Friday, February 16, 2007

It's All In Your Head

I realize that making fun of Scientology's take on mental illness is an easy and cheap shot (much like Tom Cruise himself nowadays). Still, a patient yesterday reminded me of just how laughable/misguided/disgraceful such a denial is. For the few of you who don't already know, Scientologists believe all mental illness is curable through sheer willpower and exorcism of personal demons (the latter on multiple levels), and therefore they proclaim psychiatrists to be frauds who like doping up kids for money.

Of course, Scientologists believe the gospel according to L. Ron Hubbard, a hack sci-fi writer who invented a religion based on the evil space warlord Xenu and the "thetan" spirits that inhabit our bodies. Or something like that. No, really, look online if you don't believe me. Doesn't sound like they're in any position to judge the mental fitness of anyone else.

Anyway, without divulging too much detail, yesterday I saw a six-year old who was depressed. WAY depressed. Not like "I feel sad." More as in, "I hate everybody. Everybody is mean." Sitting on the exam table quietly, looking down, not cracking a smile, for the entire 30-minute visit. Mom says he's been like this every day for 2-3 weeks now, doesn't even want to play his video games.

So, Tom Cruise, want to try to clear his thetans? John Travolta, do you believe you can make this kid happy again?

It's fair to say, without being judgmental, that this is not normal for a six-year old boy. It also doesn't take a clinical psychologist to realize that there is something acutely screwed up in his brain chemistry. Adults with major depression will remind you that their condition is not simply a "bad mood:" it's more like being taken over, becoming physically and mentally incapable of rising above. Yes, there are many factors converging here: his home and family environment, his intellect and inherent ability, his experiences around Katrina. But none of this accounts for why a six year old boy would act like this for 2 weeks straight.

He needs to see a psychiatrist. Pronto. Unfortunately, there are none around here. I'm not averse to prescribing meds myself, when appropriate--but antidepressants are tricky. Last year the FDA became concerned about a few case reports of teenagers becoming agitated and even suicidal while on antidepressant medications (specifically, "SSRIs" such as Zoloft, Paxil, and Prozac). The FDA mandated a "black box warning" and urged extreme caution. So us pediatricians (already being told by many insurance companies that psychiatry was "not our area of specialty" and therefore not a reimbursable office visit) didn't want the extra liability, and we stopped prescribing SSRIs ourself, and referred all depression to the child psychiatrists.

Of course, the vital statistics released last month revealed a double-digit percentage increase in childhood suicides last year. Gee, who would have thought: if you don't give people antidepressants, they become--wait for it--depressed, and depressed people are at risk for being--wait for it, again--suicidal?

The perfect storm: politics, legal liability, and ivory-tower academics. But until the FDA decides to rescind that black-box warning, I'll be in BIG BIG trouble for any adverse effects from SSRIs that occur on my watch. I picture the malpractice lawyers licking their chops like ravenous wolves.

The mom assures me that she will watch and notify immediately if the child becomes a danger to himself or to others. In the meantime, we've spent 2 days trying to find a child psychiatrist (thank goodness he's not on Medicaid, or we'd be really screwed). We may have one an hour away, if we're lucky, who might be able to get him in one month from now (and mom will have to pay cash because she hasn't yet met her insurance deductible). And I guess he'll just have to suffer through it until then.

10 comments:

DR. MARY JOHNSON said...

Very good post.

Sound like your problems down there rival our in North Carolina . . . where mental health care is a joke . . . especially if you're a child.

Anonymous said...

Dr. Scott:

Please check out this blog for some perspective on kids and antidepressants etc.

http://clinpsyc.blogspot.com/

Dr Scott said...

Anonymous-
I did look at clinpsyc.blogspot.com, at your suggestion. Very interesting points. Cl psych argues that antidepressant use did not decline when suicides went up. However, cl psych is misleading on his/her statistics, giving data on prescriptions in 2004, but the black box warning came out October 2004. I'd want to see the data on 2005.

Intuitively--particularly given that earlier, smaller trials failed to identify significantly increased suicidality on SSRIs (as opposed to post-marketing case reports and population-based surveillance, which potentially have more statistical power but can be much more difficult to analyze)--one would expect many more depressed kids to be suicidal OFF meds than ON them.

Surgeon in my dreams said...

If these people - these who believe adults with major depression should be able to just pull themselves out of it - could live in our world for one week, they would understand.

I've survived major depression since 1992 - and every time my meds are "adjusted", they work for shorter and shorter periods of time.

FOr me, keeping myself alive has been a major accomplishment.

Clark Bartram said...

Be carerul badmouthing the Scientologists. They have a nasty habit of ruining peoples lives who don't agree with them. Check out xenu.net, otherwise known as Operation Clambake,for some fascinating background on those nutjobs.

Shinga said...

Depression has significant associated morbidity and mortality - I don't know why this is assumed to be untrue of children.

In the UK, there is widespread difficulty in referring children to psychiatrists or psychologists because there are too few.

Interesting to see how widespread this problem is.

Regards - Shinga

CL Psych said...

Thanks to the anonymous commenter for linking to my site. I've seen some updated data indicating that prescription rates may well have gone down somewhat when the suicide rate went up, but it is just a correlation. Plus, I've not seen any data saying that the change was significant with adolescents, who are more likely to commit suicide than children. I've not given this one a close look since my posts on the topic a while back so maybe I'm missing something.

And let's keep in mind that, in clinical trials in kids/adolescents, the odds of attempting suicide are essentially double on antidepressants compared to placebo, making it difficult to understand how more prescriptions would necessarily lead to fewer suicides.

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