Tuesday, January 29, 2008

Remedy for Rosie D.: There are teams and there are teams

I had a vision today of how a team can work to keep a child with significant mental health issues healthy and functioning. That is really the vision of the Rosie D. judgment; that if we all work together, we can help families of children with mental illness to help their children grow and develop to their fullest extent. It will be quite challenging.
The vision came, of all places, at a team meeting. I hadn't seen this girl in about a year and a half; on my desk was a message announcing the time and the place of the team meeting and asking me to attend. Fortunately, I had the time to be able to go, although I had to be late to accomodate the psychiatric nurse clinician from the Massachusetts Child Psychiatry Access Project who was teaching us about the recognition and treatment of anxiety disorders in children. (In case it sounds like we do nothing but mental health in our practice- you will be happy to know that we see croup and strep throats as well.). I got to the school about 25 minutes late, and joined the team meeting already in progress.  A little (very little) background:  this was a delightful school aged child who was transferring from a private school with very strict academic standards to the public school because she was not performing well, and there was concern regarding learning issues that would be better addressed in the special education system.  On their testing, it turns out that she is a developmentally normal child with lots of anxiety issues, which came on subsequent to a lot of family issues (trauma, divorce-  I shan't go into the details, but they are impressive).   The testing showed a child who did not meet the bar for special education services, but really got anxious when faced with "time-related"tasks, who was now adapting to her new environment.
At this point in many school districts, that would be that.  School has met its obligation;  the problem in the "mental health" silo;  family and therapists should deal with it and that would be that.  At the meeting, however, we had mother, grandfather, therapist and pediatrician, as well as school psychologist, special education teacher, reading specialist, principal, classroom teacher and special education team leader.  Everyone who would be working with this child over the next year.  And we actually discussed the child:  school took off the time limits, agreed that the reading specialist would work with her through the transition, stay in touch with mother and therapist and track her through the transition year.  No one proposed medications of any kind (I was actually there mostly to assert that they weren't needed).  All left feeling that that their needs had been addressed, and that we would be watching this young lady closely for the rest of the year.  As I said before, we made a good beginning.
That's how teams are supposed to work- looking for ways in which the education system can support the family and the mental health systems, each of which can support the other.   Within the Rosie D. case is a plan to create teams like this for 10,000 children with serious emotional disturbance.  It is certainly something to aspire to;  how can we make it happen?
  • Support:  Mother and grandfather took time from work to come to the meeting;  teachers were not in classrooms, psychologists were not doing tests; pediatrician was not generating revenue (my Fellowship allows me to do stuff like this).  How much support will it take to overcome the economic disincentives to this incredibly useful work?
  • Scheduling:  We were fortunate regarding the timing the meeting.  Schools operate 7-3, doctors and therapist work on a very different schedule.  How will we make it possible to mesh these schedules?  We planning to set up a secure webconference site so that we can all get together?
  • Consensus:  Each of our professions, whether  parent, doctor, teacher, therapist, judge or probation officer,  looks at these children with different eyes.  How are we going to mediate the differences between us?  How will will we build consensus?
  • Flexibility:  CHildren don't fix into nice categories.  Supppse the official AXIS I diagnosis is "Adjustment disorder with anxiety and depression";  the difference between that and "Post-traumatic stress disorder" in some cases is razor-thin. 
This is going to be tough to pull off;  I am anxious to hear how the folks remedying the Rosie D. Case will pull it off.  I am even more anxious when I realize that the folks remedying the Rosie D. case are us.

Friday, January 25, 2008

Managing Rosie D.: Who is on the team?

In our conversation with the folks who brought the Rosie D. case, we spoke a little about the third step of the process- provision of services. The ideal, set forth in the opinion, is the treatment team, which is cross-disciplinary, shares information, is family centered and culturally competent. It seems the key is that the parent has to pick the team. Recently, an old patient came back to my office and reminded me that, as a provider, I need to respect the choices that families make. I really don't know the answers for some of the patients that pass through my office.
Last month, I told a parable about Ruel K., a preschooler with serious behavioral problems, who, through much pushing by me and my colleagues, was hooked up with a family stabilization team, Headstart, a psychiatrist and us. At the time, it seemed like there might be a positive outcome. Boy, was I an optimist.
Turns out that things haven't been going so well. The details I cannot quite figure out how to blog about without breaking HIPAA, but basically it comes down to two groups of people with two different sets of expectations. On one side, we have the agencies. All of these people see a child who is in need of services, with a family who cannot cope with his behaviors, intermittently calling for help and seeming to back away when we offer our best services. On the other side, we have the family. All they see is a child who needs medication in order to function. "He needs to be on something" for this, they will say, while not understanding that it is our sense that without the supportive services of counselling and in home safety monitoring is to neglect the complexity of his status.  Our science of brain and behavior gives me little assurance that this child can be safely treated with medication, frustrating another family in their search for help with Serious Emotional Disturbance.  The family didn't like the proposed service plan, didn't like the people who were implementing the plan and the plan hasn't worked.
Under Rosie D.'s standard, Ruel should be eligible for a case manager/care coordinator to work with the family to put together the team that would care for him.  What sort of person could put together the team to help a child like Ruel? Hold can you facilitate a connection that allows a therapeutic relationship when the members hold such different views of how the child works?  Who will the parents choose to be on the team?  What if the parent says "I don't want Headstart on the team"  Or "I don't like that psychiatrist- I will get in line for a new one in six months."?  What will happen when you try to convene these teams?
As I was pondering the reality of how this is going to work out, I remembered another story.  A baby from the mid-1980s, with a fever, on whom I performed a spinal tap that was clear, but was later found to have evidence of early H. flu meningitis.  By this time we got the spinal tap results ack, the child appeared well, and had never received IV antibiotics.   We convinced the parents to allow us to hospitalize and treat the child even though  he looked fine by the time that we had caught up with him.  After 10 days of IV antibiotics,  during which the child appeared to be in perfect health, the patient, was discharged, with no evidence of meningitis.  After that, their child was fine by both the parent's and the doctor's criteria.  I think, however,  that the parents thought I was crazy to insist on such invasive treatment of a child who appeared to have healed himself;  I followed the guidelines for the treatment of meningitis, but wondered constantly whether or not these guidelines made sense in the context of this case.  That what is going on in mental health care right now-  we have some powerful medications for the treatment of mental illness,  some guidelines for treatment, and to the outside world, those guidelines seem pretty thin.  Families want treatment in the crisis, and don't yet see the point of the other stuff we do.  In the end, I think, it will only work if the parents are to be in charge, even if their understanding of disease doesn't match ours.
Ruel's family has identified a new psychiatrist, who agreed to take the case.  I am pessimistic that medications can help him without the "wraparounds" like home-based services and Headstart, but I need to let the family form the treatment team if we are to have any hope of helping this child.

Thursday, January 24, 2008

A New Child Mental Health System: What's all the screening about?

Here we are, three weeks into the era of improved mental health screening.  So far, the world hasn't ended and I don't think that anyone has lost their rights.  Today, however, my faith in some of the instruments was tested.
  • I saw a teenager who is barely passing high school, with multiple suspensions and some evidence of alcohol abuse in the past month, currently grounded by his parents for staying out overnight without knowledge or consent.  Her Y-PSC was 20 (within normal limits) and her CRAFFT was not worrisome.  I, on the other hand, remain quite concerned that she is at risk and recommended that he see a counselor.  After much discussion, he agreed to stop by and visit the school counselor.  
Lesson learned:  Screening does not obviate a thorough history.  As Peabody said long ago, the secret of caring for patients is to care for the patient.
  • Parents of a 2 year old dutifully completed the PEDS as completely normal, and then told me about thier concerns regarding expressive language delay, after which I made a referral to EI.  The PEDS, however, was scored negative.  I asked them why they have checked "no concerns" on the PEDS under language development, and they told me that they were not really "concerned", but were a little different.
Lesson learned:  Screening questions can't capture nuance of language.  Listening can.
  • Two patients were brought to their EPSDT visits by non-custodial relatives, one of whom answered the questions despite a real lack of real knowledge of what was happening in his life and the other of whom wouldn't complete the form despite a fairly good knowledge of what was going on.
Lesson learned:  Screening is only as good as the information we bring to the table.

While I still believe that screening for children's mental health problems is a good idea, the instruments thems really are, at best, an opening into the system.  The system still has its problems.  More on that later.

Monday, January 21, 2008

Bridging gaps: Rosie D is inclusive, isn't it?

Martin Luther King Day:  Our office is closed, and I have a little more time to reflect on the way that mental health issues continually percolate through my practice.  Last week, things seems to have calmed down a bit.  No acute meltdowns, no one desperately seeking medications; I actually got home on time for a change.  
Well, almost no one.  One of my partners was pondering how to handle a teen who has issues with anxiety and depression, and pulled me into the discussion.  who seemed complicated enough that we had referred her to the the MCPAP program for evaluation.  The MCPAP clinician suggested some medication, and sent her back to us, with a recommendation that we arrange outpatient therapy and start the medication.  The medication (an SSRI, if you must know, but not one that we use very much) seemed somewhat helpful, but not helpful enough.  The patient, however, was still not "calm" enough to attend school or work, two activities that we thought we important to her future career.  We spoke to the MCPAP clinician, who suggested a second medication.  We are, in general, skeptical of our ability to manage this level of problem, and  thought a therapist would be helpful;  the girl unfortunately,  really had no interest in initiating therapy.  And, on MassHealth, it is hard to get to a psychiatrist without seeing a therapist at one of the agencies.  When we explained all of this, the patient still seemed to feel to feel that my colleague should be able to handle this problem, without the help of mental health professionals.
So, our system has reached it's limit:  we want to manage our patient's troubles in collaboration with a mental health team, and our patient really doesn't really see the point.  Nor does her family.  To our patients, it seems quite odd that we, as health care providers, don't want to prescribe multiple medications for conditions that we just don't understand so well.  It feels to me like our patients want us to oversimplify the problem and just prescribe the medications.
Ideas?  How do we talk this one through?  How do we build a system to accommodate all of these world views?  I suspect it is even harder in Polish or Spanish.
ADDENDUM:  It seems that my colleague was able to make the system work-  the patient and family understood our point, and arranged a mental health intake (within 2 weeks!).  My colleague spoke with the intake worker,  who agreed to talk to the therapist about arranging a medication consult with the psychiatrist sooner than usual.  So the system worked (so far!);  we will see if it all actually happens.  Does this change my take home message?  A little.  The system, creaky though it is, can work when you throw your weight against the door.  Communication between silos remains the important thing, and my colleague was fortunate to be able to get through to the right people during some of her administrative time.  The task of all of us in the Rosie D. process, it seems to me, is to build a system that doesn't require this degree of advocacy.

Wednesday, January 16, 2008

Got Spanish?: Next Steps in Mental Health Reform

The Op-Ed that I wrote on mental health screening made it into the Worcester Telegram and Gazette yesterday, and I would invite feedback, both from families and caregivers. It seems to me that we are embarking on a great uncontrolled experiment, and this is an opportunity to make observations about the process before it gets too out of hand. (Maybe it already has). Got an email from a colleague the other day:
Date: Fri, 11 Jan 2008
To: David Keller MD
Subject: Therapists in spanish; patient
Hello, everyone,
I saw a new family today fresh from Puerto Rico. They have a son who is 4 yo with "behavioral problems". I would like him evaluated for ADHD. It would greatly help the family if Mom can be part of his eval-which necessitates either a Spanish-speaking therapist or access to interpreter services. Please send me your suggestions- where can I send them?
(snip) MD

This was hard to answer; the system currently has us send patients like this to agencies, who may or may not have Spanish speaking psychologists available. It is even worse when the family speaks Polish or Portuguese, two languages that have recently become quite popular in our neck of the woods. How do we help families like this?

We can certainly have interpretors available; the UMass Interpretor service and the CMAHEC/ Language Link do a great job. Even those folks, however, will tell you that behavioral and mental health concerns are the most diffucult to translate. Bilingual therapists are hard to come by; my colleagues at local mental health agencies tell me that they are hard to find, and in the current environment are frequently hired away once they are trained. One barrier is the difficulty in credentialing foreign-trained psychologists and social workers. Some of us on the Worcester Mental Health Network would like to see the us make it easier to get the paperwork through for the people that could do the work we need done. One thing is clear: as we start screening kids for mental health problems, we will need resources to work with the families to ensure that we are not just finding problems that we can't do anything about.

Sunday, January 13, 2008

Screening in Practice: A Tale of Two Teenagers

As I mentioned earlier, our practice is using the PEDS, M-CHAT, PSC, PSC-Y and CRAFFT in an effort to find mental health issues.  Mostly, we were feeling that the results showed us what we already knew; some of our patients have problems, most don't and most of the ones that do have been at least referred for services. This week, I saw two patients that showed the benefits and limitations of screening. I'll start with the benefits, and end with the cautionary tale.

So, a young man in high school came in for a check-up. I have known him since early childhood have always enjoyed talking with him. He has had some challenges in his education, but is in general, one of the most upbeat and cheerful people I know, as are his parents. He was by himself, so, I walked in the room to talk with him regarding his overall health and well-being. He told me that he doing well, although school had gotten harder, and had no specific concerns regarding his health. Things were fine at home, although I noticed that one of his parents had called 6 months ago to ask about support for teens with parents with cancer. I had just decided not to push the issue with him when I looked at the PSC-Y that he had completed, showing a score of 33, well above the "at risk" level. On further exploration, I found that he was really nervous about his parent's health, given his parent's diagnosis and prognosis, and that this anxiety was affecting his schoolwork and sleep. His parents wanted him to go into therapy, but he wasn't sure it would do him any good, and he really didn't want to go on medications. We spent about 15 minutes discussing this issue, and then he brought his dad in for us to talk some more. The family left with some ideas for where to go for appropriate mental health services, and a follow-up appointment.

That's how this is supposed to work- as a stimulus for conversation to address problems before they have developed into a crisis requiring hospitalization, medications, school suspension or court involvement. The PSC-Y prompted me to push onward; as a consequence, a young man may be able access services to help him to cope with a predictable problem. The family is intimately involved in the process; nothing is done without their consent. As I left that room, I felt like Hannibal on the "A-Team", thinking to myself, I love it when a plan comes together.

Conversely, sometimes the screen doesn't find what we know is there.  I saw another teenager who is currently in a residential DYS facility, and has a significant problem with weed.   His PSC-Y was 17, indicating low risk of problems.  When I asked him about it, he said that, since going into  lock-up, he really has few problems.  I did the CRAFFT with him as well, (we are doing that in the context of a DPH contract).  He likely did meet criteria for substance abuse.  He was, however, already in treatment and the plan was for him to be seeing a counselor when he left lockup next month.  (He was in for a physical because he needed the paperwork to enroll in a new school after returning home.)  I asked his parent to check in with us after he was left lockup, to be sure that the handoff to the outpatient therapist and psychiatrist had happened.

So,the lesson here seems to be "Don't rely on the screens too much;  you still need to talk to your patients.".  The PSC-Y said to me, appropriately, situation is under control.  In reality, there is a delicate transition that could affect the apple cart on which his mental health currently sits. Screening doesn't obviate our need to pay attention to what is going on with our patients.  It does provide a trigger, that will enhance our ability to start the conversation about mental health, without, one hopes,  interfering with our ability to form relationships with children and families.  All of this is, after all, in the interest of caring for the whole child in the context of family and community.

Oh, yes, a last word about the impact of all of this on office flow.  Addressing psychosocial health in the context of well child child care for these two patients added an extra 10 minutes per patien to my day.  So far, that hasn't seemed to have backed me up any more than usual. My colleagues and I hope that it will stay that way.

Thursday, January 10, 2008

The Devil is in the Details: A Conversation with Kathryn Rucker of the Center for Public Representation

This description of our recent session does not capture all of the richness of the discussion; these impressions are culled from my notes, and reflect my conscious and unconsious biases in this matter. The nice thing about a webblog is that I can edit it, to reflect your comments- PLEASE append your thoughts, corrections or disagreements as comments to enhance our discussion and understanding of this complex matter. David
About 25 people from a variety of agencies and advocacy groups came to the 3rd floor conference room of the old St. Vincent's Hospital building in Worcester MA (chops to the Department of Social Services and Kim Ferrucchia for the space and the fresh fruit and coffee) to hear and discuss the remedy in the case of Rosie D. v. Swift/Romney/Patrick, the landmark case that has driven the rapid pace of change in the processes of child mental health in the past few months. Kathryn Rucker spoke on behalf of the Center for Public Representation, which led the team that brought the lawsuit in 2001, working with the Mental Health Legal Advisors Committee and the firm of Wilmer Cutler Pickering Hale and Dorr. She tried to provide us with three things:
We provided a constant stream of questions and reflections that showed the importance of dialogue in this process, and really gave a sense of how complex this process is likely to be. I will try to fit the discussion in to the framework that she proposed, although the interactive process really had us jumping around quite a bit.


This was a class action brought on behalf of 8 named clients with amazing, real stories that illustrated a set of consistent problems in dealing with the mental health system as currently constructed within the Commonwealth of Massachusetts. The class is “children with Serious Emotional Disturbance” (a term not used by clinicians, but defined in law under IDEA and SAMSHA). She pointed out that, while the DOE and HHS define the term differently, the judge accepted EITHER definition for purposes of this suit and its remedy. Both definitions are a bit vague, meaning that we don't know exactly who is going to get these services. Anyway, the judge found that the state Medicaid program mandates Early and Periodic Screening, Diagnosis and Treatment, and that, under the current MassHealth guidelines, the state didn't didn’t tell parents about services to which their kids were entitled, and didn’t have the services accessible when the kids needed them. He told them to do better, and appointed Karen Snyder, former Chief of Program Operations for the Department of Children and Families in CT as the Court Monitor to ensure that it all happens.

The CPR and its allies seem to view the case as a pathway to home-based services for children with severe mental illness; they have worked hard during the remedy phase of the case to ensure that whatever is done is family-centered and community-based. After much discussion and disagreement, the judge felt that that the defendents plan was a realistic way to get to the goal of home-based services, and accepted their model. The idea was simple and the pace of change rapid; the judge set the following benchmarks:
1) Improved screening by Dec 31 2007
2) Improved evaluation process by Nov 30 2008
3) Improved treatment by 30 June 2008
Embedded in this plan is the notion of the treatment team; a group of professionals picked by the parents that will work with the family in ensure that services are right and that progress is being made.

It was at this point that the talk got interesting, as both our presenter and the group realized that scope of change that will be needed to make this happen. Many issues- full of devilish details were raised, discussed, resolved and not resolved- it was a lively time. "What about co-morbidity?" was one question. Turns that that co-morbidity will not interfere with your receipt of benefits, as long as your symptoms meet the criteria for one of the two definitions of Serious Emotional Disturbance. "What do you mean by home-based services?" This one was a look at the "wrap" of the "wraparound". Kathryn said that we hoped to cover some services like mentoring and community-based afterschool programs for these kids, but that the details are still being worked out. "Right now, families end up in the emergency room looking for this kind of help. Will there be changes in the way EMH and crisis intervention is done?". Ms. Rucker presented a vision of mobile evaluation teams, able to roll out to the places where the kids are, and reducing the need to go to the ER for emergency services. Much of these details, she said, are under discussion. She expressed hope that, by the time that Emily Sherwood comes to visit in February, many of these details will be resolved.

IMPLEMENTING THE REMEDY: Ms. Rucker then moved on to a discussion of how the implementation was proceeding so far.
STEP 1: Screening: Implementing it as we speak. And, as you heard in previous posts, proceeding with few hitches, although I must say that this is the easy part.
STEP 2: Assessing: Kids identified as positive need an assessment. At this point the mental health system to begin involvement, with an assessment using an assessment tool with unlikely name of CANS. THis led to a brief but intense discussion of the validity and utility of the instrument, until the many unanswered questions surged back to the surface.
"What about pediatrician filing a 51A for refusing referral?" M s. Rucker wasn't sure how that would work out, but both DDS folk and me (representing the pediartric community) though it unllikely. "Anyone talking about Medicaid’s level of reimbursement for behavioral health services?" Yes, they have, although everyone is acutely aware that the talk needs to translate into action. No specific targets or changes have been proposed. "Is any talking about training for the future? How are we developing the training for the next generation of mental health care providers? How are we going to have a more robust clinical field? This is an area for which there are no easy answers and the court monitor has asked to talk to providers to begin solving it. Right now, one is allowed 2 hours of diagnostic time per 6 months. What if they need a psychological evaluation? This actually led to a discussion of the role of the Intensive Care Coordinator. Their hope is that the care coordinator is the the person who may be able to override medical needs. What of this treatment team? She said that the treatment team needs an intensive care coordination model; and it needs to be tailored to the individuals, but that we need to figure out how much authority the treatment team has. Finally, how do we make this work across silos, and within families in which the parents are not able to navigate this system? There was no good answer- The need for confidentiality and the need for collaboration are both real and difficult. Although the family needs to drive the team, and the process, we need mechanisms to ensure that the child is the ultimate beneficiary. It is also clear that not everyone will get every service; we will need to watch how the regions are organized in order to be sure that the services are available all across the state.

If this reads like an active and fast moving discussion, it was, and I'll bet I missed half of the questions and answers. Please add comments; let me know what we missed. In the end, the group agreed on three things:
  • Ask Karen Snyder to talk with us.
  • Watch for the RFI to come out on evaluatin process to get input into the process as it is developed.
  • Keep talking about this.
So, please leave some comments, ask some questions and join us in February.

12 February 2008, 4:00 PM:
Conversation with Emily Sherwood,
Director of Children's Behavioral Health Interagency Initiatives,
Executive Office of Health and Human Services
DSS Conference Room, 25 Winthop St, Worcester MA

Tuesday, January 8, 2008

Homework Assignment: What's Up with Rosie D.?

Today, we heard from the Center for Public Representation's Kathryn Rucker, one of the attorney's representing the plaintiffs in the Rosie D. case. I took notes, and will be translating them into a blog, once I finish watching the New Hampshire primary returns. But at today's session, we closed with a question: What questions do you have for Emily Sherwood, MassHealth's lead person in the implementation of the remedy to Rosie D? She'll be in Worcester next month, and tonight's discussion certainly whet our appetite for more discussion.

Leave your questions here as comments- I'll post them for all to see.

Rosie D. and screening: What is the view from the frontline?

Here we are, one week into mandatory screening for child mental health issues are the practice level. All seems remarkably quiet; so I asked at the end of staff meeting if the staff or providers at South County Pediatrics had any feedback on the process. They did. Of course, I wasn't really ready to take notes, but I will try to record some of the thoughts that were heard.
* Parents of young children find the process a waste of time. Particularly the parents of one or two week olds. The PEDS questions are just not relevant to them.
* No one has yet unmasked previously unknown mental illness with the questionnaires. We actually seem to know our patients pretty well. So far.
* It is a lot of paper. Nursing staff says that it makes it take longer to get the patients in and out of the room, and it takes an extra 45 minutes in the morning to get the papers organized and ready to go.Filing the extra paper is annoying and takes up extra time.
* Most of our parents either said nothing, or think that it is a good idea.
* Someone will get annoyed soon, when they get a bill for a "screening" on top of the usual charge.

My own informal count is the the "positive rate" is about 10%, and that the kids who are screening positive have already been referred, and have either gone for treatment or don't want to be in treatment. In the words of Kurt Vonnegut:
And so it goes....

Add your own comments by pushing the comments button below. I want to hear what you are feeling.
For those of you in Worcester County Massachusetts, I wanted to let you know about two upcoming opportunities to learn more about the upcoming changes:

8 January 2008, 4:30 PM: (Today)
Conversation with the Kathyrn Rucker
Center for Public Representation (the ones who brought the suit)
DSS Conference Room, 25 Winthop St, Worcester MA

12 February 2008, 4:00 PM:
Conversation with Emily Sherwood,
Director of Children's Behavioral Health Interagency Initiatives,
Executive Office of Health and Human Services
DSS Conference Room, 25 Winthop St, Worcester MA

Both events are free, convened by the Worcester Mental Health Network. The events are not wired, so I will be blogging them after the fact.

Monday, January 7, 2008

Our first poll: Is screening for mental health problems in children an invasion of privacy?

Our first poll is done- thanks to the six of you who voted. Most felt we should plow ahead. The results are:

No, because it is better to know than not know. 4 (66%)
No, because we have a number of good treatment modalities available. 1 (16%)
Yes, because we have no proven intervention for the illness. 1 (16%)

So what did I learn from this activity? First, that polls need to be simpler. I should have just said "YES", "NO" and "MAYBE" and allowed folks to post their thoughts as comments in the blogsite. Next time I will do so. Second, I learned that there are at least six of you who stop by to visit from time to time. Watching this number grow will be a useful metric for me as this process continues. FInally, I learned that we are not generating much clash. Of the six who responded, 5 of you are optimists. We need to broaden the conversation, if the Rosie D. process is to have any impact.

I'm submitting an OP-ED to the Worcester Telegram and Gazette soon- perhaps that will generate more audience.

Thursday, January 3, 2008

Treatment and Mental Health: Some Things to Ponder Before Medication

Better day today;  the records arrived on my recently patient who recently got out of lock up without a psychiatrist,  I heard from the parent of the 4 year old mentioned earlier ("It Shouldn't Be So Hard") who is making progress, slowly, and a kid who I knew last as an irresponsible teenager with ADHD and anger issues came back to see me as a pretty well put together 20 year old, who still has ADHD, but now has a lot more insight into his condition.  
Anyway,  I was thinking about this who screening conundrum- as a pediatrician, what am I going to do with a positive screen?  I emphatically am not going to refer all of these kids to a psychiatrist.  For one, there aren't enough psychiatrists in the world, and for another, I don't want to medicate that many kids.  Last summer, I heard a talk by Jeff Bostic, a psychiatrist from Mass General Hospital with remarkable good sense.  He pointed out that much of depression and anxiety (two major problems in child psychiatry) is actually about the relationship between the child and his/her family community.  Before medicating, he looks at what he called the  "Happiness Index" by asking these questions:

•What are you enjoying? What were you enjoying before became so depressed/anxious?
He finds that folks who can identify something that they like are better able to pull themselves out of a funk.
•What are you grateful for?
Same deal;  being able to identify something for which one is thankful is a marker for psychiatric self efficacy.
•Who are you connecting with? Anybody you’re working on forgiving?
Connections are important, especially the ones that are broken.
•What are you involved with in your community?
Involvement is like enjoyment; it is a good thing.
•What are you shooting for these days (goals -comparative to others vs. help
People with empathy are actually able to help themselves;  interesting concept.
•How are you doing with the Cosmos?
Doesn't matter how, but those who try to get straight with the Almighty (or the eternal Om) do better than those with no higher power.

Like all great concepts, this one was borrowed and adapted from Richard Layard's work on Happiness economics.  Anyway, this psychiatrist told us all that, before medicating anyone for depression or anxiety, he looks for the symptoms of happiness using these sorts of strength based questions, reinforces the good stuff he finds, and tells the kid to exercise for 2 weeks and come back to see him. He is always please by the number of kids who come back in 2 weeks in remarkably better spirits.

Works for me.  Tomorrow, I'll comment on the survey.

Wednesday, January 2, 2008

Mental Health and Our Kids: What I See Every Day.

Since my last post, there has been a little stirring out in the Blogosphere on the issue of Mental Health Screening.  I have read a number of posts alleging some things that are decidedly untrue:  
1)  This is part of a plot to drug our kids (although I doubt that the Center for Public Representation is a front for the pharmaceutical industry).
2)  You shouldn't screen people without any evidence of mental illness (actually, that is the definition of "screening" in public health and medical practice.- looking for folks at risk of disease BEFORE they have any symptoms, so that we can treat them BEFORE we have to use electroshock).
3)  This is an attempt to make normal variation seem like illness (that's why we only want to use "normed" screening instruments, to really look for the extreme variations)
I absolutely agree with folks who are worried that the screening can be misused;  but let's not forget the opportunity to initiate a conversation about our mental health!  Given the day I had last week,  I think that it is important to have that conversation.  Let me illustrate my point by telling  you about my day (with sufficient revision to avoid a violation of HIPAA).  
The day began with innocently enough- sisters with coughing and stomachaches, a girl with a rash.  Then came Norbert (none of the names, genders or ages in this bit are real;  the underlying stories are all too real), a school-aged child with significant autism and really minimal communication skills.  He's acting oddly, according to his mother, and she does know him best.  Turns out he has an ear infection, but it takes a while to sort that out;  his mother and the neurologist have been changing his medications since his last visit.  The medications are strong- without them, Norbert engages in "self-injurious" behavior.  His mother is pleased with his progress in school-  I say a few encouraging words, prescribe an antibiotic for the ear infection, and move on to the next patient.  Norbert's story is long and complex;  we recognized his autism when he was 2 or 3 years old, got him into early intervention, but it has taken us 4 years to get him into an appropriate educational program, during which time his family has seen several specialists before finding one with whom they could effectively partner.  Medications for kids with autism (or PDD-NOS, as the DSM-IV labels it) are a bit iffy;  I generally don't prescribe them to children under 5, and for PDD, I (and the parents) have difficulty in deciding whether or not they are helpful.  His mother has tried him on and off medications over the past year, and thinks that they are helpful.  Would screening have helped Norbert?  Might have started the conversation a bit earlier, but it still would be (and will be) a long and winding road.

After a couple of check-ups with negative mental health screens,  I see Sean,  a teenager with a few questions- some situational depression and a little alcohol abuse.  Is he in trouble enough that he needs a psychiatrist?  I think not, and, as he leaving, his mother asks me to discuss how she should handle some of his "late adolescent" issues.  No labels, but he will bear some watching in the future.  Has the screening helped me to short circuit a later problem?  Got me-  but I would rather start the conversation early, rather than waiting to deal with school failure or worse.

Then, just before lunch, a see Kira, a young adult with some psychomotor epilepsy and a history of depression; she really should be moving onto an adult medicine practice, but she still values our connection.  She's actually doing OK;  I did a bit of monitoring for her psychotropic medications to be sure that she is taking them appropriately, and to be monitor for side effects.  She sees a neurologist, and has had a therapist in the past;  generally, they keep things in pretty good control.  

I go to lunch thinking that maybe this won't be an overwhelming "mental health" day; only three of nine kids with mental health issues, and none of them that confusing.   Of course, that was 1/3 of the kids I had seen that morning, but it didn't seem like a lot.
In the afternoon, I started out with several kids with colds and sprained elbows and the like, before seeing my first check up- an adorable 9 month old with concerned parents.  One is worried about development of walking and talking, the other thinks that everything is fine.   I mostly think the boy is fine, and try to be reassuring, suggesting a path of watchful waiting.  The cause of concern is intoeing (turning in of the feet while walking), a common trait in the 9 month old.  These sorts of parental worries, screening can help with- nip the anxieties in the bud, we hope.

Then comes Paul, a 14 year old just out of a one year stay in the juvenile justice system.  Paul has been diagnosed with ADHD in the past, with some issues with marijuana use and conduct disorder.  He had a psychiatrist while in the care of the state, but that all ended when he was released, and he came back to his old pediatrician for medication refills.  No records, no reports and no idea what medications he is actually taking.  His mother and he aren't even sure of the name of the doctor who was writing the medications.  I get releases for the school, for DYS, for the unknown psychiatrist, for the probation office-  everyone I can think of who might be able to fill me in on this kid's psychiatric history.  I call the pharmacy to confirm his current medications.  And, eventually, I write prescriptions for the two medications that he seems to be currently taking.  Took me about 45 minutes to do this (he was booked for 10 minutes as a "recheck") and my patients waited while I tried to deal with it.  So where did this system break down?  Several places:
-  Transfer of care was from DYS to the mother to the Primary Care Doctor, and everyone thought that the other person shared their knowledge base.  DYS figured that mother knew the med schedule;  mother figured that DYS told me what was going on; DYS figured that a doctor is a doctor, never mind that I am not a psychiatrist and my office figured a "recheck was a recheck", even though we hadn't seen him in a year and a half.
-  Prior to lock-up, Paul had been referred to a therapist and a psychiatrist.  Coming out, the mother figured that she needed to see me before going back to those folks.  
-  Going back in time, Paul started having troubles at age 4 or 5, with outrageous tantrums and behavioral outbursts.  Aside from listening to the story, and suggesting therapy, we didn't have a lot to offer.
Would screening have been helpful to Paul?  Maybe.  Couldn't have made things any worse.

After that, the day just unraveled.  ADHD in poor control with medications- is it ADHD or just a family in crisis?  How can I tell?  Depression in a teenager who is flunking school and sees no way out- counseling is a little helpful, but he absolutely refuses medication- we'll keep checking in.  A college freshman who started SSRIs last week, and reports them to be very helpful.  Overall, 8 of the 16 kids I saw that afternoon had mental health issues as part of their visits.  

Now, I am not a psychiatrist, nor do I boast any special competence in this area.  I don't think that my experience in practice is unique.  My colleagues and I have been astonished be the changes in our practices over the last 20 years- our patients are having more mental health problems than they used to.  To us, screening is just a way to start the conversation sooner, not a nefarious plot by government overlords or pill-pushing salesman.  It is a way for us to say to our parents:  We hear you. What is up with your kids these days?  How can we help?  It is a critical first step to realizing the real promise of Rosie D.;  that when a parent says, "I want some help", we have something to offer.

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