The big problem is that guidelines alone are usually insufficient to get folks really competent and comfortable, and sustained hands-on support is what is needed, which is what we do with our national faculty of PCPs and Child psychiatrists. Go to http://www.TheReachInstitute.org, and check out the training programs and outstanding national faculty. If enough of you are interested, we could schedule a pharmacotherapy learning or training experience at your location, as well as other areas of emphasis. pj Peter S. Jensen, MD

During our fellowship program, Do others insist on a psychiatric evaluation at some point for patients on these medications? This is difficult with the shortage we face of psychiatric consultation.
I have even spoken to Risk Management as I feel we are all out on a limb on this one, with families desparate for help, demanding treatment, unhappy with various crisis centers and therapists, wanting to get medications from the pediatrician they have known for years. Yet I know I do not have the training or inclination or time to determine all that needs to be clarified before I feel comfortable writing a prescription for something like Zoloft or Prozac.
I am utterly uncomfortable assessing suicidality.
Any thoughts?

“I was one of the original opening persons for this blog, then a medical crisis forced me to cease participating in the exchange until I recovered enough “go juice” for me to return. The opportunity to revisit the two dozen exchanges provides me with an unusual vantage point for appreciating the whole range of perspectives. I cannot say I disagree with anyone’s contributions, taken as a whole; the dialogue is productive and inspiring.

Let me first say I am a community based clinician who has worked in the field since 1974, specializing in neuro-developmental disorders in 1997 to the present. I find working with a collaborative group essential, including paraprofessionals (in home service, school, and special care), educational consultants, neuropsychologists, physicians, social workers, and have even specially trained babysitters for my clients (one of many points Steven D. and I harmonize upon). I average 25% of my practice as a form of pro bono (exceptional low fee) while many clients pay top dollar for our services. The collaborative practice is structured to fit my community’s micro-cultural requirements, much of what we do would not be suitable for other areas. I am more than ever, skeptical and cynical toward the mental health profession and find my fellow licensed clinicians, astonishingly narrow and shallow in their knowledge and ability to think critically about their job responsibilities. Interviewing for clinical replacements while my medical crisis is dealt with has reinforced and amplified my views toward the utter incompetence of my community colleagues (another major shared issue with Steven).

Sara’s remarks I found to be insightful, accurate, comprehensive, sensitive, and deceptively profound in identifying the underlying problems we face in mental health. Her credentials as “mom of four children and friend to many moms,” makes her eminently qualified to participate in the dialogue. To begin with, the so called stigma around mental health is a socio-cultural illusion since in fact; all the members of her Psychology 101 class were and are coping with the problems of life that often become labeled “mentally disordered.” In order to manage our helping relationships, nomenclature is needed to conceptualize to problem that allows for the professional to become an effective change agent. The person is not the label, any more than the map is the territory, or the word is the thing itself. Diagnostic labels are only tools with a pragmatic use in helping resolve the person’s problem and not to define the person. The mental health professions tend to become sloppy in their use of language and Sara’s example of her visit to a clinician’s office provides an excellent example.

When any one, professional or otherwise, talks with a covert agenda of inferred pathology and is not working to hear and understand your experience of distress, the interpersonal connection becomes dysfunctional. R.D. Lang, a prominent British psychiatrist, referred to this form of communication as “mystification” and speculated that the interpersonal process occurs when one person attempts to improve their feelings of adequacy by lowering the other’s feeling of completeness. In this case, the clinician was likely to feel more a psychotherapist by creating discomfort in Sara, the patient as a child. Thankfully Sara’s mother had the good sense to be proactive, a rare occurrence in child psychotherapy. Probably her experience reinforces why so many of us rely on “hey, do you know a really good psychiatrist?” with friends. I am often given as such a referral, although I am not a psychiatrist.

Recently, as more cases have been referred to me because of negative prior therapeutic experiences, I have begun to conclude that unless one is really certain about the referral, perhaps a poorly informed consumer should stay clear of the clinical professions. Each week countless cases requiring relatively simple diagnosis and treatment are brought in under appalling circumstances that would be malpractice if not the community standard.

Sara’s profundity lies for me in her observation regarding the intellectual dissociation that is the standard amongst the clinical professions. I am continuously amazed to find the most reputable of highly educated and trained clinicians who treat concepts and scientific data about human consciousness as “stuff” to be practiced and fail to understand that we are all subject to the identical neurological processes. ”

John Schureman, PhD

Across these disciplines, there are some overlapping roles here, but unique roles as well. I would argue that in those severe cases, a minimum of 3-4 regularly communicating professionals will be required, one of which will like need to be a child psychiatrist, or someone specially trained to work with complex cases that require medications, therapy, physical assessment/evaluation, social work, and probably education.

If we treated cancer the way we do severe psychiatric problems, the child would go to see just one of the six or seven specialists needed, depending on whatever door the family happened to walk in, and that clinician would not talk with the other 6 specialists, all of whom would be in separate offices…there would be no team.

So, go back to my initial point; Assume 7000 persons especially trained in these complex cases, they have 2000 hours/year available. 2000 x 7000 = 14 million hours to treat 4 million kids, gives each kid 3.5 hours of that particular kind of specialist per year. The average service episode for child mental health across the US is about 10-12 hours per year.

Doing the math, this means that if you believe that severe cases need multidiscplinary care, e.g., SW, psychology, psychiatry, peds, nursing, UNLESS many of us are willing reorganize how we do care, i.e., get out of our solo office practices and re-form ourselves into multidisciplinary teams to bring all of our skills together, we will never be able to solve the current MH crisis.

Speaking about my own discipline, if I spend all my time seeing cases all by myself, doing the therapy, medication, school consultation, etc., in effect spending that 10-12 hours with a family all by myself, there will never be enough child psychiatrists to go around. But if I align myself with a team, I can spend 2-3 hours with every child, out of the 10-12 hours each family gets on average, with the other critical disciplines contributing as well. And the shortage of child psychiatrists disappears, and higher quality, integrated care becomes available.

So don’t feel insulted. Using the cancer analogy, the most severe cases are likely going have to have the input from someone who has specialized and been trained in diagnosing and treating them. But if that person, where it be a child psychiatrist, a social worker, or a nurse, tries to do it alone in office based care, without a team of all the other needed professionals, it’ll be lousy care.

Determining what is “better” is a highly subjective decision. Value is not easy to measure.

Again, to apply an economic analysis, let us assume that the marketplace of consumers, choosing what they believe to be best for their children, is what determines who or what is “better” as a consumable mental health product. The fact that child psychiatrists or other doctoral level professionals are far fewer than social workers and other non-doctoral providers is reflective of how our society values the services provided. At the “price points” of what a child psychiatrist or psychologist costs, versus what a licensed social worker or other counselor providing psychotherapy costs, the marketplace has found the optimal mix of those services.

Until we as a field increase the value of our services to society, the demand and supply for those services at the price we charge will not increase.

This is not something that central planning, through socialized medicine or government intervention can change. This is the reality of how society values what we provide. Dictating from Washington how those services are rationed to different segments of society will not change how society values them.

It may seem like a good idea for government to step in and subsidize our services so that more people can receive them. But just as the Big Three car manufacturers are flailing, because they can no longer produce a product that consumers are willing to buy at the price they charge, having the government step in and subsidize the product will not change how consumers value that product relative to other choices. It will not increase the intrinsic value of the product we provide, which is ultimately what determines how much society is willing to consume and to pay for it. It is up to us as a field to improve the product we offer, so that consumers will wish to pay for it.

I will grant that this seems an oversimplification, when most health care is paid for via private insurance and other third party payer systems (medicare/medicaid). Consumers do not consider the true cost of the fees the doctors charge when they make their decisions about how much health care they can afford, they only consider the out of pocket costs, in co-payment or non-reimbursed medical expenses. However, in aggregate, we as a society are still paying for those services in the monthly deductions from our paychecks for our health insurance and the taxes we pay to support the public health sector. Our society as a whole, through choices made by our elected legislators and by our corporations who fund the insurance benefits, as well as the millions of individual day to day decisions of each consumer about which health care provider they seek services from, and which insurance plan they are willing to pay for in their monthly paycheck deductions, are setting the value for our services and determining which is “better,” or the relative “betterness” (value) of doctoral and non-doctoral providers.

The value of mental health services is not determined by government funding, or government decisions. It is determined by the consumers of health care in the marketplace of health services. If we psychiatrists bemoan how undervalued and undersupplied our services are, because we cannot get the third party payers to pay for them, we have to realize that it is not the government or insurance companies who set our prices or determine the value of our services. It is us, who are providing those services, but demanding fees beyond what society is willing to pay, who are determining how society values what we do. If we want society to pay for more of our services, we can do either of two things (besides lobby the government to subsidize us, as Detroit’s Big Three are doing): we can lower what we charge for the services we provide, which will increase the demand, or we can increase the value we provide at the price we charge, which would also increase consumer demand. These are fundamental laws of economics that we cannot wish away.

We cannot change society by dictating through the government. We can only change what we as individuals do (and “we” as a professional group), and thereby change the effect we have on society and the value that society attaches to what we do. Our field must come to grips with this truth. If we want child mental health services to be as widespread and available as cosmetic surgery, doc-in-a-box clinics, or other economically successful health care products, we must provide more value that consumers are willing to pay for.

Lisa LaVardera-Guidice has made my point in her description of her own economic decisions regarding care for her children. I, too, am a parent of a child with ADHD and mood problems that require complex management. I am in the relatively unique position of being both a child mental health provider and a consumer. I am well aware of the economic decisions parents must make and the anguish that it can cause, wondering if the money spent for a child psychiatrist will be worth it, and feeling guilty that I would question the cost for my child’s mental health needs. These are the daily decisions that consumers must make.

Our field must find ways to provide more “bang for the buck” if we want our services to be more valued by society and thus in more demand and more available.