The Future of Child Psychiatry: Important Puzzle Pieces

Drs. Glowinski and Constantino: WUSM CAP Division
in baseball mode

Last week, at the annual AACAP meeting, Dr. Thomas Insel, the head of the NIMH, gave a highly anticipated presentation entitled "From Psychiatry to Clinical Neuroscience."

 This lecture, expert and passionate, is about his view of the future of Psychiatry and Child Psychiatry. A view where we move forward because of long overdue advances in Neurosciences, which will clarify our highly imperfect and serial nosologies, provide clearer therapeutic targets and decrease stigma, a scourge that we know too well in mental health fields.

However true and admirable this view is, pragmatically and truthfully, we are dealing with many other puzzle pieces to move the field forward.

Chief among those:

1-Prevention can be rolled out and should be rolled out even before we understand the pathways to our disorders better. Dr. Insel was concerned about the history of parents blaming (e.g., the infamous refrigerator mom and schizophrenia of yore) and that ill advised prevention efforts could yet again be stigmatizing.
In fact..the history of successful prevention is paved with disentangling causal risk factors from nefarious outcomes before specific pathophysiology is understood. John Snow was able to effectively imagine and guide the prevention of Cholera outbreaks without knowing about the cholera bacilus. By the way, embracing of his common sense prevention ideas took decades, a lesson we should remember when despite the evidence that prevention can work (e.g., the good behavior game which appears to significantly decrease serious bad outcomes in high risk children), it does not remain a systematic focus of intervention, at least in the USA. As Rolf Loeber noted (the guest speaker to our Psychiatry Department today at the occasion of the Lee Robins Annual lecture), Norway has rolled out parenting classes for all Norwegian parents. It's not blaming parents, it's helping them do a job which comes without an instruction manual, within a background of well-intentioned opinions by too many well intentioned people of variable expertise and which, in the end, does matter enormously in terms of outcomes at the population level.

2-Access is not a small issue. Access to quality and informed care is an even bigger issue. Colleagues and I across the country are exploring models of care delivery to where the patients actually are most likely to be, e.g., primary care or some specialty care clinics. Nevertheless, the epidemiology of child psychiatry disorders (even if they are ill measured) is clear: it points to one simple direction whereby our young pediatricians should be MANDATED to train in the identification and management of common, enduring and highly impairing conditions.
In Orlando I ran into a wonderful pediatrician, who used to be a wonderful WUSM medical student.
She was attending the AAP (American Academy of Pediatrics) meeting which was at another hotel. She confirmed spontaneously what I know too well: at least a third of her patients have impairing psychiatric disorders requiring clinical attention and she is heavily involved in managing those. And yes...she's had limited training to do so but has spent, by contrast, many months learning to manage presenting illnesses that she very rarely sees..

3-Cost: Especially with Dr. Insel championing the development of new, better, more effective therapeutics...how can we not be nervous about cost?
I was recently in Norway for a meeting and brought inadvertently an empty bottle for the medication I take daily for a chronic medical condition. I assertively walked into a pharmacy near my hotel and explained: a-I'm a license carrying physician; b-the medicine I need is not habit forming/has no street value and c-I could get sick without it. Would the pharmacy please provide me with a few days' worth? After some intense negotation (they wanted me to go to the Emergency Room of course), the pharmacists agreed reluctantly. They also noted that I would have to pay the "expensive" price: not subsidized by the national insurance plan.
 Will it shock you that the "expensive" price in Norway of a full month supply of my medication was one fourth of the "co-pay" to my local pharmacy after my insurance deductible is applied?

4-Complex behavioral and psychological factors: Dr. Insel noted rightly that the morbidity of cardiac disorders had substantially decreased in past decades; an advance that we want to emulate in psychiatry. The other piece of the puzzle for cardiology too however is that there are oodles of individuals who know what a cardiac disease provoking diet is and yet....embrace it day after day.  Even if/when we elucidate our disorders better, the adherence of individuals to health promotion and/or to life saving therapeutics is far from a given. Given that psychiatric disorders can affect insight and/or cognition and/or hope and many other factors which contribute in complex ways to the elements of a healthy lifestyle, there is no question that even with miracle cures we WILL need to continue knowing how to engage and encourage individuals and communities.  At present, our focus to effect that is to empower our trainees with strong conceptualizations of complex behaviors (as imperfect as those concepts may be) and to help them be good therapists, i.e., help them achieve a level of communication skills where one can, with more comfort, engage others about seemingly irrational and contradictory behaviors.

So, our vision for the future of child psychiatry: Developmental Neurosciences absolutely AND Prevention AND heeding our systems of care AND inter-disciplinary education and solutions AND communication skills (AND leadership skills and many other skills) but the point is: this is not a future that can be easily sound-bited.

Till Later,

Anne