• What kills kids? – ctd.

    I received some surprising pushback, at least surprising to me, on my post on what kills children. Some of the comments were polite and asked for cost-effectiveness data on measures to prevent suicide, homicide, or car accidents. Other less polite emails asserted that these aren’t medical problems. Still more claimed things I won’t reprint. And then a commenter went and broke my heart.

    I want to prevent kids from dying. Period. In order to do that in the most productive manner, I need to consider first what kills kids. It makes sense that to do the maximal amount of good, I’d want to focus on things kill a fair amount of children. Next, I’d want to consider whether I have ways of intervening in those mechanisms. There are deaths that just aren’t preventable. Or, where it would be so hard that I’d be wasting resources. So it’s totally reasonable to consider those factors when deciding where to put our money.

    Here’s the thing, though. Years ago, we could have looked at cancer and said that there’s nothing we can do for those kids. We didn’t do that, though. We invested billions of dollars to develop drugs and therapies in the lab. We then performed clinical studies and tested out new procedures. Today, we do a much better job. But there there was a massive investment in that area that continues today. To claim that no good interventions exist for homicide or suicide is not a reason to abandon those areas; it’s a call to get serious about doing some research into preventing death by those mechanisms.

    The commenter I mentioned before specifically asked about suicide. So here are some facts*:

    Major depressive disorder (MDD) is a specific diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).  Children with MDD are sometimes harder to pick up than adults, because their symptoms differ. A recent meta-analysis found that the prevalence of current or recurrent MDD is approximately 6% for adolescents aged 13-18 and up to 20% of adolescents will become depressed prior to age 18. Childhood depression is associated with greater risk of suicide, behavioral problems, substance abuse, and academic, social and familial problems that can persist long after the depressive episode is resolved.

    Primary care docs increasingly find themselves dealing with childhood mental health conditions such as depression.  A shortage of child and adolescent mental health professionals has created the need for these primary care physicians to evaluate and treat more children with mental health problems.  Unfortunately, these same doctors often fail to detect these disorders and many depressed children and adolescents go untreated.

    In a 2001 study looking at pediatricians’ roles and perceived responsibilities in the identification and management of depression, 90% of pediatricians felt it was their responsibility to recognize depression in both children and adolescents, but were unlikely to feel responsible for treating the condition in children or adolescents (26% and 27% respectively).  Forty-six percent of pediatricians lacked confidence in their skills to recognize depression in either children or adolescents, and fewer (10% and 14% respectively) had confidence in their ability to treat depression.  In another study, only 8% of pediatricians felt they had adequate training in the management of childhood depression; only 11% were comfortable treating childhood depression.

    There are numerous barriers these physicians face when attempting to address childhood mental health problems such as depression, including inadequate referral resources, poor insurance coverage for mental health services, limited training, and inadequate time to diagnose or provide patient education. They also struggle with assuring appropriate follow-up, monitoring depressive symptoms and medication adequately, and communicating with outside specialists.

    We aren’t even close to treating childhood depression in an optimal manner. And probably the best way to prevent childhood suicide is to recognize and treat childhood depression. We sink an appallingly little amount of money into child mental health.

    And as for those of you who ask for cost-effectiveness data, I can’t provide those until we know effectiveness first. I don’t know that because we don’t have nearly enough effectiveness studies. But I can tell you this. Preventing a 15 year old from committing suicide roughly adds on about 60 years to life. So even if the intervention cost millions of dollars per life saved, it would be cost-effective by nearly any accepted threshold of cost-effectiveness.

    So why don’t we try?

    *I had many of these data available from a grant I’d written to study how we might get primary care physicians do a better job of this. The NIH review panel did not give it a high enough priority score to get funded.

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