2007 Connecticut AG Report Critical of MH Access for Kids

The 2007 Connecticut Attorney General report on access to mental health care for children [PDF] was quite critical of the role that managed care had on shrinking access to mental health services for children and adolescents. Among the conclusions were:

The results of this survey, both the data collected and the written remarks of child and adolescent psychiatrists, show that countless children and adolescents are receiving inadequate psychiatric treatment, or no treatment at all. Although some patients may be adequately served by psychiatric care focused on the use of medication, a significant proportion of children and adolescents may need treatment that is more intensive, and more expensive, than therapy restricted to the use of drugs. Loss of access to this type of care, what psychiatrists call “relationship-based psychiatric care,” has been happening out of public sight.   

Using low reimbursement rates and bureaucratic hurdles to discourage the delivery of relationship-based care, managed care companies appear to be forcing many Connecticut child and adolescent psychiatrists out of managed care, making it increasingly difficult for many middle income children and adolescents to have adequate access to psychiatric care or to receive the relationship-based treatment that was formerly the standard of care. For many young people, the psychiatric care available appears to be either drugs, or nothing.

One of the four recommended actions included:

Plans must be required to canvas participating providers regularly to determine those providers who are actually available to see enrollees seeking to begin treatment. This information must be made easily available to enrollees so that they are not required to telephone their way through the provider list only to be told that participating psychiatrists are not participating after all, or are not seeing new patients.

Unfortunately, it is common for payers to inflate the apparent size of their network by not keeping them accurate and up-to-date and including providers who no longer accept new patients or who do not take certain age groups or clinical problems. This report found that some payers had advertised networks that were 2, 3, and 4 times their actual effective size. (Is that fraud?)

Homework for the future: How many psychiatrists are in your network? How accurate is it?

Kids and Mental Illness

I try to stay out of the whole Kiddy Bipolar Debate debate: none of the Shrink Rappers see children, so my knowledge of childhood psychiatric disorders is limited to what I saw during a 3 month inpatient rotation 20 years ago, what I read, and what I see of children in my personal life.  It's a messy topic.  

I brought it up today because the Wall Street Journal has an article that summarizes nicely all the issues, the issues with regard to diagnosis, the fear of over-treating, the problem with under-treating, the question of whether mood dysregulation in children should be a separate disorder.  Please see Shirley Wang's article The Long Battle to Rethink Mental Illness in Children. 

I'm glad they're leaning towards renaming bipolar disorder in children.  When you hear Bipolar Disorder, you think about a lifelong condition that requires medication forever.  Children have phases, behaviors occur in some arenas and not others.  Perhaps if a child's emotional life is intolerable to them, or their behaviors make it impossible to function in their worlds, it's worth the risks to administer medications.  But a kid throwing horrible tantrums, fighting, running around the room, does not necessarily evolve into the same category as an adult who has 3 episodes of depression, and 2 episodes of psychotic mania, during their lifetime.  Oh, and I'm the one who thinks we should Rethink all of the Bipolar Diagnosis, not just for kids. 

So Wang writes: 

At one of his group's first in-person meetings, the NIMH's Dr. Leibenluft, an expert on bipolar disorder in children, gave a 20-minute PowerPoint presentation with evidence for a potential new disease. She called it Severe Mood Dysregulation.
She described a decade of studying children with severe mood problems that don't fit neatly into current illnesses. Thus began a cerebral process to decide what these kids might be suffering from.
The two main options: Create a new disease, or create a variant to an existing disorder. The discussions ran for years.

Why I Am Happy That I Am Not a Child Psychiatrist

My hat goes off to kiddy shrinks.  It's a tough field, full of issues we don't see in adult psychiatry.  

Our comment section often buzzes with talk about the over-diagnosis of bipolar disorder in children and the ethics of giving psychotropic medications to children.  The Shrink Rappers never comment on these things.  Why?  Because we don't treat children.  I have no idea if the children being treated are mis-diagnosed, over-diagnosed, wrongly-diagnosed, or if the increase in treatment represents a good thing---- perhaps children who would have suffered terribly now are feeling better due to the option of medications.  I've certainly had adult patients tell me their children were treated with medications, the children have often eventually stopped the medications and emerged as productive adults.  Would they have outgrown their issues anyway.  Or did the treatment they received switch them from a bad place to a good place and enable them to carry on in a more adaptive way?  Ugh, my crystal ball is on back-order at Amazon!  

Why I'm Happy I'm Not A Child Psychiatrist:

• Two extra years of training (and being on overnight call)

• No extra pay.

• "Normal" or "well" children often display behaviors that look a lot like those of "ill" children.  Ever witnessed a temper tantrum? 

• Children often can't verbalize their feelings and they are inferred from behaviors. 

• Children are often subjected to the treatment, with all it's options for distress-- whether it be that therapy displaces soccer or that Risperdal causes sluggishness-- without the same open dialogue and choice that adults get.

• Children are often treated based on the distress of other people.

• Some illnesses in children are defined by the arbitrary standards of societal expectations.  There would be fewer hyperactive children if we didn't expect boys to sit still for long periods of time.

• It's very hard to differentiate a "phase" that will be outgrown from "pathology."  This is especially true in teenagers where some angst and rebellion are part of some people's journey.

• There are times when treatment is based on the reports of others (such as parents) and there is no guarantee that such reports are accurate or that the parent's expectations are reasonable/realistic, and parents can be quite demanding about the need for treatment and medications.

• It can be difficult dealing with the troubled parents of troubled children.

• Expanding on that, parents sometimes get angry and remove their children from treatment if it is suggested that they are part of the problem.

• I don't like treating people who don't want help and children are sometimes in treatment at the request of their parents, schools, or other agencies.  True for adults as well, but not in my office.