- The distinguished Institute of Medicine's (IOM) report that urged early detection and treatment of mental and emotional disorders in youth.
- The very influential US Preventive Services Task Force recommendations that adolescents be screened for depression in pediatric and primary care settings, using a specific, simple, low burden checklist while in the waiting room.
Why did these remarkable groups go out on such a limb? Because mental disorders are exceptionally common in adolescence -- 50% of the mental illnesses that will occur in our lifetimes appear by age 14 and 75% appear by the age of 24. But, chillingly, over 80% of these youth and young adults will not have their illness properly detected or treated. The result is that untreated mental illness becomes a primary cause of school failure and dropout, is a principal path to disability and crime, and is disproportionately found in the very high users of medical services. Depression is the most common, disabling and deadly of the mental disorders: about 6% of youth are ill with this disease annually and it has a 20% lifetime prevalence. Estimates by the IOM are that youth mental disorders generate $247 billion/year in costs to the educational, criminal justice, health, social welfare service systems -- and to families. The terrible irony is that if a depressed youth is identified by screening and receives proven forms of mental health treatment the likelihood that young person will recover is very high, better than 75%, and comparable with other major medical illnesses like diabetes and heart disease.
Three medical journal articles add fuel to the need to do something. An article in the June 1 Archives of General Psychiatry demonstrated decreasing rates of the diagnosis of depression, especially in children and youth after the FDA warning about suicidality secondary to serotonin antidepressants like fluoxetine or citalopram. An article in the June 3 Journal of the American Medical Association showed that a simple, brief, low cost cognitive therapy approach reduces the onset of depression in vulnerable youth (when a depressed parent is also treated). Finally, an article in the June issue of Medical Care identified attitudinal barriers to youth obtaining depression treatment and means of overcoming those barriers, especially in primary care offices. In other words, the problem of diagnosis and treatment is worsening while the remedies are improving.
The policy forum I attended had the task of making the case for widespread adoption of depression screening in primary care and finding ways to help primary care doctors provide treatment or referral when the illness is found. These goals are difficult because pediatricians and primary care doctors have their hands full and so are reluctant to take on more obligations. But unless they do, with proper supports, the problem of undiagnosed and untreated depression will persist, with all its disturbing consequences.
Primary care is the essential venue because families and youth often resist going to mental health care because of stigma. Moreover, there are simply not enough child/adolescent psychiatrists and youth trained mental health clinicians to serve the large number of youth in need. This is not to say that some youth with severe forms of depression, including bipolar depression or active suicidal plans, don't need referral to specialty care; but those appointments are more likely to be available if mental health clinicians are not occupied with mild to moderate problems that can be handled in primary care, by the doctor alone or with a mental health trained social worker, nurse or psychologist on site to do the therapy that is known to work.
I was struck by how tentative the discussion was at this forum. There was a lot of talk about the "necessary" conditions to implement screening -- like experts to diagnose or immediately available mental health services to refer to. I thought (and said during my presentation) that if those conditions became a standard of care that today's youth would be in nursing homes before they got the care they need.
From my experience advancing depression screening and management for adults in primary care settings in NYC (see New York Times April 13, 2005, p1) government and other payers and policy makers only expand capacity when demand is created by patients and families. Otherwise, doctors and health care providers are likely to elude what clinically we know needs to be done, and which in this case works. We need to have the will to make depression screening for adolescents a standard of care for primary care: to make it a required field in the electronic medical record and a quality standard (as are immunizations and Pap smears) for health plans and hospitals. If screening is made inescapable, a clinical standard, doctors will learn to how to do it, successfully, and soon be taking pride in the essential and effective work they are doing. That is what has happened for other illnesses like diabetes and asthma. Let's not let depression and the youth who suffer from it be denied what they need to make a good life.
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