Adolescent depression: A Pediatrician’s dilemma

Adolescent depression is a serious medical condition that deserves expert evaluation and appropriate access to mental health professionals, including those who can prescribe medication when indicated.  As a pediatric resident, I spent four weeks on the child psychiatry service, and this time was mainly focused on talk therapy.  In comparison, I spent six months, and a good deal of additional nights on call, in the Neonatal Intensive Care unit, taking care of sick and premature infants.  By the time I went out into practice, I could intubate a 26-week premie in my sleep, but knew very little about evaluating or treating depression in an adolescent.
The problem is that in our nation, health insurance companies, not pediatric training programs, often have the final word as to what a pediatrician is expected to do. I found it very unsettling over the course of my career to find that, more and more, I was expected to prescribe powerful  medications for anxiety and depression.
Depressed adolescents worry me, and every other pediatrician I know.  They are good at hiding their depression, even from themselves.  They do not come in seeking help and are sometimes angry just to be sitting in a doctor’s office.  Fifteen-year-old Marissa was a perfect example.  Her mother had called that morning, begging to be squeezed into a fifteen-minute time slot between a wheezing toddler and a feverish newborn.  Mildly overweight, sullen expression, stringy hair falling in her eyes, Marissa sat slumped against the wall of my exam room.
“I don’t know why I’m here.  Go ask my mother.  She’s the one who made me come.”  Her tone was more petulant than defiant.
Marissa was not really asking me to get information from her mother.  She was asking me to go out to the waiting room and tell her mother to go to hell.  I deliberately did not look at my watch to see how much further I was going to fall behind.  I pulled up a chair, gave Marissa an encouraging smile – which I was not even sure she saw since she had so far avoided any eye contact – and began.
“I think it would be better if you could tell me what’s been going on.”
My preliminary fact finding revealed how stupid mom was, how lame step-dad was, what a waste of time school was, what jerks all the rest of the kids were.  Marissa grew slightly more animated as we talked, shrugging or waving her hand dismissively now and then.  We slowly teased out more details as the clock kept ticking – who was fighting at home, who was drinking, what substances Marissa herself used, her sexual experiences, what she liked to do in her free time. We slowly achieved eye contact, exchanged facial expressions.
“Your mom is worried that you are depressed, Marissa.”
“That’s because she’s crazy.” Marissa looked away from me again.
“Do you ever feel sad?”
Marissa looked down at the floor with great concentration and grew completely still, almost frozen, trying to will herself not to cry. Silent streams of tears rolling down her cheeks finally betrayed her.  I handed her a box of tissues and she pulled one out, waving it like the flag of surrender that it was.
“I just don’t know what to do,” she whispered.
Marissa needed help; I nailed down that much.  But how much help?  How urgently?  Had she just hit a rough patch in her transition through adolescence?  Is she displaying a genetic tendency towards a serious mood disorder? Is she hiding a devastating event, like rape, that triggered this?  And the three most important questions:
Is she likely to hurt herself?
Is she likely to hurt herself?
Is she likely to hurt herself?
Once we worked through an anticlimactic medical history and physical exam, (I now had three other patients already in rooms, and more in the waiting room) we called her mother in.  Marissa’s mom had been keeping a lot of worry bottled up, and I could tell she really wanted airtime, but I had to move things along.  I cut her off as artfully as I could, and asked her what I needed to know: Had Marissa ever spoken of suicide, even vaguely?  Were there any firearms in the house? (Even unloaded and locked away, the presence of a gun in the house greatly increases the risk of teenage suicide).  I explained that we needed to set Marissa up with a therapist.  I knew Mom’s next question before she asked it.
“Will insurance cover that?”
I skirted that answer; all three of us were worried enough already.  I advised her to check with her insurance company and see whom they will cover and for how many visits.  I knew that the list the insurance company would provide was very different than the list of therapists our practice recommended.  None of the ones we were happy with accepted private insurance; the reimbursement was too spotty and too small.  So Marissa and her parents would have to weigh everything in the balance and go with what they could afford. I hoped they wouldn’t just give up and try their luck with herbal teas.
Before they left, I made them both swear that if Marissa had any thoughts about suicide or hurting herself, or showed any risky behavior, they would contact me.  That seemed as airtight a plan as when I told my daughters, “And if there’s any drinking at that party, I want you to call me.”
I didn’t refer Marissa to a psychiatrist.  That’s because there were no child psychiatrists in Rhode Island that would see outpatients, and few adult psychiatrists that would treat adolescents.  More healthcare economics.  Outpatient psychiatrists in our state, if they will see an adolescent, mostly get reimbursed for fifteen minute “med” visits, where they get to prescribe meds and then check in briefly with the patient now and then to make sure the meds are working OK.  If it doesn’t involve a pill, the visit isn’t covered.
Psychologists are often a good option.  I have had the privilege of working with some excellent psychologists, skilled professionals to whom I can entrust my patients.  The problems arise when these skilled professionals conclude that the patient would benefit from medication, like an antidepressant.  That is when they refer the patient back to me, the PEZ dispenser.
It’s not just that I had very little psychiatric training in my pediatric residency. SSRI’s, that major class of antidepressants that are now the mainstay of managing depression and other mood disorders, were then but a twinkle in psychiatrists’ eyes.  What I learned about Prozac and Zoloft and all the others that followed, I learned by reading articles (based on research on adults, not adolescents) and going to conferences that were often sponsored by the drug companies that make the antidepressants. Because the primary care doctor is the only medical professional in this situation that will get paid for prescribing these powerful medications, we scramble to teach ourselves what we can.  Correspondence school for depression.
The American Academy of Pediatrics, recognizing the role that pediatricians have had to take on, dutifully assumes its role as enabler, providing diagnostic questionnaires as screening tools for our patients, and publishing guidelines for referral of high-risk patients. How-to manuals. To be honest – in a way I could not be when I had patients in my care – a TV repairperson has more formal education about TV’s than I had for treating depression.
So when I sat down to write in Marissa’s chart, my antennae and my anxiety were up.  I carefully documented every crucial question and answer that arose in that exam room. My notes showed that I took it seriously: I explored the relevant issues, made my best determination that Marissa was not a suicide risk, and referred her to a mental health professional.  I gave clear guidelines for follow up.
Painful subtext: Whatever happens, it is not my fault.
When Marissa’s therapist wrote a letter to me three weeks later, recommending a trial of antidepressants, I went back and reviewed my articles.  Then I reviewed the “PDR” (Physicians’ Desk Reference) for correct drug dosages and what adverse effects to watch for.  I kept reminding myself that these drugs, contrary to some well-publicized cases, do a lot more good than harm in preventing suicide.  But I could not shake the feeling that I was flying by the seat of my pants.
What choice did I have?  Marissa probably did need the antidepressants.  If I didn’t prescribe them, who would?  What if I refused, and she went on to commit suicide?  At least in this case, I knew the therapist; I had some confidence that what she was asking me to dispense was appropriate.  If Marissa’s family had chosen a therapist from their insurance network, someone that their insurance covered but who I didn’t know, then I would have been flying blind, practicing medicine by the keeping-my-fingers-crossed method.
It made me worry for my patients and for myself, professionally. I resented it.  I resented that Marissa’s psychologist could not call up a partnering psychiatrist (Hah!)  to evaluate Marissa for meds.  I resented that I was the Pez dispenser for the clinical decisions of nonpyhsicians; in no other area of my clinical practice would I have taken on therapies that I was not completely comfortable with. I resented being forced to compromise my own professional standards.
Fortunately for Marissa, and me, she weathered the remainder of high school fairly well. But I have watched pediatric colleagues suffer the profound grief of losing a patient to suicide.  They are left tormented by their own crisis of confidence, while railing helplessly at the inevitable lawsuit.
Medical practice that is based on reimbursement policies shortchanges both patients and doctors. The dilemma of shaping my practice, and Marissa’s care, around what insurance companies covered rather than what I felt trained to do was emblematic of the growing discrepancy between who I was, professionally, and what was expected of me in our health care system. Such dilemmas played a significant role in my decision to leave pediatrics a few years after I first met Marissa. On a larger scale, this discrepancy underscores the disconnect between the remarkable progress we have made in medicine, and the stranglehold that we have allowed private health insurers to place on its delivery.

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