Mandatory Mental Health Screening for Massachusetts Medicaid Kids

As reported initially by the Boston Globe, then covered by the AHRP Blog and Furious Seasons, Massachusetts has implemented a mental health screening process for its children on Medicaid. It would make sense that if mental health is to be examined, one would look for symptoms of mental illness. To assist in the process, one of eight questionnaires is to be used by doctors to identify mental health issues. Here are some of the issues mentioned on one of the mental health screenings:

• Complains of aches and pains
• Is less interested in school
• Is absent from school
• Refuses to share
• Blames others for his or her troubles
• Teases others
• Does not understand other people's feelings
• Does not show feelings
• Gets hurt frequently
• Wants to be with you [the parent] more than before

There are a few others that seem iffy, but I think the above are the worst offenders. So what? Apparently, it may be a sign of some yet to be defined mental illness that a child would want to be with mommy more often, refuse to share toys with a sibling, and not show interest in school. 'Cuz kids should show little interest in their mothers, school is pretty exciting, and most kids love letting their brother share their coolest toy.

Yes, I understand that any of the above could possibly be linked to a mental health issue. If I counted right, there were 35 of these issues listed on the questionnaire. Who is going to spend time going over each of these 35 issues? Nobody. It would seem that if we are going to screen kids for mental health problems, we might want to stick with the more important issues rather than a kid who does not like to share toys.

It is certainly a good idea for doctors to pay attention to the mental health of their patients. However, I'm not sure that this sort of overly inclusive checklist of potential issues is going help much.

Mental Health Problems: An Epidemic? There is the black undercurrent of labeling developmentally relatively normal behavior as indicative of a mental disorder and sticking the kids on all sorts of psychotropic meds that (in many cases) have little data to support their use.

But there is more to it than drugs. It's our culture. We've come to accept that there is an epidemic of autism, depression, anxiety, ADHD, bipolar disorder, and who knows what's next in our kids. While the drug industry certainly played a role in these developments, it says something about our culture that we are readily willing to buy into the idea that mental illness has spread like a plague throughout American society. Have we bought into these disorders hook, line, and sinker because:

• It abdicates parents of any responsibility for their children's behavior
• It lets kids off the hook for their behavior (I couldn't help it -- I have ADHD)
• It adds yet more drama to the teen years (Gina is, like, so moody. I bet she is, like, bipolar)
• It seems so scientific. We uncover yet more diagnoses with each edition of the DSM and we then think that we have a better understanding of human behavior.
  

I'm not claiming that these are especially deep thoughts, but there is something about the interaction of science, marketing, and American culture that seems to have gone awry here.

SSRIs, Anxiety, Kids, Suicide, and Credible Evidence

I wrote a while ago about Christopher Lane's assertions that social anxiety was overdiagnosed and overtreated, particularly among children. Many people disagreed with Lane. One person who disagreed was Dr. Ronald Pies, a psychiatrist at SUNY Upstate Medical Center, who wrote in the New York Times that

... there is no credible evidence to support Mr. Lane’s implication that S.S.R.I. antidepressants are linked with increased risk of suicide in children prescribed these medications for social anxiety. The Food and Drug Administration’s initial concerns stemmed from studies in children with major depression, not anxiety disorders, and the latest evidence has not supported a strong link between S.S.R.I.’s and risk of suicide.

I re-read the latest summary of evidence regarding SSRIs and suicide in kids. Mind you, the article that I referenced (Bridge et al., 2007 in JAMA) came to decidedly pro-SSRI conclusions -- I didn't get my evidence dropped to me from a black helicopter. Based on trials submitted to the FDA, as reported by Bride and colleagues, there were data that pertained directly toward Dr. Pies' assertion. Here are the data regarding SSRI's and suicide in children and adolescents with anxiety disorders.

Note: AD represents Antidepressant; PL represents Placebo

Condition	Suicidal Ideation					Suicide Attempt/Preparatory Action
OCD	AD: 3 of 362 PL: 1 of 339					AD: 1 of 362 PL: 0 of 339
Non-OCD Anxiety Disorder	AD: 5 of 573 PL: 0 of 582					AD: 1 of 573 PL: 0 of 582
Total for Anxiety Disorders	AD: 8 of 935 PL: 1 of 921					AD: 2 of 935 PL: o of 921

Compare the odds of having suicidal ideation on drug to the odds of having suicidal ideation on placebo. Kind of a large difference, eh? I realize that the odds of developing suicidal ideation are still small, even on medication, but they are substantially higher than a child taking placebo.

While one could point out correctly that the difference is not "statistically significant," I think one would be foolish to fall back on that argument. We have seen in adults and children that SSRIs are related to more suicide attempts and that this finding is pretty consistent across trials, at least among children and young adults. When events occur rarely, then we need exceedingly large samples in order to be quite certain that the event (such as suicidal ideation in SSRI trials for anxiety in kids) is not an anomaly. But when kids are being treated for disorders that are very rarely associated with suicidality, yet the children show a much higher rate of suicidal ideation on a drug compared to a placebo, does it not make sense to warn patients about such potential hazards? One could run to the less SSRI's cause more suicide argument, but that hasn't really held up so well scientifically.

In my eyes, the above data represent "credible evidence" that SSRIs can indeed lead to an increase in suicidal thoughts among kids with anxiety disorders. Either Dr. Pies was unfamiliar with the above evidence or he believes it is not credible.

No actual suicides were recorded during the trials. Of course, if someone got worse during the study, then quit the study and killed himself/herself, then who knows if such data were included. Perhaps such events occurred -- I don't know. And there was much more supervision of these kids in a clinical trial then you'd see in real life, which could have kept some people from suicide. Further, let's suppose that the drug causes a child with social anxiety to become suicidal. He does not make an attempt on his own life, but he is suicidal for a month. Doesn't prior suicidal thinking predict later suicidal thinking and later attempt of suicide? So even if the child makes no immediate attempt on his life, couldn't he be at higher risk down the line? Maybe I'm losing my marbles, but I think it's a reasonable question.

Related posts on SSRI's and suicide:

• SSRIs, Suicide, and Dunce Journalism
• FDA on SSRIs and Suicide
• More on FDA, SSRIs, and Suicide
• Keller, Bad Science, and Paxil

Dimetapp or Zyprexa?

It appears that the FDA is conducting an investigation of the safety of over the counter cold medications for children. Apparently, the safety of these medications in children is largely unknown despite their widespread use in kids. There are also concerns that in overdose, these meds may be harmful or perhaps fatal.

I appreciate that the FDA is getting off its duff, but Stephany at the Soulful Sepulcher has an even better idea -- how about the FDA investigating the safety of psychiatric medications in kids? Something tells me that Zyprexa, Seroquel, and Depakote might, just maybe, have more safety issues in kids than Dimetapp or Robitussin. Hey, maybe there is a problem with the cold meds, but can we at least consider that heavy duty psych meds might also impact the health of youth? After all, meds such as the atypical antipsychotics are experiencing quite the boom in prescriptions for kids -- wouldn't we want to be sure that this boom was not leading to a corresponding increase in health problems?