Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Thursday, September 10, 2015

Screening for Mental Health Disorders: A Double Edged Sword?


Recent calls for screening for a range of mental health problems point to an important recognition of the need to identify and address emotional suffering. Such screening offers an opportunity to decrease the stigma and shame that often accompany emotional pain.

A powerful new documentary The Dark Side of the Full Moon calls attention to the under-recognition and under-treatment of postpartum depression. In one scene, a mother refers to resistance from doctors who lack resources to address positive screens as "ridiculous." She is correct, if the alternative to screening is to look the other way in the face of women who are suffering.

But she is highlighting a real dilemma. For the value of screening lies in being able to listen to, and offer healing for, the diverse range of struggles of individuals and families that fall under the umbrella of postpartum depression, or other DSM defined mental illness.

Recently a colleague spoke of her distress at the lack of care available in her clinic where large numbers of women struggled terribly in the early weeks and months of motherhood. “At least a doctor gets them started on a medication, but it’s a long wait for an appointment with a therapist.”
 In a primary care practice, for a teenage who screens positive for depression, medication may similarly be the only option. 

 When a person feels alone and overwhelmed, whether a socially isolated sleep-deprived mom with a fussy baby, a parent at a loss in the face of an out-of-control preschooler who disrupts the whole family, or a teen struggling to make sense of a new explosion of feelings that accompany this stage of separation and identify formation, an hour of listening, particularly with someone with whom we have a longstanding trusting relationship, can have great healing power. 

Decades of longitudinal research in developmental psychology  offer evidence that when people who are important to us listen for the meaning of behavior rather than responding to the behavior itself, we develop the capacity for empathy, flexible thinking, emotional regulation and resilience. 

Connectedness regulates our physiology and protects against the harmful effects of stress. Charles Darwin, in a work less well known but equally significant to the Origin of Species, addresses the evolution of the capacity to express emotion. He identifies the highly intricate system of facial muscles, and similarly complex systems of muscle modulating tone and rhythm, or prosody, of voice that exist only in humans. These biologically based capacities indicate that emotional engagement is central to our evolutionary success.

This week the US Preventive Services Task Force (USPSTF) called for universal screening of depression in teens. A recent New York Times article addressed the controversy surrounding screening for autism. This summer the USPSTF made a similar call for screening for depression in pregnant and postpartum women.

Screening is an essential first step in alleviating emotional suffering. However, universal screening for mental health disorders, in the absence of opportunity to listen to the full complexity of the experience of a child and family, may lead to massive increases in prescribing of psychiatric medication.  Medication may have an important role to play, and may at times be lifesaving. However, as I argue in my forthcoming book, prescribing of medication in the absence of protected space and time for listening may actually interfere in development.

These recommendations for screening can be understood as a well-intentioned effort to bring attention to the troubled state of mental health care in our society.  But as we move forward to address the vast scope of problems that we will uncover, we need to think very carefully. The value of listening cannot be underestimated.



4 comments:

  1. This is an excellent discussion of an extremely important clinical concept: the healing power of connecting to someone whom we trust.

    I wish you hadn't blown by the objection that there aren't resources to address positive screens with a facile comment that 'an hour of listening' can make a huge difference.

    I have a question: what hour of clinical activity should be replaced by the hour of listening?

    Peter Elias, MD
    (http://petereliasmd.com)

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  2. Hi Peter
    Thanks for your comment. I agree that the concern about screening without adequate resources for treatment is a huge problem. Placing a value both cultural and monetary on time spent listening is critical. I'm not sure what you mean by your question. I don't think of it as a replacement but rather as a valuing and prioritizing. In my forthcoming book I deliniate in detail both the healing power of listening and the forces in our culture that work against listening, including the lack of adequate reimbursment in the primary care setting for time spent listening.

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    1. My question is based that, at least in my clinical universe, time is a finite quantity. If I spend an hour listening to a patient because of a positive screen for depression (or for any other reason), it means that two or three other patients do not get seen. I do not have any extra hours in the closet to use. Every single additional activity, from the shortest(one extra click on a form in the EHR) to the longest (my institution making me spend 4 hours learning ICD10 coding) comes at the expense of some other activity.

      The way this plays out in my real world is typified by what happened this afternoon. I saw a patient with a significant new social crisis during his 20 minute BP follow-up visit. We spent 50 minutes today and will spend 30-45 minutes again before the end of the week. Today that meant that several patients waited an extra half hour and a patient later in the week will have his appointment rescheduled for 4-6 weeks down the road.

      My comment was because I thought (think) you gave pretty short shrift to the time pressure and ***chronically*** unmet and unmeetable needs in primary care. We already do only 1/2 to 2/3 of what the literature says is shown by evidence to be appropriate and effective - because we do not have time.

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    2. Thank you for this clarification. I completely agree that the shortage of time in the primary care setting is in many ways the essence of the problem, as you clearly articulate with this example. Your criticism that I gave the issue short shrift in this piece is valid. My aim in my writing in general, though not specifically in this piece, is to call attention not only to the value of listening in healing but also the way the lack of protected time and space can be harmful. This is particularly true in the case of children whose development is unfolding. So I am not saying that you should "take away" from other activites on any given day, but that we need to think about changing the whole system to re-prioritize listening.

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