when they’re already stretched thin with heavy caseloads, burnout and long lists of families trying to get in to see them.

Telehealth doesn’t work well for many younger kids with short attention spans, said Souza. It’s common for keiki to prefer tactile ways of connecting, like making art or working with sand trays or stuffed animals.

Many providers who once saw clients in person but pivoted to virtual appointments during the pandemic have stayed online because of the convenience of talking by phone or Zoom from their home. It’s also cheaper because they avoid the overhead expense of renting office space.

Psychiatry or therapy by computer also doesn’t work for many people who live without broadband internet, who can’t take time off work, who don’t speak English, who don’t have the right insurance or simply aren’t comfortable with a virtual format.

Seeking Solutions

Some states have managed to beef up Medicaid reimbursement rates to help schools expand their behavioral health services, including suicide prevention trainings.  

Others are taking innovative steps to recruit new mental health workers, providing grants to schools to develop programs to support children’s mental health, putting more counselors into schools, and providing free mental health consultations to students.

In his State of the State address, Gov. Josh Green said Hawaii is “in the midst of a health care crisis.”

The state is grappling with “4,000 unmet health care job openings” and growing mental health disparities among the state’s most marginalized populations, he said.

To address the crisis, he wants to add over 60 faculty positions and invest $4.4 million in nursing and medical-related training programs across University of Hawaii campuses and community colleges.

He’s also pledging to increase the Medicaid reimbursement rate for providers by seeking $30 million in state funding and $35 million in federal funding.

To attract new doctors and mental health workers, Green said he’s seeking $10 million in fiscal year 2024, which starts July 1, and $20 million the following year to repay student loans for primary care and behavioral health providers who serve rural and underrepresented populations. 

Recruiting Hawaii residents to become mental health providers is a long-term strategy that several people in the profession said is the best way to tackle the shortages.

Local residents know what it’s like to live here. They understand the cost-of-living pressures, the cultural diversity and the geographic challenges of life — especially on the rural neighbor islands. Armed with that knowledge, they may be less likely to move to the mainland when things get tough.

But a significant barrier to entering the profession pops up immediately after graduates earn their master’s degree in social work, psychology or counseling.

New graduates need to gain hundreds of hours of clinical experience working under a licensed professional’s supervision before they can bill insurance companies to collect payment.

During that time, which typically takes one or two years, the master’s-level degree holders can only accept clients who pay out of pocket. Beyond that, they just work for free until they accumulate enough hours to get their license.

Some people can’t afford the financial strain, especially if they’re already starting to pay off student loans. Some end up switching professions or becoming life coaches where no degree is required.

A bill to address the licensing hurdle is working its way through the Legislature. House Bill 1300 would establish a provisional or associate-level license for mental health workers new to the field.

The legislation, which cleared its final Senate committee hurdle Tuesday, would authorize insurance reimbursement for services provided by unlicensed practitioners who are in the process of accumulating their supervised hours.

“This is about increasing the number of providers available to people who have insurance,” said Souza, who’s optimistic the bill will pass this session.

Hilo therapist Kim Pierce said it’s critical for Hawaii to have more licensed mental health providers not just to ease the psychological suffering of children but to prevent many from ending up in the criminal justice system later on in life.

“The counts at the jails are only going one way,” said Pierce, owner of Root2Rise Counseling Center.

Pierce has written multiple recommendation letters for people applying to the master’s program in counseling psychology at the University of Hawaii Hilo. But only about 20% of all applicants end up getting accepted.

The person who directs the program, Charmaine Higa-McMillan, said she would love to admit more students but with the current size of the faculty, it’s impossible.

Higa-McMillan wants to hire two more assistant professors and a program coordinator to expand the master’s program. The Board of Regents has asked the state for an additional $210,000 so that the hiring can move forward.

Christian Kimo Alameda, vice president of business development at Hawaii Island Community Health Center and a licensed clinical psychologist, said getting HB 1300 passed and expanding the counseling program at UH Hilo are two concrete steps that need to happen to help solve the youth mental health crisis on the neighbor islands.

The way Alameda sees things, it’s a matter of equity and moral responsibility.

“There are a lot more options on the island of Oahu than there is on the neighbor islands. It kind of makes us feel like stepchildren almost. It’s significant and we need to raise the consciousness and do something about it,” Alameda said.

Janikowski, the mom of the 18-year-old son with ADHD, said she could not agree more. Having psychiatrists who live and work on neighbor islands would help families to deal with the complexities and burdens that come from raising a child with mental health challenges.

At the very least, it would lift some of the strain of having to repeatedly search for a psychiatrist, a process that typically involves multiple phone calls, voicemails, emails, callbacks, referrals and copious amounts of paperwork. And that just starts the waiting process.

“It takes a great amount of time,” said Janikowksi.

Cabatu said having someone on island to help her better handle her son’s behaviors would greatly ease some of the strain she bears as a single, working mom. Often times, she feels alone. Asked what she does to educate herself about raising an autistic son with ADHD, Cabatu said she does what many struggling parents are left to do. She relies on Google.

“I search online,” she said.

Civil Beat’s coverage of Maui County is supported in part by grants from the Nuestro Futuro Foundation.

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.