Q&A: Top Doctor Ray Hsiao of Seattle Children’s Hospital Helps Kids With Mental Health and Substance Abuse Issues

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This article appears in print in the April 2018 issue, as part of the Top Doctors cover story. Click here to subscribe.

Why did you choose this specialty? 
When I was a medical student, I volunteered in the inner-city housing projects in Chicago. There was one child in particular who I worked with closely who struggled with co-occurring substance abuse and psychiatric issues. Her promising athletic career went to waste after her father forced her to deal drugs and got her hooked on cocaine. She inspired me to become an adolescent addiction psychiatrist to ensure kids who need help receive it early on, and to help them accomplish all the things they are meant to accomplish and maximize their life potential.

What do you like about working with adolescents?
Adolescence is a time full of challenges and potential. If untreated substance abuse and psychiatric issues are present at that time, many kids will go on to develop problems for life. This is a time that we can really make a difference. Unfortunately, these kids are not able to advocate for themselves, so they need their doctors to advocate for them. I devote a lot of my personal time to work on public policy and advocacy through medical organizations to help these kids get the services they need.

Is there a recent development in your field that you’re especially excited about? 
I’m most excited about the integration of substance abuse treatment into mental health treatment and eventually integrating both of them into our physical health treatment system. Most adolescents with substance abuse have co-occurring psychiatric and/or medical issues that are not being treated. In fact, many patients and their parents have experienced frustrations when they seek care. Their story would typically go like this: After waiting for months, they finally got to see a mental health specialist for help. The therapist would say, “Well, you have substance abuse issues. I can’t treat you. You need to do drug treatment first.” They then go see a substance abuse counselor who would say, “Well, you also have mental health issues, so I can’t help you.” By the time the parents managed to get their adolescents appointments with the right doctors, the adolescents have changed their mind and refused to engage. In Washington state, our government leaders and key stakeholders have stepped up to the plate to integrate all of our services into one system so kids with complex issues can go to one place and receive the care they truly need.

What is the biggest mental health issue that children have?
The biggest problem we continue to have is the stigma against mental health and substance abuse issues. With advanced technologies, kids are faced with multiple inputs and challenges that many adults did not have to deal with during their childhood, oftentimes resulting in feeling pressured personally and/or academically. Many of them are feeling overwhelmed. The best thing we can do is to destigmatize this issue so kids can open up and talk about it and ask their parents and doctors for help as soon as possible. 

What’s the biggest misconception that patients have about what you do? 
Many patients assume psychiatrists just want to give them medications. We actually believe in comprehensive care. We want to make sure our patients are getting psychosocial interventions—like participating in support groups or engaging in cognitive behavioral and other types of psychotherapies. Current research evidence shows those are some of the most effective treatments for addiction-related issues.   

Our country is in the midst of an opioid epidemic. What do you think is the most effective way to combat opioid addiction?
Opioid addiction is very complex. There is often a biological component, a psychological component and a cultural or societal component. For the best treatment possible, we have to address all components effectively. Right now, we have a very complex treatment system that patients have to navigate on their own for medical and psychiatric issues related to addiction. In addition to sorting through their insurance benefits, they have to figure out how to access additional benefits, such as social services and housing and employment assistance, on top of finding the right doctor. Unfortunately, finding the right doctor is very difficult when there is also a dearth of professionals who are qualified to deal with both psychiatric and substance abuse disorders. Therefore, the best way to tackle this problem is through a comprehensive treatment system consisting of specialized treatment teams that are able to help patients receive the right care at the right level and at the right time while addressing all factors contributing to ongoing opioid addiction.

Sadly, the biggest barrier to successful opioid addiction treatment in the U.S. is the complexity of our medical system. We could learn a lot from other countries on ways to reduce administrative burdens and simplify the way that patients receive care. For example, are we better off as a system having me spend an hour on the phone debating the merits of a type of treatment with an administrator who does not have the same level of qualification and expertise as I do, or having me see a patient who has been turned away by others due to the complexity of the case? We need to let doctors be doctors so that they can deliver the care that patients need in a timely fashion. It’s a tragedy that we are having so many people die from opioid-related issues because they have given up on our very flawed treatment system.

Is there a patient behavior that you wish you could change? 
I wish that all of my patients could understand the severity of their substance use disorders and the impact that substances have on their lives and rationally come to a decision to stop using. Unfortunately, for many of them, even when they understand the consequences, they still choose to use. That’s why addiction is such a powerful disease.

What’s the most important thing that patients should pay attention to when choosing a doctor? 
Patients should look at the educational background of the doctors and make sure they have the proper training and clinical expertise to help them with the issues at hand. They can start by talking with their primary care providers about the concerns they have and receive the referrals to specialists as needed to help them make the right diagnosis and generate the right treatment plan

What’s the most fun—outside of medicine—that you’ve recently had? 
My 9-year-old daughter just started junior golf. At her second outing, she sank a very difficult putt to help her team win. Watching her smile triumphantly was one of those father-daughter moments that I wished I had a camera for it. I’m looking forward to more outings with her and my 5-year-old son.