Ped Med: Non-drug options slighted?

SAN FRANCISCO, July 13 (UPI) -- When it comes to treating children with mental, behavioral and/or emotional problems, the cards seem stacked against giving the non-pharmaceutical way a chance, some U.S. specialists say.

"Managed-care organizations are less likely to pay for psychotherapy and family interventions," said Peter Conrad, professor of sociology at Brandeis University in Waltham, Mass.

The development of direct-to-consumer pharmaceutical advertising has heightened the public's proclivity to seek or accept drug solutions to an array of human problems and lowered its tolerance of even mild symptoms and minor troubles, analysts said.

"All signs point to this trend continuing well into the 21st century," Conrad wrote in the Archives of Pediatrics and Adolescent Medicine.

Among those signs, a study published in Psychiatric Services showed one of every 10 office visits to a primary-care or specialty provider made by boys between the ages of 14 and 18 resulted in an order for psychotropic medication -- even though up to a quarter of the time no diagnosis of a mental illness was recorded.

The authors and commentators on the study proposed a variety of interpretations for the findings.

These included:

-- greater awareness and acceptance by parents and physicians of medical treatments for behavioral, emotional or mental conditions;

-- third-party-payer restrictions on talk therapy;

-- availability of new and improved pharmaceuticals;

-- direct-to-consumer advertising permitted more broadly under legislation passed in 1997, and

-- for those with a cynical bent, indiscriminate medicating of troubled youth by industry- and insurance-influenced doctors.

Another survey -- of child and adolescent psychiatrists starting out their careers -- indicated nine in 10 youngsters who came to see the doctor left with a drug prescription.

This is a particularly telling sign of the times to come because it represents the perspectives and practices of the up-and-coming generation of specialists, the authors noted in the Journal of the American Academy of Child and Adolescent Psychiatry.

The trend promises to be a costly one, considering the numbers of drug-treated youths are climbing and doctors' tastes are running to newer, more expensive medicines, analysts said.

"The impact of managed care and pharmaceutical marketing effects on these trends warrants further study," urged one group of analysts.

Already, practitioners are posting warning signs the collision with immovable insurance policies has set off a chain reaction, shutting off access to specialized services and creating traffic jams in primary-care settings.

"You're a pediatrician who must see six children per hour to make ends meet; (when a) parent complains (a) child's depressed or has school problems, you have no luxury of referring the child to a psychiatrist for a workup, so you're inclined to use medication," said Ronald Brown, dean of the College of Health Professions and professor of public health, psychology and pediatrics at Temple University Health Sciences Center in Philadelphia.

"Managed-care companies, private for-profits are basically deciding who the gatekeepers will be and what services they will provide and how much of the service will be covered and how extensively."

The concern with doctors' prescribing habits hit the headlines when a member of a Food and Drug Administration advisory committee, Ohio cardiologist Dr. Steven Nissen, said he favored placing strong warning labels on stimulants because he wanted to "cause people's hands to tremble a little bit before they write that prescription."

Other medical authorities think the healthcare system is letting down children not by overprescribing the medicine but by ignoring the patient.

"Inadequate treatment is a fairly significant problem, and underdiagnosis is also a problem," said psychiatrist Dr. Cynthia Pfeffer of the Weill Cornell Medical College who served on the FDA panel that recommended antidepressants bear a "black-box" warning of increased risk of suicidal thoughts and behaviors in some adolescent users.

"There are many untreated children and adolescents because they are not brought to the attention of mental-health professionals."

Of psychologically disturbed children who do see a professional, some three-quarters seek help from primary-care physicians -- many of whom are short on training and experience in this area, specialists said.

Offering little reassurance, two new studies disclose most hospitals and health plans do not initially require pediatricians to be board certified, a process by which a physician's competence is professionally assessed and acknowledged.

Although such formal sanction does not necessarily provide proof of aptitude or guarantee of quality, passing the test lends a certain comforting legitimacy.

Many critics found it disconcerting that 78 percent of 159 hospitals and 90 percent of 193 health plans surveyed do not require pediatricians to be certified at the time they are first granted their hospital privileges or health-plan credentials.

Although most hospitals mandate board certification at some point in the pediatrician's tenure -- typically within four to six years of coming aboard -- 42 percent leave the deadline open ended.

Even more lax, 59 percent of health plans do not call for certification in their criteria, and of the few that do, 98 percent define no time frame within which it must be achieved, according to a study published in the Journal of the American Medical Association.

"The health plan credentialing and hospital privileging processes are a major way that the healthcare system can assist consumers in identifying physicians who are up-to-date and competent and who maintain certain standards of professionalism," noted an editorial that accompanied the studies.

The authors predicted that "growing public concern regarding patient safety, as well as demonstrated patient preferences for certified physicians, will likely result in greater emphasis on quality assessments."

(Note: This column is based on dozens of reports, conferences and more than 200 interviews with specialists in children's health issues. Wasowicz is the author of the new book, "Suffer the Child: How the Healthcare System Is Failing Our Future," published by Capital Books.)

--

UPI Consumer Health welcomes comments on this column. E-mail: lwasowicz@upi.com.