Brain Tumor

In the United States, we’re increasingly facing a host of serious issues affecting our health care. Costs continue to rise (my small business health insurance costs rose 25% this past year in Massachusetts, where health insurance coverage is mandated) — unchecked by apparently anyone — while treatment options seem to decline.

Need further proof? In yesterday’s Boston Globe, pediatrician Claudia Gold wrote an op-ed lamenting the American public’s attitude toward mental health care, and the lack of accessible mental health care in many parts of the country. She makes the point that while we wouldn’t think twice about visiting a specialist in a big city hospital for a brain tumor, we hem and haw when it comes to properly treating our children’s mental health issues:

But consider that your son has another serious illness affecting his brain, but one you cannot see on a scan. I am referring to serious mental illness. Rather than assuming that this child deserves to have access to the same specialized care, our culture has colluded in the belief that a primary care doctor will be an acceptable provider of care.

She laments the inability to refer patients to proper mental health care professionals and lays out her beliefs about what’s wrong with child mental health in the U.S. today, from a pediatrician’s perspective:

So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.

On first blush, I agree with her. Americans far too often rely on their primary care physician or pediatrician to treat a mental health issue, at the expense of getting the level of quality care they normally would expect. The same person who wouldn’t think twice about traveling 60 miles to see a specialist at Dana Farber Cancer Institute in Boston might think traveling 30 miles to see a similar specialist in mental health a chore and a burden.

But then when I got to thinking about the factors at work, I found myself disagreeing with the three she fingered for blame.

First, the pharmaceutical industry has certainly become the favorite whipping boy for all the evils in the medical and mental health worlds. Yet without the medications provided by the pharmaceutical industry, so many maladies today would have few other effective treatment options. If the pharmaceutical industry has been successful at promoting the idea that a fix is in a pill, it’s only because it had a receptive audience that is looking for the quick, easy fix that requires little effort on their part. Psychiatric medications are so popular because so many are simply not willing to devote the time and effort to finding a good therapist and working with them on longer, harder fixes.

Second, I’m not sure what the insurance industry has to do with simply referring a patient to a mental health professional. Yes, it’s true, just like docs, not all mental health professionals take all insurance plans. But you could make the same argument about referring to any specialist. Most physicians find a number of reliable mental health professionals within their community to refer to, and regularly do so.

Third, there very well may be a shortage of child psychiatrists. But there’s no shortage of qualified child psychologists, and other mental health professionals from other professions that can offer mental health treatments for children and teens. Child psychiatrists are not the only professionals who provide treatment for mental health concerns. Shortages vary from geographic region to geographic region, with most shortages occurring in rural areas — not surprising, given how sparsely populated such areas are.

Which brings me to the heart of the matter. In all of the cases this pediatrician discussed, not once did she mention any type of non-medication treatment for the children. In discussing treatment of ADHD in children, not once did this pediatrician note that the best treatment strategy for ADHD in children are behavioral interventions first, not medication (as we noted a few days ago). But if all you have is a hammer as your tool, all you see around you are nails. If you’re a pediatrician, you’re taught the value of medications, but less so the value of psychotherapy and behavioral interventions.

Good therapists tend to be in demand, especially in this economy, but most have room in their schedules for new clients (or know of equally good colleagues who have some). Good psychiatrists — especially child psychiatrists — are a little harder to find, and are in greater demand than their supply. But children don’t just need medication (in fact, medication is usually the last thing they need). They need a good child therapist who has experience and a background in helping them with their mental health concerns.

Pediatricians aren’t there to simply make a referral — they can educate their patients about the importance and value of seeking specialized mental health care (prescribing “information therapy”). And then refuse to prescribe psychiatric medications. Because if a parent can’t get the medication from the pediatrician, perhaps they will be more motivated to seek out appropriate mental health treatment from other professionals in their community. This expectation that a pill will solve everything (or most everything) can be halted in the doctor’s office, if the physician is willing to stand up to their patients. But few physicians are, and perhaps fewer patients are willing to listen or try alternatives.

And so the cycle continues…

Read the full article: Backed into a treatment corner.