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.

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