What is our role in tackling mental health disparities in kids with rheumatologic diseases?
June 3, 2016
A month ago, the CDC came out with a report about a recent increase in suicides in the United States. The most disturbing trend was an increase of 200% among girls age 10-14 from 1999 to 2014. This statistic was quickly picked up by news outlets across the country. I heard it on NPR on my morning drive to work.
But what about our kids? Are we sufficiently treating our patients in pediatric rheumatology for depression and anxiety? Are we sufficiently identifying them in the first place? In a study just released inThe Journal of Rheumatology, the authors (Andrea Knight, Ming Xie, and David S. Mandell) examine some of our most vulnerable patients and find that certain groups may be falling through the cracks. (Read more…)
The authors analyzed Medicaid claim data from 2005-2007 to estimate the prevalence of depression and anxiety, and the use of antidepressants and anxiolytics, among white, African-American, Latino, and other 10-18-year-olds with lupus. Overall, 19% of lupus patients in this population were identified as having depression, compared to 4% of Medicaid patients in the same age groups. This is striking but comes as no surprise given the many reasons we think kids with lupus are at greater risk for depression, including reactive depression, medication effects, or possible CNS disease.
What is noteworthy is that African-Americans have lower rates of depression and anxiety diagnoses and lower rates of prescribed antidepressants and anxiolytics. Even after taking into account sex, age, and other relevant covariates, the odds of African-Americans having a diagnosis of depression were half that of whites. Although one could argue that this group is at lower risk for depression and anxiety, Andrea Knight’s previous work and what we know about the general pediatric population indicate the opposite.
The disparities that Knight et al. uncovered may have complex etiologies. In Congresswoman Robin Kelly’s 2015 “Kelly Report” on health disparities in the US, both lupus and mental health are explored. The report on mental health makes reference to a “double stigma” for minority patients with mental illness. Such a stigma may act as a barrier for minorities in discussing emotional health with providers and seeking treatment. Several strategies are proposed to overcome stigma and disparities, among them building partnerships between PCPs and mental health providers.
We’ve certainly seen the impact of bringing psychologists to primary care pediatric clinics at my home institution in the Bronx. But my 19 year old patient with lupus, CNS disease, nephritis, and complaints of anxiety has not stepped foot in her pediatrician’s office for 3 years. Anecdotally, it seems to me that the more organs involved and the more complex their care, the less likely my patient is to know their general pediatrician’s name. Once I opened up a lupus patient’s chart and saw that my name had been replaced on the banner where the PCP’s should have been. Where are our lupus, vasculitis, arthritis, chronic pain, and fibromyalgia patients’ medical homes?
Unlike our cardiologist, nephrologist, neurologist, or gastroenterologist colleagues, we take care of disease processes more than organ systems. These diseases often place us as coordinators of care among other subspecialists. How much we should take on a generalist role is likely a divisive question, separating our community into those of us who believe that in doing so we overstep the boundaries of our training and our expertise and those of us who feel we must take a more holistic view of our patients and their diseases. Both points of view are valid and not mutually exclusive.
The answer may be more effectively promoting our patients relationships with their primary care providers and advocating that mental health services be appropriately provided for our vulnerable populations. Or taking on the role of screening for mental illness and connecting our patients to service ourselves. Regardless, it appears there is still work to be done.
Recent President’s Updates
"Isn't there something natural or a diet we can use instead of these poisons?" This is a question all of us hear on a regular basis. And while we may believe we are recommending treatments utilizing the best evidence, that may not be the perception of some families....read more
Mental illness is certainly an important aspect of many of our patients’ struggles, and I hope I’ve made the case earlier that it’s something pediatric rheumatologists should be paying attention to… There is a lot of good literature to show that patients with chronic...read more
Teenagers are notorious for poor sleeping habits. (And probably pediatric rheumatologists aren't much better, at least not the ones I know.) The average teenager gets about 7 hours of sleep each night, but needs about 9 hours or more. I've had a personal interest in...read more
It is not unusual for pediatric rheumatologists to be asked to see a child with persistent fever, without arthritis, who may or may not have had rash. Usually by the time the rheumatologist is called, the child has often been treated with antibiotics, and bacterial cultures have been done and were negative, and serologic or PCR studies for tick related illnesses and other infectious etiologies are in process or negative. Viral studies are done, and how specific/ disease related is the finding of a positive recovery of a respiratory pathogen from a nasal swab?read more
Perhaps you missed the New York Times article published in October 2015, “Overselling Breast Feeding” or the firestorm that erupted afterwards. I didn’t. I was up nursing my newborn on our first week home and reading resultant Facebook posts, emails, and even an...read more
By Jay Mehta, MD
As the parent of a 4-year-old, and the resident of a major metropolitan area, the word “share” (and its various constructions) is a daily part of my lexicon. I’m constantly reminding my daughter the importance of “sharing” (which she thinks is giving her friends the toy that she doesn’t want to play with). The other day I took an Uber, and on my last vacation, I stayed in a house I found on AirBnB, both of which are parts of the “sharing economy.” And yesterday, I “shared” with my Twitter followers an interesting article on medical education.read more
By Kenneth Schikler, MD
As I am sure occasionally happens to us periodically, a young toddler was referred to me by gastroenterology after being evaluated for hepatopathy regarding elevated “liver enzymes.” This young boy ended up having muscle disease, and genetic testing confirmed Duchenne Dystrophinopathy. While he has been sent on to our MDA clinic for his future care, I was interested in looking into what was new in Muscular Dystrophy.read more
by Brian M. Feldman, MD, MSc, FRCPC
We often hear of the glass ceiling that prevents the rise of women in academic medicine. In 2016, there is still much gender inequality in the world, as the UN clearly pointed out late last year. I’m old enough to remember the iconic “bra-burning” episodes in the 1960s; while much has been achieved, it’s remarkable how far we still have to go.read more
By Jay Mehta, MD
“What about dietary changes?” I’m sure I’m not alone in getting this question more and more frequently with each passing year. It’s interesting that as our drugs get more effective at treating patients, families seem to be more interested in trying to treat with non-pharmacologic means.read more
By Brian M. Feldman, MD, MSc, FRCPC
Point-of-care ultrasound – with its clever acronym POCUS – has become a big thing in rheumatology, and in peds rheum. As someone who hasn’t received ultrasonography training, I find it highly mystifying, and I’m not sure on which side I fall.read more