What is our role in tackling mental health disparities in kids with rheumatologic diseases?

By Tamar Rubinstein, MD, MS

June 3, 2016

Tamar Rubinstein, MD MS

Tamar Rubinstein, MD MS

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.

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