Pediatricians Prescribing Psychiatric Medication: A Dose of Reality

Recently I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of
Pediatrics(MCAAP) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.

One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said.

First, clinicians went in groups of 4 to attend conferences run by Joseph Biederman, who, this doctor stated, "runs one of the best research programs in the country." (This is the same Biederman recently found guilty of violating conflict of interest rules in accepting, and not reporting, millions of dollars from the pharmaceutical companies that make psychiatric medication- see previous post.) Then a child psychiatrist, a close colleague of Biederman"s, started bi-weekly phone consultation with the group as a whole.

Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions."

In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.

This practice is paid by Blue Cross Blue Shield under the new model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.

Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.

Until this point, I had been silent, taking this all in, trying to find some solid ground to stand on. In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a holding environment through relationships. I volunteered that providing a setting in which mental health professionals and pediatricians in a community could develop relationships, such as a monthly collaborative case conference, might be the best model. Fortunately the leader of the group was intrigued by this idea as a model to implement and study.

Unfortunately this point of view is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first doctor's model. Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention, and on promotion of healthy social -emotional development in early childhood through relationship based interventions. I will continue to focus my efforts, as I have written about at length on this blog, both on working with young children and their families and teaching pediatricians about the world of research and knowledge coming from the discipline of infant mental health.

I left the meeting feeling a combination of horrified and hopeful, but certainly energized to forge ahead, even if at times it really feels like swimming against the tide!