Aware that mental illness generally begins early in life and that four teen-agers commit suicide every day, several organizations and agencies are stepping up efforts to expand voluntary mental health screening and suicide prevention initiatives for youth-but they are doing so in the face of stigma and vocal opposition.
Child psychiatrist Kenneth Duckworth, MD, speaking on behalf of the Campaign for Mental Health Reform, a national partnership of organizations representing the mentally ill, their families, service providers and many others, said at a Congressional briefing last year, "We strongly believe that voluntary mental health screen with parental consent and involvement can have a huge benefit for youth at risk of mental and emotional disorders" (Duckworth, 2005).
Yet, these efforts are being met with resistance by opponents who claim screening will lead to the "labeling" and "drugging" of children and interference with parental rights.
Well informed about the controversies, child psychiatrist Steven Adelsheim, MD, former director of and now consultant to New Mexico's school mental health program, told Psychiatric Times that voluntary mental health screening programs are critical for safety and suicide prevention.
Suicide among teenagers is a national problem, he pointed out. It is the third leading cause of death among teen-agers. In 2002 (the latest year for which data is available), 1,531 children 15 to 19 years of age, and 260 between 10 and 14 years of age committed suicide (Center for Disease Control and Prevention, 2005). New Mexico, Adelsheim said, has the fifth highest rate of teen suicide in the country. Last year, the New Mexico Department of Health was among 14 state-sponsored youth suicide prevention and early interventions selected to receive an estimated $400,000 each in federal funding from the Substance Abuse and Mental Health Services Administration (SAMHSA). The grants were made possible by the Garrett Lee Smith Memorial Act (SAMHSA, 2005).
New Mexico's challenge with regard to youth suicide is outlined in the 2003 New Mexico Youth Risk and Resiliency Survey, which involved 103 of 191 high schools in the state and 11% of the high school students. Researchers found that nearly 31.9% felt so sad and hopeless almost every day for two or more weeks in a row that they stopped doing their usual activities; 20.7% seriously considered attempting suicide, 14.4% attempted suicide one or more times in 2003, and 7.5% indicated that their attempt required medical attention by a doctor or nurse (New Mexico Department of Health, 2004). For comparison, 16.9% of a national sample of 15,000 high school students surveyed the same year reported they have seriously considered attempting suicide, 8.5% have actually attempted it one or more times during a year and 2.9% needed medical attention (Centers for Disease Control, 2004).
Since many mental health disorders, such as anxiety and impulsive control disorders, begin in childhood or adolescence, it is wise to identify them early to avoid treatment delays, said Adelsheim, also associate professor of psychiatry, family/community medicine and pediatrics at the University of New Mexico Health Sciences Center.
He pointed to research [National Comorbidity Survey Replication reports] published last year in Archives of General Psychiatry that indicated half of the individuals who develop a mental health disorder in their lifetimes exhibit symptoms before age 14 and three-quarters by age 24 years (Kessler et al., 2005). What's more, those same reports revealed a substantial delay in the time from illness onset to the time people get treated (e.g., delays of six to eight years for mood disorders and nine to 23 years for anxiety disorders) (Wang et al., 2005).
"So it seems to me that being able to identify kids at risk early and then linking them early to services will decrease the chronicity of illness and will decrease the seriousness of other risk factors that might develop, such as violence, suicide, teen pregnancy and/or substance abuse problems," Adelsheim said. "When we are looking at depression and other mental health conditions, there is real value in identifying these problems early, getting kids services and getting them back on track in school."
Mental health problems that go undetected and untreated frequently persist, leading to educational ramifications as well, he added. A child who is very depressed or has other mental health problems that go untreated isn't going to learn or become a productive citizen.
A vocal opponent of the early detection concept is Rep. Ron Paul (R-Texas), a physician, who in 2004 and 2005 introduced legislation to prohibit the use of federal funds for a "universal or mandatory mental health screening program," arguing that it negates parental rights, encourages overmedication of children and is unsupported by evidence that it decreases suicide attempts. Paul's legislation (which did not pass) was backed by some anti-psychiatry and conservative political organizations, including Concerned Women for America, Gun Owners of America and the Eagle Forum. Paul's legislation particularly sought to prevent grants to states to implement recommendations of the President's New Freedom Commission on Mental Health.
Additionally, in several states across the United States, legislation has been introduced that prohibits mental health screening of children in schools, prohibits school personnel from recommending psychotropic drugs for children and limits the ability of school personnel to make recommendations or even have dialog with parents about behavioral health diagnoses, according to the National Mental Health Association (2005). States with such legislation have included: Alaska, Florida, Georgia, New Mexico, New Hampshire, New York, Pennsylvania, Tennessee, Utah and Vermont. In both Utah and Florida, the legislation was passed by the legislature but vetoed by the governors.
Much of the controversy over mental health screening stems from an endorsement of the practice by the President's New Freedom Commission on Mental Health. While the commission has been accused of calling for mandatory screening without parental consent, Michael F. Hogan, PhD, director of the Ohio Department of Mental Health and chairman of the commission, in a 2004 letter to the Washington Times, said:
The commission did not call for mandatory universal mental-health screening for all children. I am at a loss to explain why this misrepresentation persists, since it is at odds with the plain language of our report to the president. ... [T]he commission proposed broad screening only in settings where many children are known to have untreated behavioral problems. Beyond this, the commission promoted programs that provide voluntary screening only with parental consent.
A SAMSHA backgrounder recently pointed out that the Administration does not support mandatory screening nor screening of children without parental consent.
1.Center for Early Diagnosis and Treatment (2004), Columbia University TeenScreen Program-Science into Policy, Prevention and Action, 2004 Overview. Available at: www.teenscreen.org/cms/docs/ AnnualOverview2004.pdf. Accessed Jan. 7, 2006.
2.Centers for Disease Control and Prevention (2004), Youth Risk Behavior Surveillance-United States, 2003. Morbidity and Mortality Weekly Report 53(SS-2):8-9.
3.Centers for Disease Control and Prevention (2005), Deaths: Leading Causes for 2002. National Vital Statistics Reports 53(17):13.
4.Duckworth K (2005), Congressional Briefing. Available at www.mhreform.org/ kids/duckworthstatement.htm. Accessed Jan. 8, 2006.
5.Hogan MF (2004), Long-term study needed. Washington Times. Oct. 21.
6.Kessler RC, Berglund P, Demler O et al. (2005), Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. [Published erratum Arch Gen Psychiatry 62(7):768. Merikangas, Kathleen R (added).] Arch Gen Psychiatry 62(6):593-602 [see comments].
7.National Mental Health Association (2005), State trends: legislation prohibits mental health screening for children. NMHA Issue Update: March 28. Available at: www.nmha.org/sher/issuebrief/ childrenScreening.cfm. Accessed Jan. 9, 2006.
8.New Mexico Department of Health, Public Education Department, University of New Mexico Prevention Research Center (2004), New Mexico Youth Risk and Resiliency Survey (YRRS)-2003 Report of State Results. Available at:www.ped.state.nm.us/ div/sipds/ health/dl/yrrs. 2003.final.report.pdf. Accessed Jan. 7, 2006.
9.SAMHSA (2005), SAMHSA awards 37 grants totaling $9.7 million for suicide prevention. Available at:www.samhsa.gov/ news/newsreleases/ 050920_grants.html. Accessed Jan. 8, 2006.
10.Wang PS, Berglund P, Olfson M et al. (2005), Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):603-613 [see comment].