Friday, November 10, 2006

Kiddy Shrinks/ Just a Thought

I have to start with a disclaimer: I am not a child psychiatrist.
Also ClinkShrink posted below while I was typing this. Make sure you check it out, and by all means, comment on her post, it makes her day!

So this month's American Journal of Psychiatry arrived in the mail today. I read for a bit about how the suicide rate in children ages 5-14 has was lower in areas where the number of SSRI prescriptions were higher. It's a complex issue, I'm not sure I followed it all (--okay, I read it really quickly and I skipped to the Results and Conclusions sections) but the point was that the Black Box warning on anti-depressants may be inaccurate, or may discourage use of a medication that lowers, rather than raises, suicide rates.

So I came home and ran through my blogroll. Shiny Happy Person and FooFoo are still missing in action. Fat Doctor and Dr. A are both tired and have photos of trains on their blogs. Dr. Crippen across the way on the NHS Blog has a post about children and depression. Poor Dr. Crippen is frustrated; he has a long post--- a really long post-- on how mentally ill children in the UK no longer have access to child psychiatrists, that the system has been dummied down with non-physician, under-qualified mental health care workers.

Over here, at least in major metropolitan areas, mental health centers which treat children all have child psychiatrists on staff. At least on good days. I've already written my thoughts about why psychiatrists should see patients for psychotherapy. As important as that is, it's even more important for child and adolescent psychiatrists to see their patients for psychotherapy, and it's hard to find docs who do both, who do both well, who have time to accept new patients, and it's expensive and really an option only in the private sector.

So why do I think this is so important? And remember, I'm not a child psychiatrist.

Suppose we assume that the FDA is right and that SSRI's cause some children to have suicidal tendencies (-- note that none of the children in the studies of these medications died of suicide). The current thinking is that this may well be right, that a small percentage of children, say 1 to 2 per cent, start thinking about suicide after beginning these medications, and that the thoughts are the result of the medications, not simply a pre-existing symptom as a result of the depression. It seems that the highest risk is in the first few weeks, perhaps even the first few days, of treatment, and as such it is now suggested that children be seen weekly during the initiation of pharmacotherapy. At any rate, warranted or not, the Black Box warning has given parents reason to pause before allowing their children to be medicated, and has given pediatricians reason to refer to specialists.

So a child is seen for depression. Perhaps he sees a psychiatrist who does only medication evaluations, and not psychotherapy. In this setting, the psychiatrist generally does a comprehensive evaluation with the patient and the parents. Based on his/her exam and the reported symptoms, a medication may be started. The problem with "medication evaluations" is that there is some pressure to make a decision about medications fairly quickly. Generally, patients walk away from these first-time visits with a prescription, maybe an appointment to come back in a few weeks for a "med check." It takes the medicines weeks to work, so this makes pharmacologic sense, it just doesn't make patient sense when dealing with a distraught human being. With kids, though, the stakes are higher now, we have that wonderful Black Box warning discouraging the use of anti-depressants. Oh yeah, and there's this other thing with kids: they go through "phases." It can be hard to figure out what's a reaction to circumstances -- think things like parental divorce, moves, new schools, broken hearts-- or what's a normal developmental stage-- think teenage angst, moodiness, irritability, some of which is psychopathology warranting medication and some of which is not. So, if the psychiatrist sees a child for psychotherapy, there isn't a rush a to determine if a medication is needed immediately, he's able to try psychotherapy as a first-line treatment in less severe cases, and he's able to more closely monitor the child's progress, response, and adverse reactions.

Just my thoughts.


HP said...

I understand your viewpoint and wish there were more psychiatrists who took this approach, rather than simply dispense medications and haul the patient back for a review weeks later, regardless of whether the patient is an adult or a child.

I would be much happier referring my patients on to someone who would take a much more comprehensive approach. Alternatively, to refer to someone at least be prepared to work in a team approach with a psychologist to ensure all bases are covered. I wonder what you feel about the latter?

Sarebear said...

Makes complete sense. My iatrist is actually a child and adolescent psychiatrist, and apparently the best around (which may explain his cut through the bull attitude, although he did it on me when I wasn't playing games, but now we understand each other, lol, right before he's closing his practice . . .). But, will no longer have a private practice.

I know HP's question is for the Rap'ers, but I actually think, based on my experience over a year ago, starting professional help after 20 years of praying for it, that I wish my iatrist had done some, well maybe more in-depth appointments, say every other week for the first 8 weeks, to get to know what's going on with me better, as well as monitor the titration and efficacy of the medication(s), if any prescribed. Even though that might be a bit of duplicate effort, since I had an ologist (well, I started the ologist a few months after starting the iatrist, but I think it would have been good to start at the same time) that the both of them starting off with me, together (well, they'd be separate appointments, but they could compare notes or something, and these two I have do do that on mutual patients) could both form their initial impressions and assessments and after the first 3-4 appointments then kinda see what page all three of us are on.

THAT is how I see a good synergy working for someone first starting to get help; THAT is how I think it would really get both professional's perspectives and such, especially at the same time in my life, in case there's any adverse events or extra stressors, and their evaluations of me or this hypothetical patient and have a good foundation to a working, mental health team, relationship.

See, I'm not dissing iatrists doing both meds and therapy. That's great! I think for some people who choose to have two professionals, or for whatever reason have ologist & iatrist, that this coming together (not physically, w/both professionals in the room at the same time, altho if that ever happened at any point, I think that'd be cool to touch bases from time to time, like every six months after the patient was stable and in continuing treatment, etc.), that this coming together, tho at different times, and most likely over the phone between the two professionals, that this patient centered team would be cool.

It isn't that mental health care ISN'T patient centered, but coordinating this stuff, and other things, I don't mean to insult anyone by that, but it's a . . . there's a synergy that I'm trying to convey that I don't think is coming across, is all.

This would only be the ideal sometimes, depending on the treatment options the patient has (insurance defined, ugh), and other factors, and, I don't think, wouldn't happen the majority of the time, but would be nice if it did happen an appreciable percentage of the time, depending on when appropriate, like 20% of the time, or 15% even, or whatnot.

Anyway, just some rambling ideas from someone who has very recently been through her first contacts ever with mental health doctors (yeah, the ologist isn't an MD or DO, but he does have a PhD, as well as a deep respect from me and high regard).

Anonymous said...

The problem with child psychiatrists is that there aren't nearly enough of them. I was a personal assistant to one while in grad school and he was constantly bombarded with requests from people looking for a child psychiatrist. It didn't matter that on his machine he specifically stated that he wasn't taking new patients...people would still leave messages and beg him to take them. I think half my job ended up being calling each of these people to give recommendations to other child psychiatrists in the area. The only way to become a patient was to be a family member of a current patient (basically inherit his services) or have an extreme case of what he specializes in (autism, ADHD, and psychopharmacology). There is such a shortage here (DC) of child psychiatrists that now he has expanded his job to giving 2nd opinions for other doctors because they are at a point that they don't know what else to try. The only way kids are going to get the care that you are suggesting is if you can convince more psych residents to specialize in child psychiatry. Good luck with that!

thinkingthings said...

Psychiatrists who will see young children are rare here in the Ozarks, and those that do sure aren't doing any therapy. However, the good ones almost always refer the kids to a licensed clinician (usually an LCSW or LPC since the psychologists usually do evals) for therapy, and then maintain close contact.

Sadly, the committee that authorizes funding for Missouri Medicaid have decided that therapy doesn't really help children, so it becoming rare that a young child on Medicaid will be allowed to participate in therapy. Tragically this lands even 4 and 5 year olds in acute care psych units because they can't find a psychiatrist to see them and they can't get approved for psychotherapy. It is a mess.