Monday, May 5, 2008

Blogging Live from the PAS: Promoting Mental Health

So, what would a meeting be without a little real-time blogging? If you follow the link, you will find that I have been at the PAS meeting in Hawaii for the past 5 days (I got here Wednesday for the APA Board meeting, as I joined as Treasurer this year.)

Topic Symposium: Promoting Mental Health for Pediatric Patients
Chairs: Kathi J. Kemper and Jane Foy, Wake Forest University School of Medicine, Winston Salem, NC.
Featuring Jim Perrin, Larry Wissow and
Scott Shannon.

Pediatricians are increasingly faced with patients who have significant mental health concerns. Given the shortage of child psychiatrists, pediatricians are eager for additional training in communication skills during these challenging encounters; an algorithm to guide an approach to evaluation, health promotion and treatment; and effective strategies to promote mental health. This session will focus on the algorithms newly developed by the AAP Task Force on Mental Health; an interactive approach to enhancing communicating skills; and practical guidance on ways to promote mental health based on lifestyle choices and natural therapies.
Target Audience: Clinicians, trainees, administrators and medical educators interested in mental health, communication skills, and complementary medicine.
Program developed by the AAP Provisional Section for Complementary, Holistic and Integrative Medicine; AAP Task Force on Mental Health; APA Special Interest Group for Integrative Medicine; Society for Adolescent Medicine and the Pediatric Academic Societies.

Please note: This is what I heard, which may or may not reflect what was said. Larry, Kathi, Jim and Scott are encouraged to correct me in the comments sections.
Kath Kemper chaired the meeting, opening with the epidemiology- anxiety is very common. Her take home message is that "You can do it. We can help".
  • Communications skills can health.
  • Promoting physicial health can promote mental health.
  • You already know how to do this.
Jim Perrin told us that the Academy does not yet have it's algorhythms already identified, but that they will do so later. He then spoke of the algorhythms that are going to come, and how they are appropriate for our practices. Primary care is a good place for this: we have the relationships, we understand chronic diseases and we are uses to intervening at multiple levels. He acknowledges that there are time constraints and payment issues that constrain access to services, and that collaborative care is really hard to do.

The AAP Mental Health Task Force has three goals:
1) Facilitate system change
2) Build confidence
3) Incremental system change.
System change: He feels that there are examples of success in system change: NC encourages co-location of mental health and physical health services( they apparently allow treatment without a diagnosis- what a cool idea!) , Massachusetts has the MCPAP (we are a national model after all), Arizona (tele-psychiatry consultation), New York (skills training) and South Carolina (routine screening for child MH problems and family distress).
The task force has given us the Chapter Action Kit to encourage collaboration within the community, and negotiations with insurers and business leaders at the national level.
Building confidence: Working on policy statements about what the pediatrician should be doing, with new competencies and changes to the residency training process. ADHD was the low hanging fruit: depression, anxiety, substance abuse are all harder. The chronic illness model is likely to be the way to go. You need a plan in place, with close follow-up.
Practice change: Algorhythms are still under development, and toolkits will happen. There will be decision support, and the toolkit will include both proprietary and non-proprietary items. Mental Health Competencies of the Care of Children and Adolescents will have some Task Force Reports, one on models of care and one on clinical care. There will likely be some changes in the screening recommendations, that emphasize functional outcomes and family diagnosis.

Larry Wissow spoke about practical paradigms in primary care. The medical paradigm says "make a diagnosis, then prescribe a treatment". In mental health, kids often don't fit neatly into a specific diagnosis. Even when you have a diagnosis, parents have many preconceived ideas about what they want, and that forcing treatment doesn't work. He likes to think about the therapeutic relationship, and the ways in which the therapeutic relationship allow you to influence behavior change.

So what do the patients expect: Parents of children with behavior problems don't believe that they are effective change agents, and don't see the pediatrician as the place to go. Kids are not used to having a role, and they usually have their own agenda of the visit. Doctors are concerned that they with be presented with insoluble problems, that take a long time to discover that you can't resolve. Larry then talked about the training program that he rolled out in Worcester, to show that it works. Key points:
1) Find a common agenda: That means talking to parent and child, and getting them to enlist them in a common set of rules.
2) Respond to negative emotions between parent and child: That means empathy without taking sides and focusing on the process, trying to get out of the middle and reframing this to be more goal oriented.
3) Focus on the problem: Check back with the family while you are in progress. People want treatment for the problem that brought them in.
Ideas: Take a "generic" approach. Think about how we approach rashes. Identify the emergencies, try something that is evidence based and follow-up. Hawaii has done some cool stuff on evidence-based stuff. Bright Futures will have some links to the evidence for treatment.
Remember, the family is the patient.

Scott Shannon is talking about lifestyle and natural therapies. Five Interventions for Pediatric Mental Health. He is not a normal psychiatrist. He sees this as a pyramid of care: Pharmacology is the last resort. We are practicing way out in front of the evidence base.
He proposes five things to worry about:
Look at sleep, exercise, omega fatty acids,

Sleep: Poor sleep is a barometer of later mental health risks. Sleep quality is a pretty good indicator of stress. When kids sleep less, they are grumpier and they don't do as well. We sleep 20% less than we did 100 years ago. This is a problem. Happens in ADHD- watch for it before you medicate.
  • Remove media from the room.
  • Stable routine, limit screen time
  • Reduce light and noise.
  • Eliminate caffeine. (finds this a lot)
  • Aromatherapy, hot baths, calming music
Exercise: Moderates stress- works as well as Zoloft, and lasts longer. Exercise doesn't have a black box warning. Also helps with the obesity issues.
  • Family fitness is a good thing.
  • TV free weekends. (Limiting screentime makes then more active)
  • Find seasonal activities.
Omega-3 essential fatty acids: Seems to be good for what ails you. Profound anti-inflammatory illness. Crucial is neuronal development. Seems to affect most chronic illness. Supplementation seems to help all diagnoses: depression and borderline PDO, among them. Minimal side effects.
  • Minimize the hydrogenated oils and trans fats.
  • Watch the glycemic load.
  • Eat cold water fish, nuts, seeds, game, grass fed beef and flax seed.
  • Garlic helds too.
Screen time: Just not good for you. ADHD is linked to early TV exposure. People still let their kids watch the tube. ADHD he can't treat with his supplements; you know what to do about this.
Sunshine: Vit D deficiency is a pandemic, he think. We are not out in the sun anymore. SAD is a real disease. He finds Vit D levels need to be augmented, and all mood disorders respond well to light therapy. Dawn simulator seems to work better.

So, you don't need to use drugs first. Honest.

In conclusion, Kathi took behavioral pediatrics and motivational interviewing into a comprehensive whole.
  • Pick a positive goal: Why is that important? Better mood, more cheerful.
  • Pick a specific strategy: What can you do about it? Exercise, sleep, nutrition or whatever.
  • Identify a small, achievable step: You've got to win early on. Be real specific. Important that they talk themselves into it, and that they have confidence that they can achieve it. Anticipate barriers, so that they don't talk themselves out of it.
  • Plan the reward/ celebration: How often and the timing?
From the the DBP Book, Miller and Roznick and Schwartz. You can really do this.
The questions are always the most interesting part of the session:
Jack Pascoe: How much does omega-3 fatty acids cost? There is a prescription form available in Colorado.
Person from AZ: Neonatologist worried about infant mental health. Maternal depression is a key problem; system is not in place to handle it.
Person from Columbia: Trying to do co-location, any thoughts. What is the business model that can sustain it. North Carolina is the model.

My fingers are beginning to tingle. I have to stop. Hope I captured this.

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