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.

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