“The systems to take care of the most severely mentally ill kids are completely broken.”
Children Trapped by Gaps in Treatment of Mental Illness
The 16-year-old girl had needed help, no question. She was throwing chairs, she was taking rides from strangers, she was acting
suicidal. Finally, she ended up in a psychiatric hospital, where, her mother says, the staff effectively saved her life, stabilized her, worked on her bipolar
disorder.
But once in, the girl could not get out. Not for months after the staff thought she was ready to go. No matter how she cried. She had joined the ranks of
thousands of mentally ill children and teenagers in the country who, doctors, advocates and officials say, are trapped in psychiatric hospitals and in other
institutions for lack of treatment programs outside.
…There are the children who must wait for hours in emergency rooms while in full-blown psychiatric crises. There are the “boarder kids,” children stuck for
days or weeks — or in extreme cases, months — in pediatric wards because there is no place for them in a psychiatric ward or hospital.
There are the “wait-listed kids,” waiting months for outpatient therapy or case management. And there are the “stuck kids” themselves, usually about 100
of them at any time in the state, according to official figures, who are ready for discharge from psychiatric hospitals but cannot leave for lack of outside
treatment programs.
At the hospital I direct, here in Massachusetts, the state most well-endowed in the United States with mental health professionals per capita, we have “stuck kids”
occupying 10-15 of our 42 child and adolescent beds at any one time, waiting for a place to go long after stabilized, for as long as 18 months at the extreme.
2-3 months is not unusual. The problem grows faster than grandstanders like the state’s commissioner of mental health, quoted in this New York
Times article, can throw money at it, proclaiming “an overall crisis in mental health” and citing a shortage in psychiatric staffing and numbers of child and
adolescent psychiatric beds in the state. She dances neatly around one of the real issues, the impact of managed care, perhaps because of the need
to maintain good relations with the succession of draconian, for-profit contractors to which the state has sold out the management of the Medicaid benefits
that fund so much of child treatment. “Private managed care, experts say, tends to reduce coverage for mental health, and parents often wait too long before
seeking help. In some states, managed care programs for children covered by public money have so cut the amount of treatment received that state
governments have abandoned the programs.” The contraction in numbers of hospital beds is a direct result of the reductions in reimbursement levels, making
it impossible for hospitals to cover the expense of providing the care — whether for-profit or nonprofit. Paradoxically, length of stay increases and
quality of care decreases as inpatient mental health care becomes more severely managed; hospitals cutting staffing levels in the interests of
economizing and increasing workloads of professional staff such as social workers and psychiatrists translates directly into inefficiency of treatment. Direct
care staff are really the ‘stone from which no blood can be gotten.’
While the article also cites demographic shifts (the ‘boomlet’ in adolescent
population), it misses a more important change in societal attitude — a conceptual problem which, IMHO, is the most important sense in which “the
systems to take care of the most severely mentally ill kids are completely broken.” Child and adolescent mental health care resources are more and more
wasted — yes, I know, a stark word — on social control of behavior and conduct problems rather than ‘true’ mental illness, in what I feel is a displacement of
responsibility for the failures of other segments of society — social service agencies, the educational system, the legal-judicial system and, most important,
parental responsibility. The psychiatric profession, perhaps to protect and expand its market niche in the era of managed care. colludes and enables this
process willingly or inadvertently via the increasing medicalization of these problems. (now, as an aside, this, as detailed in the National Post, is not what I would propose as an alternative…) We ‘bless’ these conditions with diagnostic labels, thus making them
reimbursable. To wit:
the official codification of diagnoses such as “oppositional-defiant disorder” and “conduct disorder” for what are essentially bad
behavior;
the increasing treatment of adolescent substance abuse as a mental illness;
the overdiagnosis of ‘trauma’ and ‘post-traumatic stress’ in
the aftermath of virtually any disturbing childhood events;
the supposition that there is a mental illness whenever an adolescent has made a suicide
gesture, and the vastly broadened notion of what constitutes a suicide gesture;
the expansion of the diagnosis of ADHD (attention deficit hyperactivity
disorder) from a meaningful indicator of dysfunction in the machinery and physiology of directing and sustaining attention to a meaningless label for any
unruliness or distractibility; and
recent efforts to expand beyond anything reasonable the boundaries of the domain of adolescent bipolar disorder.
Wouldn’t you assume, as does the author of this New York Times article unquestioningly, that this surely represents ‘true’ mental illness in need of
medical care? You’d be wrong. Adolescent psychiatric ‘experts’ are trying dogmatically to re- educate the rest of us to the fact that adolescent mania has
been underrecognized because it looks nothing like adult mania; with handwaving and smoke and mirrors, any mood instability or lability is now seen as
such.
I used to lecture medical students and psychiatric residents about the conceptual bases of psychiatry, flooring all but the most sophisticated with the assertion that
diagnostic categories, rather than being etched in stone, are built on shifting sands. There have been marked differences, both over time and from culture to culture or
even region to region, in the numbers of ‘official’ diagnoses, the extent of what is included in each. The flavor of the moment in categorization — whether you
want to be a ‘lumper’ or a ‘splitter’, to see similarities or differences, whether (to paraphrase Gregory Bateson) a given distinction makes a difference — changes over
time and place as well as with the individual predilection of the diagnostician. For something to shape up as a meaningful diagnostic category, it ought to have an accumulation of evidence along some or all of the following lines:
homogeneity of presentation;
consistent neuroanatomic or physiological alteration (as indicated by psychological test results, laboratory measures and/or
alterations in functional or structural imaging);
consistent longitudinal course over the affected individual’s life cycle;
consistent comorbidities, or associations with other conditions
heritable characteristics;
consistency of responses to therapeutic measures
Done properly, categorization based on such factors does not lead to circular definition. Done sloppily, it almost always does. The most profound example of that in
psychiatry is the way in which diagnostic categories tend to proliferate as new types of medications, or new applications for existing medications, are found. If you
define your disease states merely on the basis of what works to treat them, you’re in for conceptual trouble and confusion. The classic case was the vast expansion in
the numbers of people diagnosed with manic- depression (bipolar disorder) after the introduction of lithium in the late ’60’s. You might argue that this is innocent; all
of a sudden, because an effective treatment existed, it became useful and important to make the diagnosis (à la Gregory Bateson’s “distinction that makes a
difference” notion). I would argue that it’s often a far more malignant pathology in our reasoning, more akin to Molière’s pontificating physician in Le
Malade Imaginaire who thinks he’s explained something meaningful when he says that the opium poppy makes its user sleepy because it contains
(drumroll) ‘a dormative principle‘! And, while we’re at it, keep in mind the ‘use it or lose it’ phenomenon in medical care. Because of initial enthusiasm and
self-fulfilling prophecy, after a new therapeutic breakthrough is introduced, it quickly amasses an impressive track record. Its touted efficacy spreads by anecdote and
word of mouth. Later, when gold standard placebo-controlled double-blind studies with large enough numbers of subjects to be statistically significant are conducted,
results are never so impressive…
More recently, pharmaceutical-driven circularity in the definition of diagnostic categories has vastly expanded beyond the lithium example. Is it ADHD because it
‘responds’ to a psychostimulant? Nearly anyone will feel an enhanced sense of wellbeing and increased cognitive efficiency with this class of drugs. Is it a depressive
disorder because it ‘responds’ to an SSRI antidepressant? The quintessential ‘cosmetic psychopharmacology’ class of drugs, there are benefits to epiphenomena such
as emotional reactivity and irritability in most, even psychiatrically well, users. Is it an anxiety disorder because it ‘responds’ to an anxiolytic? By no means. And, back
to adolescent bipolar disorder, there is little or no evidence that patients so diagnosed will turn into adult bipolars; little or no evidence that adolescent mania and adult
mania are comingled in family trees; and little or no demonstrated consistent biochemical abnormality characterizing members of the class. Can you say they have a
disease because they seem to respond to the medications that are used to treat bipolar mood swings? No, because the ‘mood stabilizers’ — which by now have grown
beyond lithium to include a variety of anticonvulsant drugs — will dampen the intensity of most emotional turmoil and instability, nonspecifically!
Now, don’t misunderstand, I’m not trying to be a diagnostic nihilist here. No, wait, maybe I am; the more and more I pry up the rocks and peer underneath, the more
I see the bugs in the field… But, usually, I think there is a careful way to do diagnosing that remains meaningful and — this is the ultimate
point, isn’t it? — has therapeutic utility in helping our afflicted patients. Our truly afflicted patients.
Okay, I’ll get off my soapbox now… for the moment.
icon will allow you to post a comment to an item here, and the number in brackets shows how many comments have been posted to that item. Thanks in advance for comments on anything or everything, agreeable or contentious; fire away! And thanks to everyone who wrote with suggestions for a discussion system. Please let me know if FmH’s load speed (sluggish as it is already!) seems to take a hit now that ReBlogger’s in place.
