Editorial Opinion
6. Lawrence NS, Jollant F, O’Daly O, Zelaya F, Phillips ML. Distinct roles of prefrontal cortical subregions in the Iowa Gambling Task. Cereb Cortex. 2009;19(5):1134-1143. 7. Xue G, Lu Z, Levin IP, Weller JA, Li X, Bechara A. Functional dissociations of risk and reward processing in the medial prefrontal cortex. Cereb Cortex. 2009;19(5):1019-1027. 8. Chen C-H, Suckling J, Lennox BR, Ooi C, Bullmore ET. A quantitative meta-analysis of fMRI studies in bipolar disorder. Bipolar Disord. 2011;13(1):1-15.
9. Graham BM, Milad MR. The study of fear extinction: implications for anxiety disorders. Am J Psychiatry. 2011;168(12):1255-1265. 10. McClure EB, Monk CS, Nelson EE, et al. Abnormal attention modulation of fear circuit function in pediatric generalized anxiety disorder. Arch Gen Psychiatry. 2007;64(1):97-106. 11. Finger EC, Marsh AA, Blair KS, et al. Disrupted reinforcement signaling in the orbitofrontal cortex and caudate in youths with conduct disorder or oppositional defiant disorder and a high level of psychopathic traits. Am J Psychiatry. 2011;168(2):152-162.
12. Stringaris A, Goodman R. Longitudinal outcome of youth oppositionality: irritable, headstrong, and hurtful behaviors have distinctive predictions. J Am Acad Child Adolesc Psychiatry. 2009;48(4): 404-412. 13. Fontaine NM, McCrory EJ, Boivin M, Moffitt TE, Viding E. Predictors and outcomes of joint trajectories of callous-unemotional traits and conduct problems in childhood. J Abnorm Psychol. 2011;120(3):730-742.
Mental Health Services for Children and Adolescents Challenges and Opportunities Paramjit T. Joshi, MD
We clearly are at the cusp of great change in our health care system, which raises important questions: What will the delivery of mental health services look like in the near future? Will the treatment be evidence based? How much will Related article page 81 it cost? Will our patients get better treatment, and how will the outcomes be measured? Olfson et al1 address how best to understand the delivery of outpatient mental health services in light of how the provision of these services has evolved over 15 years. They reviewed nearly 500 000 national ambulatory medical care surveys to identify psychiatric treatment trends between 1995 and 2010. They looked at mental health care indicators across the age range. They compared the background and clinical characteristics of children, adolescents, and adults whose recent visits (2007-2010) resulted in a mental disorder diagnosis. The 4 general indicators of mental health care that the authors looked at were clinical mental disorder diagnosis, psychotropic medication prescription, psychotherapy provision, and psychiatric care. The results of their study1 revealed that the total number of office visits resulting in a psychiatric diagnosis increased significantly over the 15 years; however, this increase was seen to be faster for youths than for adults. Psychotropic medication visits, however, increased at comparable rates for both youths and adults. While psychotherapy visits increased for youths, they decreased for adults during the same period. The authors concluded that, compared with adult mental health care, the mental health care of young people has increased more rapidly and has coincided with increased psychotropic medication use. Over the last several years, the increase in the number of youths with psychiatric disorders who are being treated with pharmacological drugs has been largely supported by the results of several large multicenter, federally funded studies such as the Multimodal Treatment Study of Children with ADHD,2 the Treatment for Adolescents With Depression Study,3 the Treatment of Early Age Mania study for the treatment of bi-
polar disorder,4 and the Research Units on Pediatric Psychopharmacology Autism Network study for autism spectrum disorder,5 in addition to numerous industry-sponsored treatment trials. During this same period, we have seen increased public acceptance over the appropriateness of treating major psychiatric disorders with prescription medications.6 Although the public is much more knowledgeable about the choices in medications, it is less so about the choices in evidence-based psychotherapies. Some of this discrepancy may be fueled by the dramatic increase in direct-to-consumer advertising by the pharmaceutical industry. With the more recent release by Congress of the Sunshine Act guidelines, there is now transparency regarding potential conflicts of interest between the providers and the pharmaceutical industry.7 In addition, advocacy groups have been persistent in providing support, preparing and disseminating educational materials, and lobbying with politicians over access to services. As has occurred with cancer, human immunodeficiency virus, and epilepsy, scientific discoveries and effective treatments have helped to reduce the stigma associated with mental illness. At the same time, there have been several evidence-based psychotherapies for common child and adolescent psychiatric disorders that have been incorporated into disorder-specific clinical practice guidelines by both the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.8 Other changes have also influenced office-based practice, such as the shift away from acute psychiatric hospitalization resulting in the substantial reduction of inpatient beds for both adults and children. As Olfson et al1 point out, much of the pharmacological treatment is being provided by nonpsychiatric primary care physicians, including pediatricians and internists (which reflects the growing problem of a workforce shortage and the resulting long wait times, especially for children being seen by child and adolescent psychiatrists).9 It is estimated that there will be a severe shortage of physicians in the United States in the next few years across all disciplines. Although new medical schools have opened, the number of residents training in
jamapsychiatry.com
JAMA Psychiatry January 2014 Volume 71, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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17
Opinion Editorial
psychiatry has remained stagnant if not decreased. Because primary care physicians are not trained in or knowledgeable about effective psychologic interventions, pharmacologic treatment becomes increasingly the default intervention. It is ironic that while the Affordable Care Act will allow many previously uninsured people to afford the care they need, there will be far fewer providers whom they will be able to access. Furthermore, the stakes are high, with mental illness having a significant impact on the country’s youth, their families, and our communities. According to the National Institute of Mental Health, 1 in 5 children either currently or at some point during their lifetime will have had a seriously debilitating mental disorder, but only about 20% of youths receive appropriate treatment.10 More adolescents and young adults continue to die of suicide than of all natural causes combined (more than those who die of cancer or diabetes mellitus)—it is the third leading cause of death. Ninety percent of those who die of suicide have a mental illness (diagnosed before death). So despite recent advances, we have not been able to make much progress in reducing the rates of youth suicide. Approximately 50% of students younger than 14 years of age with menARTICLE INFORMATION Author Affiliations: Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, Washington, DC; Behavioral Sciences and Pediatrics, George Washington University School of Medicine, Washington, DC; The American Academy of Child and Adolescent Psychiatry, Washington, DC. Corresponding Author: Paramjit T. Joshi, MD, Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010 (pjoshi @cnmc.org). Published Online: November 27, 2013. doi:10.1001/jamapsychiatry.2013.3193. Conflict of Interest Disclosures: None reported. Correction: This article was corrected on November 27, 2013, for an error in the References. REFERENCES 1. Olfson M, Blanco C, Wang S, Laje G, Correll CU. National trends in the mental health care of children, adolescents, and adults by office-based physicians
18
tal illness drop out of school. Seventy percent of youths in juvenile justice systems have a mental illness. The longer patients with mental illness stay ill, the more expensive it is to manage (this cost would include the cost of care and the loss of productivity at work and in society). Because of the 8- to 10-year delay between the onset of symptoms and intervention, the timely access of care, the standards of care, and the perceptions about mental illness still remain challenging issues. There is still no standard of care for mental illness in the United States. We have guidelines and evidence-based practices; however, these are not always followed, especially when the care is provided by primary care physicians. By targeting the individual rather than the disorder, we can identify and treat mental illness earlier, and markedly improve outcomes. Time and resources invested in children’s care will make a significant difference in their health, quality of life, and cost of care in the future. Ensuring a cross-disciplinary assessment of children will optimize both the collaboration and the standardization of mental health care, with the electronic medical record serving as an integrated database. The future can and should be brighter for our patients and their families.
[published online November 27, 2013]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.3074. 2. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073-1086. 3. March J, Silva S, Petrycki S, et al; Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820. 4. Geller B, Luby JL, Joshi P, et al. A randomized controlled trial of risperidone, lithium, or divalproex sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. Arch Gen Psychiatry. 2012;69(5):515-528. 5. McCracken JT, McGough J, Shah B, et al; Research Units on Pediatric Psychopharmacology Autism Network. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347(5):314-321.
6. Mojtabai R. Americans’ attitudes toward psychiatric medications: 1998-2006. Psychiatr Serv. 2009;60(8):1015-1023. 7. Physician Payment Sunshine Act final rule: quick reference guide. Policy and Medicine. February 13, 2013. http://www.policymed.com/2013/02 /physician-payment-sunshine-act-final-rule-quick -reference-guide.html. Accessed February 18, 2013. 8. Birmaher B, Brent D, AACAP Work Group on Quality Issues, et al. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526. 9. Thomas CR, Holzer CE III. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2006;45(9):1023-1031. 10. Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010;125(1):75-81.
JAMA Psychiatry January 2014 Volume 71, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a SUNY Binghamton User on 05/13/2015
jamapsychiatry.com
6. Lawrence NS, Jollant F, O’Daly O, Zelaya F, Phillips ML. Distinct roles of prefrontal cortical subregions in the Iowa Gambling Task. Cereb Cortex. 2009;19(5):1134-1143. 7. Xue G, Lu Z, Levin IP, Weller JA, Li X, Bechara A. Functional dissociations of risk and reward processing in the medial prefrontal cortex. Cereb Cortex. 2009;19(5):1019-1027. 8. Chen C-H, Suckling J, Lennox BR, Ooi C, Bullmore ET. A quantitative meta-analysis of fMRI studies in bipolar disorder. Bipolar Disord. 2011;13(1):1-15.
9. Graham BM, Milad MR. The study of fear extinction: implications for anxiety disorders. Am J Psychiatry. 2011;168(12):1255-1265. 10. McClure EB, Monk CS, Nelson EE, et al. Abnormal attention modulation of fear circuit function in pediatric generalized anxiety disorder. Arch Gen Psychiatry. 2007;64(1):97-106. 11. Finger EC, Marsh AA, Blair KS, et al. Disrupted reinforcement signaling in the orbitofrontal cortex and caudate in youths with conduct disorder or oppositional defiant disorder and a high level of psychopathic traits. Am J Psychiatry. 2011;168(2):152-162.
12. Stringaris A, Goodman R. Longitudinal outcome of youth oppositionality: irritable, headstrong, and hurtful behaviors have distinctive predictions. J Am Acad Child Adolesc Psychiatry. 2009;48(4): 404-412. 13. Fontaine NM, McCrory EJ, Boivin M, Moffitt TE, Viding E. Predictors and outcomes of joint trajectories of callous-unemotional traits and conduct problems in childhood. J Abnorm Psychol. 2011;120(3):730-742.
Mental Health Services for Children and Adolescents Challenges and Opportunities Paramjit T. Joshi, MD
We clearly are at the cusp of great change in our health care system, which raises important questions: What will the delivery of mental health services look like in the near future? Will the treatment be evidence based? How much will Related article page 81 it cost? Will our patients get better treatment, and how will the outcomes be measured? Olfson et al1 address how best to understand the delivery of outpatient mental health services in light of how the provision of these services has evolved over 15 years. They reviewed nearly 500 000 national ambulatory medical care surveys to identify psychiatric treatment trends between 1995 and 2010. They looked at mental health care indicators across the age range. They compared the background and clinical characteristics of children, adolescents, and adults whose recent visits (2007-2010) resulted in a mental disorder diagnosis. The 4 general indicators of mental health care that the authors looked at were clinical mental disorder diagnosis, psychotropic medication prescription, psychotherapy provision, and psychiatric care. The results of their study1 revealed that the total number of office visits resulting in a psychiatric diagnosis increased significantly over the 15 years; however, this increase was seen to be faster for youths than for adults. Psychotropic medication visits, however, increased at comparable rates for both youths and adults. While psychotherapy visits increased for youths, they decreased for adults during the same period. The authors concluded that, compared with adult mental health care, the mental health care of young people has increased more rapidly and has coincided with increased psychotropic medication use. Over the last several years, the increase in the number of youths with psychiatric disorders who are being treated with pharmacological drugs has been largely supported by the results of several large multicenter, federally funded studies such as the Multimodal Treatment Study of Children with ADHD,2 the Treatment for Adolescents With Depression Study,3 the Treatment of Early Age Mania study for the treatment of bi-
polar disorder,4 and the Research Units on Pediatric Psychopharmacology Autism Network study for autism spectrum disorder,5 in addition to numerous industry-sponsored treatment trials. During this same period, we have seen increased public acceptance over the appropriateness of treating major psychiatric disorders with prescription medications.6 Although the public is much more knowledgeable about the choices in medications, it is less so about the choices in evidence-based psychotherapies. Some of this discrepancy may be fueled by the dramatic increase in direct-to-consumer advertising by the pharmaceutical industry. With the more recent release by Congress of the Sunshine Act guidelines, there is now transparency regarding potential conflicts of interest between the providers and the pharmaceutical industry.7 In addition, advocacy groups have been persistent in providing support, preparing and disseminating educational materials, and lobbying with politicians over access to services. As has occurred with cancer, human immunodeficiency virus, and epilepsy, scientific discoveries and effective treatments have helped to reduce the stigma associated with mental illness. At the same time, there have been several evidence-based psychotherapies for common child and adolescent psychiatric disorders that have been incorporated into disorder-specific clinical practice guidelines by both the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.8 Other changes have also influenced office-based practice, such as the shift away from acute psychiatric hospitalization resulting in the substantial reduction of inpatient beds for both adults and children. As Olfson et al1 point out, much of the pharmacological treatment is being provided by nonpsychiatric primary care physicians, including pediatricians and internists (which reflects the growing problem of a workforce shortage and the resulting long wait times, especially for children being seen by child and adolescent psychiatrists).9 It is estimated that there will be a severe shortage of physicians in the United States in the next few years across all disciplines. Although new medical schools have opened, the number of residents training in
jamapsychiatry.com
JAMA Psychiatry January 2014 Volume 71, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a SUNY Binghamton User on 05/13/2015
17
Opinion Editorial
psychiatry has remained stagnant if not decreased. Because primary care physicians are not trained in or knowledgeable about effective psychologic interventions, pharmacologic treatment becomes increasingly the default intervention. It is ironic that while the Affordable Care Act will allow many previously uninsured people to afford the care they need, there will be far fewer providers whom they will be able to access. Furthermore, the stakes are high, with mental illness having a significant impact on the country’s youth, their families, and our communities. According to the National Institute of Mental Health, 1 in 5 children either currently or at some point during their lifetime will have had a seriously debilitating mental disorder, but only about 20% of youths receive appropriate treatment.10 More adolescents and young adults continue to die of suicide than of all natural causes combined (more than those who die of cancer or diabetes mellitus)—it is the third leading cause of death. Ninety percent of those who die of suicide have a mental illness (diagnosed before death). So despite recent advances, we have not been able to make much progress in reducing the rates of youth suicide. Approximately 50% of students younger than 14 years of age with menARTICLE INFORMATION Author Affiliations: Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, Washington, DC; Behavioral Sciences and Pediatrics, George Washington University School of Medicine, Washington, DC; The American Academy of Child and Adolescent Psychiatry, Washington, DC. Corresponding Author: Paramjit T. Joshi, MD, Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010 (pjoshi @cnmc.org). Published Online: November 27, 2013. doi:10.1001/jamapsychiatry.2013.3193. Conflict of Interest Disclosures: None reported. Correction: This article was corrected on November 27, 2013, for an error in the References. REFERENCES 1. Olfson M, Blanco C, Wang S, Laje G, Correll CU. National trends in the mental health care of children, adolescents, and adults by office-based physicians
18
tal illness drop out of school. Seventy percent of youths in juvenile justice systems have a mental illness. The longer patients with mental illness stay ill, the more expensive it is to manage (this cost would include the cost of care and the loss of productivity at work and in society). Because of the 8- to 10-year delay between the onset of symptoms and intervention, the timely access of care, the standards of care, and the perceptions about mental illness still remain challenging issues. There is still no standard of care for mental illness in the United States. We have guidelines and evidence-based practices; however, these are not always followed, especially when the care is provided by primary care physicians. By targeting the individual rather than the disorder, we can identify and treat mental illness earlier, and markedly improve outcomes. Time and resources invested in children’s care will make a significant difference in their health, quality of life, and cost of care in the future. Ensuring a cross-disciplinary assessment of children will optimize both the collaboration and the standardization of mental health care, with the electronic medical record serving as an integrated database. The future can and should be brighter for our patients and their families.
[published online November 27, 2013]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.3074. 2. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073-1086. 3. March J, Silva S, Petrycki S, et al; Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820. 4. Geller B, Luby JL, Joshi P, et al. A randomized controlled trial of risperidone, lithium, or divalproex sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. Arch Gen Psychiatry. 2012;69(5):515-528. 5. McCracken JT, McGough J, Shah B, et al; Research Units on Pediatric Psychopharmacology Autism Network. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347(5):314-321.
6. Mojtabai R. Americans’ attitudes toward psychiatric medications: 1998-2006. Psychiatr Serv. 2009;60(8):1015-1023. 7. Physician Payment Sunshine Act final rule: quick reference guide. Policy and Medicine. February 13, 2013. http://www.policymed.com/2013/02 /physician-payment-sunshine-act-final-rule-quick -reference-guide.html. Accessed February 18, 2013. 8. Birmaher B, Brent D, AACAP Work Group on Quality Issues, et al. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526. 9. Thomas CR, Holzer CE III. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2006;45(9):1023-1031. 10. Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010;125(1):75-81.
JAMA Psychiatry January 2014 Volume 71, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a SUNY Binghamton User on 05/13/2015
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