When you decided to go to medical school, did you expect that you would be seeing as many patients with mental health complaints as you are seeing now? If you have been practicing pediatrics for more than 15 years, has your patient mix significantly taken on a more behavioral flavor? Do you think that more of your patients are experiencing serious mental health issues?
If you answered yes to any or all of those questions, your perception of the mental health status of this country’s children agrees with mine and probably that of most other Americans. However, a recent study suggests that not all of our perceptions are reality based ( N. Engl. J. Med. 2015;372:2029-38 ). The authors used a parent-scored scale of the children’s impairment and found that the rate of severe mental illness has fallen significantly over the last generation. Despite the decline in severe cases that they observed, the percentage of children receiving outpatient mental health services (including psychotherapy and psychotropic drugs) has increased. In other words, while we and other providers are indeed seeing more children and adolescents with mental health and behavioral complaints, the tip of the iceberg is shrinking.
Does that divergence make any sense? As the chief of the National Institute of Mental Health’s in-house genetic epidemiological research program observes, it is hard to make any sense of the results of this new study, or any study, because there is a plethora of agencies doing surveys often using different methodologies. In Kathleen Merikangas’ words, “It’s a nightmare” ( “Severe Mental Illness Found to Drop in Young, Defying Perceptions” by Benedict Carey in the New York Times on May 20, 2015).
The situation seems to be a classic case of comparing apples and oranges. It is probably even worse because different agencies can’t even agree on whether McIntoshes and Granny Smiths should both be counted as apples. With this degree of uncertainty, the officials charged with making decisions about funding and allocating mental health services are flying blind much of the time.
When it comes to divining the trends in the prevalence of mental illness in children and adolescents, your guess is as good as mine. So … because I happen to have the time, I’m going to give you mine.
From my lofty perch here on the rocky coast of Maine, it appears to me that the recent study in the New England Journal of Medicine is accurate in its observation that serious mental illness is not increasing and may in be decreasing. But why does it feel that our office schedules are bulging with the patients presenting with less serious behavioral problems? One answer is that many of the cases of serious physical illness that we once saw never make it to the waiting room. For example, most children with congenital heart disease are now diagnosed in utero and delivered and treated in tertiary centers. Serious infectious diseases such as meningitis and epiglottitis have been damped down by successful immunizations. The abundance of subspecialists, the tendency of some physicians to issue knee-jerk referrals, and the awareness by parents that they can self-refer has left a void in our schedules that in the blink of an eye has filled with the walking worried.
It is worry and anxiety that in my estimation is on the rise and generating a large percentage of visits. Whether this is a post 9-11 phenomenon or simply a reflection of too-much-news-too-quickly is unclear. But the bottom line is that parents are worried and as a result so are many of their children. I am less sure on whether there has been a true increase in depression. It may be that people are more willing to talk about their unhappiness or it may be a ripple effect from our national sleep deprivation.
Finally, there has been a tendency to narrow the definition of normal that goes hand in hand with the notion that if it isn’t “normal,” there must be some medication to fix the problem. Attention-deficit/hyperactivity disorder is the poster child for this schedule-filling duo.
So that’s what I think. I suspect you feel you are seeing more behavior-related problems. But is this because of a true increase in the level of mental health problems in this country? How do you explain it?
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at email@example.com.