Saturday, November 22, 2014

Like Water

The flustered mother told me this about how difficult it was to get her school-aged son to do what she wanted: "He's like water. Whatever I try to do, whatever rules I set up, he finds a way around them."

I said, "Well, that must be very frustrating."

Here's what I wish I had been clever enough to say to her instead: 

"You're right. Kids are a lot like water. The harder you try to grab them, the more they slip through your fingers.

Like water, kids can mirror their surroundings. They are given shape by their environment, while over time they are also shaping the environment.

Similar to water, kids can exist in different states. Too much heat or too much cold, and they may become explosive or get more rigid and brittle.

Water is very resilient. Most of the time, like water, kids can return to their previous state after a perturbation if the environment allows it.

It always takes energy to change the flow, the direction, the trajectory of water. Otherwise it just follows the path of least resistance.

Just as you can make water move against gravity through capillary action, giving the right scaffolding for a child can make all the difference. 

While water running rampant can be destructive, water put to purpose can do immeasurable good.

So you're absolutely right: your child is very much like water. Now what shall we do about it?"

Saturday, November 15, 2014

Why I Love Wall-E (and Question the ACA)

Spoiler warning: If you haven't seen Wall-E yet, why not? See it first before reading this post if you don't want certain aspects of the plot revealed.

Let me tell you why Wall-E is my favorite Pixar move. The title protagonist begins the movie as a humble robot, programmed with a very specific purpose: to pick up garbage, compress it, and stack it in neat, towering piles. In Wall-E's world, man-made trash overwhelmed the earth generations ago, smothering all plant life. The humans escaped in giant spaceships, leaving robots behind to clean up the mess. Over time, all of the other robots broke down, with Wall-E the sole survivor living a repetitive, lonely existence. Yet Wall-E somehow transcends his programming and develops a sense of curiosity about the world. What were those humans like? What are these relics that they left behind? What's that green thing growing amongst the trash?

After a series of improbable but exciting events, Wall-E finds himself on board one of those giant spaceships. There, he encounters real, live humans and the robots that serve their needs. The people were uniformly plump with adiposity, reclining comfortably on mobility chairs while sipping futuristic Big Gulps™ and fixated on screens. Wall-E was aghast, eventually discovering that the villainous AI of the ship was trying to keep the humans confined to their blissful but vacuous existence. Wall-E finds a way to rally the other robots and spread the news that plant life was growing on earth once again. The movie ends on a hopeful note, with the ship returning home and the humans taking small, earthbound steps that feel like giant leaps. I love that Wall-E acted in humanity's long term interests instead of either rejecting these disappointing humans or attending only to their short term comfort.

Recently, I was reminded of Wall-E when I attended a session at AACAP's Annual Meeting in San Diego titled: "The Affordable Care Act [ACA] and How We Think About Systems, Care, Quality, and Ethics." The discussants covered various aspects of the ACA (for an overview of the ACA, see this recent post from Psych Practice). What interested me most was the talk by Dr. Michael Houston on how the ACA relates to child and adolescent psychiatrists. Dr. Houston discussed the ethical underpinnings of the ACA, namely how it seeks to institute a more egalitarian and less libertarian health care system. The law lays the groundwork for transitioning us from a fee-for-service system in which doctors have a financial incentive to do lots of procedures to a system in which both patients and doctors have a responsibility to society to contain costs.

Clearly, one of the goals of the ACA is to make doctors provide more efficient care. One of the justifications for why we need this is the chart above (from this HuffPo article) showing how, despite spending way more than any other country on health care per capita, the U.S. trails most other developed nations in life expectancy. The logic seems to be that since we're not getting good bang for our buck, the health care delivery system must be streamlined.

This focus on efficiency would have an especially high impact on child psychiatrists, given how relatively few of us there are compared to the high numbers of patients. Here's an old article from 2006 about the shortage, and not much has changed since, except that even more children are being diagnosed with conditions like ADHD and taking multiple medications, putting further strains on the health care system. Last year, AACAP published a document describing how the ACA will impact the practice of child and adolescent psychiatry. More mental health care will be delivered by pediatricians and care managers, with psychiatrists overseeing cases but not seeing patients directly unless they were especially complicated.

To me, this seems like a herculean effort to create ever more efficient Wall-Es, without trying to address why there was so much for Wall-E to clean up in the first place. Instead of just focusing on the shortage of child psychiatrists, why are we not doing more about the over-abundance of patients? After the session, I asked one of the speakers this very question. Her answer was sobering: she had thought about this issue herself, but when she tried to a submit a paper on the prevention of mental disorders in children, no child psychiatry journal would accept it. She thinks that is just not our mindset, just not what we are trained or paid to do. It reminded me of the old adage by Upton Sinclair, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

Don't get me wrong, I believe in universal health care. I just don't think that the ACA is going to successfully address the mental health issues of children in this country, just as it won't address the obesity epidemic by making obesity treatment more streamlined. For example, today's NYTimes article that I linked to earlier profiled a California mother who has a child with ADHD and severe behavioral issues. Here's the crucial paragraph:
Some would consider Matthias a textbook candidate for combined treatment. His rages have overwhelmed schools and child care programs for years, and he is already struggling in first grade. He and his mother — a medical technician whose typical workday drawing blood lasts from 7 in the morning until 4 p.m. — share a cramped and clamorous three-bedroom ranch house with her sister and brother-in-law and their spirited children, ages 3 and 6 months. Matthias is having nightmares and bladder-control issues.
I'm not sure that any amount of meds or access to a child psychiatrist would help this child as much as having a less stressful home environment. I don't claim to know what the best solution for our society as a whole would be, but I do think we need to put more effort into investigating what can be done to better support children and families, and not just from a medical/health care system point of view.

I hope that more of us in the child psychiatry field can be a bit more like Wall-E: a bit more curious about the world we find ourselves in and how it became that way, a bit more willing to ponder what can change things for the better. Let's not continue to just put our heads down in order to squeeze ever more efficiency and productivity out of our days.

Sunday, August 31, 2014

Boyhood Movie Review

Putin. Gaza. Ebola. ISIS. Ferguson. Robin Williams. This has been one of the more unsettling summers in recently memory. However, as we head towards Labor Day and I look back on the last couple of months, what I recall most clearly and fondly (besides some personal and family matters that are irrelevant here) is watching Boyhood, by director Richard Linklater.

The film stars Ellar Coltrane as Mason, who is 6 at the beginning of the story. We watch as he grows year by year into an 18 year-old young man. Forget all those gimmicky 3D movies; this is a 4D film, where the genuine passage of 12 years of time adds an extra dimension that cannot be faked by CG.

Boyhood succeeds in capturing something about the essence of our times when it comes to parenting and childhood. The parents have split, and the dad, played by Ethan Hawke, is barely around initially, only occasionally swooping into his kids lives like a tornado of fun. Meanwhile, the mom (Patricia Arquette) struggles to raise her children while trying to go back to school so her family could break free from the struggles of low-wage America.

Amazingly, the director found a young actor in Coltrane who was able to deliver a consistently convincing performance from childhood to adolescence. The film opens with him lying on the grass staring into the sky, leaving us to wonder what he makes of life. Coltrane was able to project this introspective nature throughout, and as a young man engages in the kind of philosophical discussions that Linklater's characters are known to do.

However, Boyhood is as much a coming of age movie about Mason's parents as it is about Mason's own journey. I found it interesting that the adults seemed to be engaged in a search for identity as much or more so than the children. The character who evolves the most over the 12 years is Mason's father, who becomes a minivan-driving, church-going actuary in middle age. Mason's mother ends up as a somewhat tragic figure who has to balance her career with parenting while dealing with a string of bad relationships. Our culture really is harder on women, and this film reflects that reality.

Boyhood has been the best reviewed movie of the summer and deservedly so. One may look at the box office receipts for the latest Transformers assault on the senses ($243.8M) vs. Boyhood ($16.3M) and despair; I choose to see the fact that this movie was made at all as a sign that there is still hope.

Sunday, July 6, 2014

The Limits of Big Data in Psychiatry

While browsing The Atlantic earlier this week, I came across this:

Yes, I was tempted to click on the article involving electric shocks, but it was the ad "Rising Mental Health Issues Facing Our Children, in Five Charts" that caught my attention. The colorful charts show some alarming-looking numbers that most readers of this blog are probably used to seeing by now: that there is a large increase in children receiving mental health diagnoses, that ADHD is diagnosed at very high rates (especially in the South), that children on Medicaid are more likely to receive a mental health diagnosis than children with commercial insurance, etc. The data for the charts were gathered from pediatrician visits across the country by athenahealth (apparently they're too cool for capital letters), the electronic health record (EHR) company who paid for the ad.

They helpfully included a video at the bottom of the ad so we can get "perspectives on these trends from top health care leaders." Take a look:

Watching this video, I was struck by the words of Kurt Newman, M.D., President and CEO of Children's National Medical Center:
"These graphs are just probably the tip of the iceberg. The directional trend is very disturbing, but also the magnitude is disturbing, and these pediatricians are swamped.
That's why we need to do more research, we need to have a better system in terms of more providers, we need to be able to pay the providers a reasonable amount for the care they're giving. But I think if we do all that, we're going to have a huge impact for these kids and families."
Classic. There's an epidemic on, doctors are swamped—we need more funding so we can provide more treatment! No wonder he's the CEO. And like many other CEOs, he oversells when talking about the future:
"We're on the cusp of something really huge there. It's kind of like big data and big analytics that are gonna really revolutionize how we can identify these trends or get specific about certain diseases […] Autism might be a hundred different rare diseases that are all rolled up into one. We won't figure that out unless we have the analytics, all of the the really sophisticated capability of probing into: is that patient like that patient, is that child like that child, what made them more similar?"
Perhaps I'm too dumb to comprehend big data/analytics, but I fail to see how information mined from an EHR is going to shed light on the etiology of autism. Also featured in the video is Angela Diaz, M.D., Director of the Mt. Sinai Adolescent Health Center, who seems to have a more common sense take on the data:
"We need to figure out what is leading to these kids…30% of U.S. students to feel sad and hopeless for the last 12 months, and of those, 40% of the girls? What is going on? So we need to get to the root causes of these things, and try to identify and then figure out, how to prevent?"
I certainly agree with Dr. Diaz on the importance of trying to determine the root causes of the rising rates of these conditions. However, having the raw data and figuring out causality are two very different things. I would argue that in psychiatry we already have access to tons of data, but unfortunately much of it is interpreted through a very narrow, biologically-oriented lens. Having faster access to bigger pools of data is not going to help. Example in point: the January 2014 JAACAP article that described rising rates of ADHD in the US, which I had previously blogged about. That article was accompanied by an editorial by Drs. Walkup, Stossel, and Rendleman that essentially heralded the findings as good news and a sign that ADHD is being increasingly recognized and treated, which is desirable from a "public health" point of view.

In the June 2014 issue of JAACAP, Dr. Jonathan Posner wrote a very reasonable letter to the editor (subscription required), pointing out that other, more rigorous studies (relying on both parent and teacher report instead of parent report only) have found rates of ADHD closer to 5-7% instead of the 11% reported in the JAACAP article. He concludes that the reason for the rapidly increasing rates of ADHD diagnosis in the community may be "that a substandard approach to diagnosing ADHD has become the norm." Drs. Walkup and Rendleman wrote a reply (subscription required); here's the first paragraph of their response:
Thank you very much for your comments. Your position is one that we believe is shared by many, which is why we wrote the piece. Although we respect your and others’ opinions, we find it difficult to support the statement that rising rates are due largely to substandard assessment of ADHD—it is just too simplistic an explanation. The solution that you allude to is likely not tenable for a high-prevalence condition such as ADHD, because there just aren’t enough child psychiatrist providers to do it all. We are not advocating poor-quality diagnosis or inappropriate treatment; rather, the goal of the editorial was to understand the role of advocacy and education in rising rates, the importance of a public health approach to high-prevalence conditions, and to help child and adolescent psychiatrists come to terms with the fact that our traditional model of care, which is time intensive and highly personalized, is not likely to be able to address the public health burden of ADHD. We certainly do not want to inhibit the pediatric prescriber from taking on the challenge. They need our support to do it well.
So the assumption they make is that cases of ADHD reflect a biological disorder and that increasing awareness of the condition amongst the population, diagnosing it, and treating it with medications is good and proper.

Imagine, for moment, something like this happening with the obesity epidemic. The maps of child obesity in the U.S. look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South. Sure, there are drugs to treat obesity, but would anyone talk with a straight face about a "public health" approach to obesity consisting of identifying the cases and then treating them with medications? Wouldn't a better (and true) public health approach be to ensure that children can get adequate exercise, good nutrition, and that people aren't incentivized to buy the cheap calories and processed "foods" that are making them obese?

Thus, as long as the prevailing view of psychiatric conditions is a narrow one, the data will be used for narrow purposes, such as academic leaders/CEOs arguing for more resources, or to justify the high rates of psychiatric medication prescribing. Here, I'm not even going to get into some other questions I had about the athenahealth ad, including who its intended audience is and what it is trying to achieve. Most doctors recognize that EHRs do not help them care for patients. These systems mostly appeal to large clinics and hospital organizations, for reasons that I will let Dr. George Dawson's recent blog post explain.

Saturday, June 21, 2014

The Impact of False Diagnostic Labels

Back in April, an extraordinary article was published by Dr. Peter Parry, an Australian child psychiatrist, about his correspondence with an American adolescent who had been diagnosed with pediatric bipolar disorder (PBD) during the PBD craze in the early 2000's. I had linked to the article on Twitter, but I haven't had a chance to write about it until now.

The power of this article comes from the fact that it includes a detailed first-person account from the patient "Adam." He comes across as an extraordinarily thoughtful young man, who had a tragic but far from uncommon encounter with psychiatry. Here's what Adam had to say about being diagnosed with PBD and treated:
I was 12 when first diagnosed. I had suffered depression and anxiety including severe OCD, which has since disappeared. It should also be mentioned I come from a screwed-up family and was physically abused by a sibling. Parents divorced young. My mother had a lot of issues, etc. So it goes without saying there was a lot the psychiatrist should have asked if he was ever so inclined. But unfortunately, he holds a faculty appointment at [edited—A PBD oriented child and adolescent psychiatry clinic].

Within about three months, I was on 8 different medications at one time. Very scientific treatment—all the best—several anticonvulsants, several antipsychotics, a couple of antidepressants and lithium too.

Things got so bad, that I ended up being referred to the neurology department, for different opinions about strange symptoms I began having on this cocktail. Which resulted in their giving me a working diagnosis of some kind of mitochondrial myopathy. "Bipolar plus mitochondrial disease" as it went. Which I have been told only recently could have been precipitated by the huge amounts of divalproex I was taking. The symptoms quickly disappeared when I coincidentally stopped the drug for unrelated reasons. Oh well, but it is a clear illustration of what one of the "best" academic medical centers in the world has to offer a struggling young boy.
And here is Adam's perspective on how the diagnosis and treatment affected him:
But the worst part of this, which I have only been recently able to shake within the last year (2008/9), is the defectiveness I felt. Just kind of in some core way. Like I'm totally different. When I was younger, that feeling was a lot stronger and more prominent. Now I feel like a fool for even having given thought after eight years to the question of whether I might go to sleep one night and wake up manic. I decided with my (new) psychiatrist's support a year ago to stop my medicines. I’m not doing especially well now, but I have at least been able to shake the feelings the diagnosis itself carved into me. The same can’t be said for its physical and social effects though.
It's not just children and teenagers who are vulnerable to being misdiagnosed with bipolar disorder; it can even happen to an NBA millionaire. A couple of weeks ago, I read one of the best articles that I've ever encountered on mental health in professional sports, titled "Why Isn't Delonte West in the NBA?" As a casual basketball fan, I knew that West had been a part of the Cleveland Cavaliers during the LeBron James years. I've heard that he struggled with mental illness and had been diagnosed with bipolar disorder. I recalled that he had been arrested after being found driving around with multiple weapons, and there were even rumors that he had slept with LeBron's mother. But this article provides the inside story of what actually happened, and the facts were deeply unsettling.

Delonte West grew up without a stable home, with a single mother who worked multiple jobs just to keep afloat after his parents divorced.
West has an older brother, a younger sister, and a vast extended family that he refers to as "a village." He stayed with many of those relatives growing up. "I lived off of every exit," he says, rattling off 11 specific ones from memory. "I lived in so many apartments … with cousins, uncles, and aunts, just making it."
In the NBA, he had several outbursts of anger, which led to him seeing a psychiatrist.
West was diagnosed as bipolar by a D.C.-area specialist. He says that when he saw the doctor, he’d been feeling down, having days when he was sad and tired and didn’t want to get out of bed. But he told the specialist that there were also times when he "might just go out and buy a car. Or go to the mall and spend 25 grand." West doesn't think the doctor took into consideration that such behavior might not be unusual for a professional athlete with a big paycheck. He now thinks that he was suffering a temporary bout of depression, not exhibiting symptoms of a chronic disorder.
Another part of the article provided additional context for West's inner struggles:
As a kid, moving from school to school, he often found himself the target of playground taunting. "I was real funny-looking," he says, with big ears, a mole on the back of his head that he had removed once he got to the NBA, and a birthmark below his lip that he's also had partially removed. His light skin and red hair stuck out, too. "I was made fun of a lot growing up, but I just knew the basketball court was the place where you couldn’t make fun of me, you had to respect me." He says he always had "more jokes for me than you had," but that he internalized the cruel things kids said to him. Last year, West told an interviewer that he believed his real problem was not bipolar disorder, but "self-loathing."
This was what actually happened in the weapons incident that contributed to derailing West's NBA career:
It was the offseason, and a few of West's cousins had come over to his house with their children. West's mother was looking after the kids while he slept and the other adults went out. At some point in the evening, West's mother woke him up. She said the kids had gotten into a closet in his small, in-home music studio, where he stored guns that he had bought, legally, in Cleveland. He needed to do something about those weapons, she told him.

With the driveway crowded by his cousins' cars, West got on his motorcycle so he could bring the guns to another residence. Earlier in the evening, he'd taken Seroquel, which is often prescribed for bipolar disorder. Seroquel makes you drowsy, and as he headed out on the highway, he found that he was dozing in and out. After he felt himself drifting off, West was pulled over for making an unsafe lane change, and he told the officer that he was carrying weapons. The day after the arrest, a police spokesman said that West was "very cooperative the entire time."
After his arrest, West played for the Cavaliers for another season, but the article makes the plausible argument that because West had been labelled with a mental illness, people were willing to believe whatever crazy things they heard about him, including the false rumor that he had slept with his teammate's mother. Undoubtedly, taking Seroquel contributed to his arrest. Without the "bipolar disorder" label, if instead the narrative had been that West had emotional issues due to childhood stresses, he may well still be in the NBA.

Earlier this week, Dr. David M. Allen had a blog post on misdiagnosis: "Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?" (The short answer is "yes.") However, according to Dr. Parry's article, when Adam looked into his legal options, he was told "his treatment would be deemed 'standard practice' where he lived," which is a big deterrent for the lawyers when it comes to medical malpractice lawsuits. What a sad irony: the crappier the standard diagnosis and treatment becomes, the more the practitioner is protected by the herd.

When I was in medical school at a very biological psychiatry-oriented institution, the psychiatry professors made sure to educate us on the past evils of blaming refrigerator mothers for schizophrenia. And yet, as Dr. Parry pointed out, we have gone from the "brainless psychiatry" of the psychoanalysts to today's symptom-focused "mindless psychiatry" that tends to ignore the patient's inner life and the developmental biopsychosocial context. Here is my favorite section of Dr. Parry's article:
In addition to being a method of inquiry, science is a social process and there is a vast research literature concerning the sociology of science. Scientific disciplines do not build on knowledge in a purely linear fashion, but at times undergo dramatic upheavals according to paradigm shifts. The dominant paradigm governs what is acceptable to study, research, publish and practice. Softer sciences like psychiatry can be more susceptible to extreme paradigm shifts. The history of psychiatry reflects this. 
One of my biggest frustrations while reading Dr. Parry's words is that his wisdom is relegated to an opinion article published in a little known open-access journal, while the leading child psychiatry journal, which claims to be "advancing the science of pediatric mental health and promoting the care of youth and their families" [emphasis mine] would never permit such a sharp critique within its pages.