Mental-health treatment in America has plenty of room for improvement. Depression, in particular, is underdiagnosed and undertreated.
The American Academy of Pediatrics took a big step in February to address one deficit — early identification of depression in adolescents. The group called for every child to be screened for depression every year, starting at age 12.
This may well catch more kids who are symptomatic, and catch them earlier. However, once you have a diagnosis in hand — then what?
Then teens and their parents will face a new problem: getting treatment. Finding a provider who takes your insurance, who has availability, who is not too far away, who has after-school hours and whom your kid clicks with is no easy task.
Kate — a Washington state mother who, like other parents in this column, insisted on being identified by first name only to protect their families’ privacy — was grateful that her family’s primary-care provider prescribed antidepressants when her 16-year-old daughter asked for help. She also knew that her child, who was diagnosed with severe depression and suicidal ideation, should see a specialist. In her town, there were two adolescent psychiatrists who took private insurance; however, they had waiting lists of 10 and 12 months.
A Chicago mother had trouble finding a therapist who took Medicaid for her child who was depressed and cutting herself. “We spent a lot of time working with random therapists who allowed us to pay out of pocket,” she wrote in an email. “These people were good, but none were psychiatrists, [so they] couldn’t prescribe meds.”
Becky in Connecticut adds another layer to the challenge: “Trying to choose a therapist from a website that gives minimal info, looking for ‘teens,’ ‘depression,’ and ‘LGBTQ’ in the list of specialties and hoping that’s enough to make a good match.”
These examples represent a too-common story line, which was substantiated by a 2017 study. Harvard researchers called 601 pediatricians and 312 child psychiatrists in five cities, posing as parents of a 12-year-old child with depression. Appointments were scheduled with 40 percent of the pediatricians and 17 percent of the child psychiatrists. Long wait times were the good outcomes. Most psychiatry practices were not accepting new patients or had incorrectly listed phone numbers.
“Mental-health care is not highly valued,” says Paul Gionfriddo, president and CEO of Mental Health America, a patient advocacy group. Psychiatrists are paid less than most other specialists, and psychologists’ rates have fallen in the past two decades. Many therapists have social work degrees; they are reimbursed at even lower rates than psychiatrists and psychologists. (These comparisons come from Medicare data, which private insurers often use as bench marks to set their own rates.) “We don’t pay enough to providers, so there’s not enough providers around,” Gionfriddo says.
His group’s latest report, The State of Mental Health in America, says that 63 percent of youth with major depression do not receive any mental-health treatment. The reports states: “That means that 6 out of 10 young people who have depression and who are most at risk of suicidal thoughts, difficulty in school and difficulty in relationships with others do not get the treatment needed to support them.”
There are other impediments to getting from diagnosis to treatment. Parents may not want to believe their child is depressed. Teens themselves don’t always want to take the recommended steps.
There’s more than stigma involved, says Ana Radovic, a specialist in adolescent medicine at the University of Pittsburgh. One patient didn’t want Radovic to tell her mom about her diagnosis because the mom was struggling with family issues and the teen didn’t want to be another burden.
Laura in Baltimore says her teen’s biggest issue was with talk therapy. “She understood that combining medications with talk therapy was the best approach, but she really hated the idea of seeing someone every week or every other week,” Laura wrote in an email. “Eventually, she said she’d try it if the therapist was young and female. That turned out to be quite difficult to find.”
Parents can harbor guilt, wondering if their child’s troubles stem from divorce or parenting style. “When you tell a family your kid might be depressed, it opens up a lot of feelings,” Radovic says.
Candace in New York shared her concern via email: “I felt like it was my fault — I had severe postpartum depression and anxiety [and] he grew up with this. I was a single mother. I had to work. Was I not present enough?”
These deeply personal issues can be hard for a primary-care provider to address in a well-child visit, Radovic says.
If pediatricians start screening regularly for depression, they will probably identify more teens with depressive symptoms. What can those providers do to help families take the next step? Ideally, primary-care practices would have in-house mental-health providers or a referral list.
Radovic says a case manager can help follow up with patients who screen positive and prevent some from falling though the cracks.
Gionfriddo says that in addition to offering referrals for treatment, it’s important for doctors to make it easier to access information on such topics as how depression differs from anxiety (the two often coexist) and what the different types of therapy are. “Traditional cognitive behavioral therapy in’t right for everybody,” he says.
Radovic and Gionfriddo say that having teens engage with other teens can be very helpful, such as in group therapy sessions. Radovic has also developed a website, SOVA (Supporting Our Valued Adolescents), that is a moderated online chat forum for teens with depression and/or anxiety.
“Teens who have been through treatment, they want to help others,” Radovic says. Her team is now studying outcomes, including such questions as “Does interacting on the site get kids into treatment sooner?”
Radovic says she would like people to know that it’s normal to resist help for anxiety and depression. Resources and social support can be valuable, she says. “Don’t be scared to ask, ‘Might this be a problem?’ It’s better to be wrong than to be too late.”