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   MGMH Newsletter                                                                                                                                        JUNE 2014
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MGMH Newsletter-  JUNE 2014
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Are children overmedicated ? 

Thomas R. Insel M.D., is the Director of National Institute of Mental Health, USA. 

 

A recent symposium at the Carter Center featured a report by the Centers for Disease Control and Prevention (CDC) that as many as 10,000 toddlers may be receiving psychostimulant medication, like methylphenidate (Ritalin).1 The media reports of this, like many past reports, decried the overmedication of children. The numbers are notable.

 


The latest estimate from the National Center for Health Statistics reports that 7.5 percent of U.S. children between ages 6 and 17 were taking medication for “emotional or behavioral difficulties” in 2011-2012.2 The CDC reports a five-fold increase in the number of children under 18 on psychostimulants from 1988-1994 to 2007–2010, with the most recent rate of 4.2 percent.3 The same report estimates that 1.3 percent of children are on antidepressants. The rate of antipsychotic prescriptions for children has increased six-fold over this same period, according to a study of office visits within the National Ambulatory Medical Care Survey.4 In children under age 5, psychotropic prescription rates peaked at 1.45 percent in 2002-2005 and declined to 1.00 percent from 2006-2009.5

Taken together, what do these numbers mean? A common interpretation: children with behavioral or emotional problems are being overmedicated by psychiatrists too busy to provide therapy, at the request of parents too busy to provide a healthy home environment. A corollary of this interpretation is to blame schools too busy to provide recess or activities for fidgety boys. And usually the blame extends to the pharmaceutical companies that market medications in pursuit of profits.

While blaming psychiatrists, parents, schools, or drug companies might seem legitimate, some of the facts just don’t fit. First, most of the prescriptions for stimulant drugs and antidepressants are not from psychiatrists.6 In fact, outside of a few major cities, families in much of the nation have very limited access to child psychiatrists. Blaming parents is easy, but as Judith Warner argues in her book, We’ve Got Issues, most parents resist medication rather than request it.7 Schools in many parts of the country have reduced unstructured time, but the increase in medication is now seen in toddlers, years before children begin school. And drug companies, while frequently maligned, have reduced, not increased, their marketing budgets in the US.8

If psychiatrists, parents, schools, or drug companies are not the culprit, who is? The answer is potentially more complicated and more worrisome. Is it possible that the increased use of medication is not the problem but a symptom? What if more children were struggling with severe psychiatric problems and actually the problem was not over-treatment but increased need? Surely, if we discovered more children were being treated for diabetes or immune problems, we wouldn’t blame the providers or the parents. We’d be asking what drives the increase in incidence. And, there actually are large increases in the incidence of Type I diabetes and food allergies.9,10,11

Skepticism regarding increased rates of emotional and behavioral difficulties as opposed to increases in other medical disorders can be attributed in part to the absence of biomarkers or laboratory tests for psychiatric diagnosis comparable to glucose tolerance tests for diabetes or anaphylactic reactions for allergies. Absent these kinds of consistent, objective measures for mental disorders, we cannot distinguish between a true increase in the number of children affected or simply changing values or trends in diagnosis. Clearly context matters. What one parent might consider hyperactivity, another parent might consider healthy exuberance.  What physicians once called attention deficit hyperactivity disorder (ADHD), often now elicits a diagnosis of childhood bipolar disorder, leading to a 40-fold increase in prevalence from 1994-1995 to 2002-2003.12

No question, in a field without biomarkers, there is a risk of over-diagnosis. No question, subjective diagnosis could invite unnecessary treatment and over-medication. But what if the increased use of medication reflected more children with severe developmental problems and more families in crisis? What if the bigger problem is not over-medication but under-treatment? Hearing that 7.5 percent of children are on medication (4.2 percent on psychostimulants) seems stunning, but knowing that 11 percent of children have a diagnosis of ADHD raises a possibility of under-treatment.

In fact, evidence from nationally representative surveys of youth in the U.S. challenges recent concerns regarding widespread overmedication and misuse of medications, at least in adolescents.13,14,15 Among those with current mental disorders, only 14.2 percent of youth reported psychotropic medication use, and the majority who had been prescribed medications had a mental disorder with severe consequences, functional impairment, suicidality, or associated behavioral or developmental difficulties. In light of the evidence that about 1 in every 12 youth suffer from a severe developmental, behavioral or emotional disorder, under-treatment remains a serious problem.

Of course, the problem may be both over-treatment and under-treatment. It is possible that children with issues that would be resolved by psychotherapy alone are receiving medication.  It seems very likely, given the data in adolescents, that many who would benefit from medication and psychotherapy are receiving neither intervention. It is also worth considering that the rates of childhood mental disorders could be stable, but that more children are getting the treatment they need and, for many, detection and intervention is at an early age. If it is your child suffering acutely from anxiety, autism, anorexia, or depression, the problem is certainly not over-treatment. The CDC report showed that parents of more than one-half of those children who used a prescribed medication for emotional or behavioral difficulties had reported that this medication helped the child "a lot.”16 What I hear from families in crisis is lack of access, poor quality care, and a desperate need for answers. In the media reports on over-medicating children, this perspective is missing. The possibility that there is a real increase in the number of children suffering with severe emotional problems, just as there is a real increase in the number of children with diabetes and food allergies, is not even considered. Shouldn’t we be asking why so many children, at younger ages, are being seen for emotional and behavioral problems?


The Mental Health Innovation Network:
why it matters now

   

By Vikram Patel & Shekar Saxena 



 
Building communities of practice is not new to public health. Or even mental health. There are great examples of expert and advocate networks catering to the professional and educational needs of mental health stakeholders such as the UK’s Mental Health Network (supporting service providers within the UK’s National Health Service), and Canada’s EENet (providing a platform for communication and evidence exchange in Mental Health across the state of Ontario). These are tailored to the particular needs of those communities. So what about the global mental health community? Could it benefit from a similar network?



 

The global mental health community is growing rapidly, not least due to an increasing public awareness about the unmet needs of people affected by mental health problems and the investment by governments and donors in supporting actions to improve access to care and promote the human rights of persons with mental health problems. Guided by landmark priority setting initiatives such as the Grand Challenges in Global Mental Health in 2011, donors like Grand Challenges Canada (who support the Mental Health Innovation Network) and the NIMH are leading the way not just by making a financial commitment to innovation but also supporting efforts to maximise the impact this funding can have through improved networking and knowledge translation. There are nascent networks developing within the field, and with other global health priority fields such as maternal health, early child development, and HIV/AIDS, and an increasing recognition of the need to embed mental health within the NCD agenda.

This growth has led a flowering of innovations aimed at mental health promotion, prevention, treatment and care services across the globe – and in particular in low and middle income settings. It has become critically important to synthesize the knowledge generated by these innovators and to communicate this effectively to a wide range of stakeholders, from implementers to researchers, from policy makers to advocates, with the goal of bringing the benefits of these innovations to larger numbers of people. The Mental Health Innovation Network (MHIN) aims to achieve these precise objectives in a number of ways, for example through sharing innovations, getting people talking and providing the right information to the right people in the right way. The demand for knowledge is very large indeed, fuelled by the strong commitment shown by countries in adopting the Comprehensive Mental Health Action Plan 2013-2020 in the World Health Assembly in 2013.

Case studies detailing how and why innovations in mental health have been successful provide invaluable knowledge for implementation and to advocate for the field. The WISH conference in December 2013 and resulting Global Mental Health report was an example of the contribution of MHIN to this goal. Through the report, twelve outstanding mental health innovations were promoted to a wide audience of decision makers. Accessing the right people can be difficult. In a new and fast-moving sector like global mental health, supporting people to identify the networks they want to engage with can make a huge difference. MHIN’s website allows each member to build up a profile of their interests, their expertise and their academic and professional outputs.  Effective knowledge transfer is fundamental to achieving impact. MHIN’s team works to identify, synthesise and package global mental health research and disseminate it to relevant audiences. MHIN also aims to build links between individuals and groups, providing mechanisms by which individuals and organisations can profile what they do and build their own networks. MHIN attempts to build on other similar efforts and neither duplicate nor compete with them.

Ultimately, the success of MHIN will lie with its users, those who are committed to the vision of global mental health, to contribute to, engage with and utilize its resources. In doing so, MHIN hopes to become the ‘go-to’ resource for global mental health innovators of all hues, and contribute to the dream of transforming lives and building communities committed to mental health around the world. 


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Myth vs. Fact: Violence and Mental Health 

A Q&A with an expert who studies the relationship between mental illness and violence

After mass shootings, like the ones these past weeks in Las Vegas, Seattle and Santa Barbara, the national conversation often focuses on mental illness. So what do we actually know about the connections between mental illness, mass shootings and gun violence overall?

To separate the facts from the media hype, we talked to Dr. Jeffrey Swanson, a professor in psychiatry and behavioral sciences at the Duke University School of Medicine, and one of the leading researchers on mental health and violence. Swanson talked about the dangers of passing laws in the wake of tragedy ― and which new violence-prevention strategies might actually work.

Read more



 

There is a tremendous opportunity for innovative solutions to increase the number of people who have access to quality care and to ensure the greatest outcome for each person reached. Grand Challenges Canada support bold ideas to improve treatments and expand access to care for mental disorders through transformational, a­ffordable and cost-eff­ective innovations which have the potential to be sustainable at scale

Click here to download the brochure for more information 
 

‘Psychiatric cases more in women than men’         

By Maymunah Kadiri

Women experience more mental health problems than men due to the stress of juggling many roles. They are seen as the wife, mother and carer. Stress related to pressure on women to fill many different roles is likely to be a major factor for higher rates of everything from depression to phobias, according to Professor Freeman, a clinical psychologist. The greatest causal factors are environment, rather than genetic causal factors. It’s certainly plausible that women experience higher levels of stress because of the demands of their social role

Read more

A unique and novel  idea of the forum that  campaigns for Inclusive family ,Facemi is an India based  joint forum for the care providers and care receivers (who are also known as “Users”) By “Inclusion” we mean one where the devastating effects of mental illness is recognized as impacting the whole family without any discrimination as family members and patients. Labels shall not be given within the family. It is common practice to empathize with the carers more than the users. . “Mental illness often has a ‘ripple effect’ on families, creating tension, uncertainty, troubled emotions and big changes in how people live their lives. Different family members are likely to be affected in different ways.” Inclusive Family believes in the equality of all its members based on functional family norms, personal needs and rights.

For more information visit http://facemindia.org.in/
Trustcircle is a Peer-centered mental health network for consumers, caregivers, and healthcare providers

Learn more about it in this Video 


 


 
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