Tag Mental Health

Entries 14 Total

Are Meds Alone Sufficient to Treat My Child’s Psychiatric Symptoms?

Dec 8, 12 11:05 PM

teenandmedicationMany parents wonder about the efficacy of using only medication to treat their child’s psychiatric condition. While a full treatment of this question far exceeds the scope of a blog, it’s possible to briefly summarize some important themes and issues.

Clinical work limited to an initial interview and medication therapy risks misdiagnosis.

This is an example of an evidence-based, cost effective and clinically effective, outpatient evaluation for a child’s or teen’s mental health symptoms (assuming medical causes have been ruled out): a family interview, an interview alone with the youth, the collection of parent, teacher and child behavior rating scales and a review of relevant records. This is complex business and I worry about the accuracy of a diagnostic formulation if one or more of these elements is missing. Moreover, it is possible for a child to improve on a given medication without the child actually having the disorder that the medication is supposedly treating (e.g., low doses of stimulant medication will often improve the concentration of any child, regardless of whether or not that child has ADHD. Of course, sometimes it isn’t possible to do more than a brief interview and a medication trial, but if it’s possible to add the other elements that would probably be advisable in most instances.

Treatment with medication alone is rarely indicated.medication

There are some mental health conditions in youth for which medication treatment will almost always be a part of an evidence-based treatment plan (e.g., ADHD, bipolar disorder, schizophrenia). However, the best designed research studies on these conditions almost always indicates that evidence-based talk therapies (usually behavioral treatments) significantly improves the efficacy of the medication treatment (e.g., decreasing the dosage of medication needed, speeding along the management of the symptoms, strengthening the degree of  improvement, reducing the odds of suicidality). Moreover, in the very large majority of instances, children with a psychiatric diagnosis have at least a second diagnosis as well, and many of these co-occurring conditions are either best treated with evidence-based talk therapy alone or are  better treated when evidence-based talk therapy is added to the treatment plan.

Certain diagnoses, while perhaps improved with medication treatment, may not need such if evidence-based talk therapy is tried first.

teenfamilytherapyFor example, for mild to moderate depressive disorders and anxiety disorders, cognitive-behavioral therapy or other evidence-based treatments (e.g., interpersonal therapy for adolescent depression) may sufficiently manage or heal the presenting symptoms without the need to add medication therapy to the treatment plan. While these treatments take more effort than swallowing a pill, they may be preferred by parents who wish to avoid artificially altering their child’s brain chemistry when talking treatments may do the job as well or better.

There are many instances when the science on medication treatments leaves important questions unanswered.

There are many unanswered questions about the pros and cons of providing childmedicationmedication therapy to very young children as there are regarding the long term consequences of being on the same medication and the degree to which medication treatments alter the development of a youth’s brain. If a child needs medication treatment in order to avoid significant here-and-now impairment, most would agree that such questions often need to take a back seat.  But, if a youth’s symptoms can be effectively treated either by not taking a pharmaceutical, or by taking a lower dose, that would appear to be a preferable choice in many instances.

The short-term conveniences affiliated with medication treatments should give us all pause.

I believe the best available evidence would support the position that effectively moneyandpillsdelivered talk therapies for youth spares money, aggravation and pain over the long run. However, in the short run, talk therapies may offer more hassles (e.g., additional costs and inconveniences) than medication treatments. Moreover, considering only short-term costs may create incentives for decision makers (e.g., insurance companies, clinicians with capitated insurance contracts, hectic parents) to gravitate towards treatment plans that only include medication therapy. Such factors should cause us all to pause and reflect on both the available scientific evidence and issues affiliated with longer term consequences.

A take home point is that it is usually a good idea to have a mental health professional on your child’s treatment team who is aware of the relevant science and clinical practicalities and who can help you to effectively navigate your choices. If you’re interested in speaking with a psychologist more about these matters, please click here.

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What Do I Say To My Teen When Another Teen Has Committed Suicide?

Sep 29, 12 2:47 PM

Few tragedies make us wonder more about the order of our lives than when a teenager or young adult commits suicide. Sadly, this is too common as suicide is the third leading cause of death among those aged 15-24. Moreover, a recent national survey by the Center for Disease Control indicated that 16% of U.S. high school students report that they think seriously about suicide and half of those state that they have made an attempt.

As we consider this topic we also all do well to keep in mind that there is a risk of contagion whenever a teen commits suicide (e.g., a risk of another teen committing suicide). I’ve never known an adult who intended to glorify suicide. But that can be exactly what happens when a teen suicide is sensationalized or overly memorialized.

With those comments in mind, here are a few tips for approaching your teen about this topic:

• Don’t force a conversation about the suicide, but make it clear you’re interested in discussing your teen’s thoughts and feelings about it if he or she is open to that.

• Let your teen take the lead in the discussion. Try to avoid sharing your perspective until your teen’s thoughts and feelings appear to have been fully vetted. (In my experience this is hard for many of we parents to do).

• Offer empathy in response to whatever your teen says. Empathy to a teen is like a warming sun to a spring tulip: it facilitates more opening up.

Some things to consider offering once it is your turn:

• Let your teen know (or affirm the point if your teen has already made it) that suicide constitutes the worst possible choice a person can make. There is nothing about suicide that is worthy of glory, reinforcement, romanticizing or undue attention. It is a tragic and terrible behavior engaged in by people who are experiencing overwhelming pain and/or confusion.

• Ask your teen if he or she has ever thought about hurting himself or herself. (It’s a myth that asking this question, by itself, will promote or worsen suicidal thinking or behavior.) If he or she states that he or she is thinking about committing suicide arrange for an immediate evaluation by a qualified mental health professional (you can call the emergency services unit of your local community mental health center or take your teen to your local emergency room).

• Consider asking your teen what he or she thinks it would be like for you if he or she ever committed suicide. Then, either agree with what he or she has said or share more. This would also be a good time to reaffirm your deep love for your teen and the specific things that your teen says or does that you value.

• If your child knew the teen who committed suicide let him or her know that a grieving response is normal and expected. The balance is to give those thoughts and feelings the time and space they need while also trying to live life as normally as possible.

• If your child knew the teen who committed suicide stress that there is no way to know the causes of that particular teen’s suicide. Very little insight can usually be gleaned from the circumstances of the teen’s life (e.g., the degree of academic success, how much cohesion appears to be in the family, etc.). As a psychotherapist my clients usually let me in to very private and hidden areas of their lives; however, even I do not often know every important factor that causes them to behave in a particular way.

• Let your teen know that you will arrange for him or her to speak privately with a qualified mental health professional about these issues if he or she would like that.

There are many preventative strategies Here I will share three (I am more thorough about this in my parenting book):

√ Spend at least one hour a week doing special time with your teen. A regular line of communication makes it more likely you’ll be in the loop if your teen’s mood darkens. Click here for a download on how to do this weekly exercise.

√ Do all that you can to make sure that your teen has identified his or her competencies and is manifesting them in the world.

√ Try to ensure that your teen is sleeping at least 8.5-9.5 hours a night, is eating a balanced diet that limits processed carbohydrates and sweats and breathes hard an hour 5-7 days a week.

In closing, if your teen is showing signs of mental health disturbance, please err on the side of caution and arrange for a qualified mental health professional to do an evaluation, even if your teen is opposed to the idea. For a referral, click here.

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Ignoring Kids’ Mental Health Needs is Expensive

Jun 30, 12 10:15 AM

With most of the Affordable Care act being upheld this week by the Supreme Court, it seems like an apt time to review an example of how costs rise when kids’ mental health needs are not sufficiently addressed.

A few months ago The American Journal of Child and Adolescent Psychiatry published a national study regarding the cost of pediatric (age ≤ 18) usage of emergency room visits in the U.S. from 2001 to 2008. (As many know, ER and hospital care is usually much more expensive than outpatient care. Moreover, mental health problems are more likely to be treated in this more expensive setting when a youth’s outpatient needs for care have not been adequately attended to.) The abstract can be found here. Some high points:

• Of the 73,105 visits, 1,476 were for mental health issues. When appropriate statistical adjustments were made, it was estimated that there are 480,700 emergency department visits for mental health issues in the US each year.

• 21.8% of the mental health contacts arrived by ambulance compared to 6.3% of other kinds of contacts; they also stayed longer  (median 169 minutes vs. 108 minutes) and had a higher rate of admission into the hospital (16.4% vs. 7.6%).

• The rate of usage was not significantly different across gender and between Caucasian and African-American kids; however, the usage rates for Hispanics was lower than non-Hispanics.

• Quoting the authors: “Depressive disorders were the most common principal diagnoses, followed by anxiety and disruptive behavioral disorders or ADHD.”

• Following appropriate statistical adjustments, the researchers determined that 1/3rd of the mental health related visits to hospitals result in a hospitalization.

• Additional collateral costs (e.g., the need to have security personnel monitor the youth, the fact that many arrived with escorts that had a professional role in the child’s life) were also noted.

• Quoting the authors: “Probability of extended stays for mental health visits rose over the period that we studied. By 2008, the odds of an extended stay (> 4 hours) was almost twice that in 2001, and we did not observe comparable growth in the duration of non-mental health visits.”

The authors also acknowledge that their rates may represent underestimates of usage as they used stricter criteria for defining a mental health visit than have other investigators that have examined this area.

For me this study place another brick in the wall that demonstrates the tremendous costs–financial only being one of them–that accrue when we neglect the mental health needs of our children and teenagers. If you’d like to read more about this, please see Chapter 10 of my book Working Parents, Thriving Families, or any of the blog entries below:

Signs That a Kid Needs Mental Health Services

Seven Common Myths About Counseling

Affording Mental Health Care

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Mental Health Concerns Are Nearly Universal By Age 21

Oct 28, 11 7:09 PM

Earlier this year a landmark study on the prevalence of psychological disorders in youth was published in the Journal of the American Academy of Child and Adolescent Psychiatry. Examining youth living in 11 counties in the southeastern US, it is the first to track kids’ mental health status from ages as young as 9 through age 21 (a total sample size of 1,420). The authors–Drs. William Copeland, Lilly Shanahan and E. Jane Costello and Ms. Adrian Angold–note some key findings in their report:

• Assuming that there was no incident of psychiatric disorders among the missing cases (an unlikely event), 70% of the sample met criteria for a mental health disorder, at some point, by age 21. (This is referred to as the unimputed number.)

• If one were to assume that the rates of psychiatric disturbance are the same among the missing cases, the frequency of a mental health disorder by age 21 rose to 82.5%. (This is referred to as the imputed number.)

• Child participants entered the study at one of three different ages: 9, 11 and 13. Among the youngest cohort (i.e., entered the study at age 9), the rates of having a diagnosable mental health problem by age 21 was “higher than 90%.” The authors note “This suggests that the experience of psychiatric illness is not merely common but nearly universal.”

• When examining the imputed analyses, these were the most common disorders: substance abuse–42%, behavioral disorders (e.g., ADHD, Oppositional Defiant Disorder)–23.5%, anxiety disorders–20.9% and mood disorders–14.8%.

While all research studies have their flaws, and this one is no exception (e.g., an under representation of African-American and Hispanic children), this study numbers among those contributing to the notion that mental health disorders and physical disorders, as they manifest in youth, have many similar characteristics:

• The odds of having at least one by adulthood are nearly universal.

• Most are not chronic or severe.

• Most can be cured or effectively managed through evidence-based interventions.

• Most will either worsen, or promote needless suffering, when they go unrecognized or untreated.

However, there is a key way that mental health and physical disorders in youth are substantively different. As the authors indicate: “Only about one in three individuals with a well-specified psychiatric disorder received any treatment at all, and even when treatment was obtained, it rarely conformed to best practice recommendations.” I find myself wondering when we will grow weary and intolerant of this needless suffering that our babies endure.

If you, as parent or caregiver, would like to find an ally in your neighborhood to help you to understand whether a child or teen under your charge could use help along these lines, click here. To read a consumer guide for child mental health services, see Chapter 10 in my book Working Parents, Thriving Families: 10 Strategies That Make a Difference.

You may also find value in reviewing posts I’ve written on related topics:

• Affording Mental Health Care

• Signs that a Kid Needs Mental Health Services

• Seven Common Myths About Counseling

• Millions of Teens are Suffering Needlessly

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