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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