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An Illinois draft plan to screen children and pregnant women for mental illness has stirred controversy and raised questions about some elements of the President's New Freedom Commission on Mental Health report. Some critics fear the Illinois case sets a worrying precedent for mental health care throughout the United States.
An Illinois draft plan to screen children and pregnant women for mental illness has stirred controversy and raised questions about some elements of President Bush's New Freedom Commission on Mental Health (NFC) report. The Illinois draft screening guidelines, issued in July by the Illinois Children's Mental Health Partnership (ICMHP), were based on recommendations made in 2003 by the Bush-appointed NFC, which proposed a far-ranging reform of state mental health care systems. One of the five key recommendations in the report was:
In a transformed mental health system, the early detection of mental health problems in children and adults--through routine and comprehensive testing and screening--will be an expected and typical occurrence.
The NFC report anticipated states moving individually and in parallel with federal efforts to reform the Medicaid system and, to a lesser extent, the state grant programs under the aegis of the Center for Mental Health Services (CMHS), a part of the Substance Abuse and Mental Health Services Administration (SAMHSA). A. Kathryn Power, M.Ed., director of CMHS, has been charged with writing an NFC Action Plan with implementation specifics. Publication of that plan has been repeatedly delayed.
Meanwhile, Illinois was the first state to move forward on its own, albeit only in the area of children's mental health. Passed by the state legislature with near unanimous support in August 2003 and quickly signed by Gov. Rod Blagojevich, the Illinois Children's Health Act of 2003 contained a number of provisions including the creation of the ICMHP. The ICMHP was charged with the development of a Children's Mental Health Plan containing short-term and long-term recommendations to provide comprehensive, coordinated mental health prevention, early intervention and treatment services for children from birth through age 18.
The ICMHP's draft plan, released on July 16, caused a political eruption in the state. Its priority recommendations were that all children receive periodic social and emotional developmental screens and that all women be screened for depression during pregnancy and for up to one year postpartum.
State Sen. Chris Lauzen (R-Aurora) was quoted in the Illinois Leader as saying:
If this negative interpretation of the Act is accurate, it is personally discouraging to me that this bill could have gone through the hearing process with everybody voting it forward, and none of the true implications of what this bill was all about were understood by many of those voting on it.
The bill was passed unanimously by the Illinois Senate.
Barbara Shaw doubles as chairperson of the ICMHP and director of the Illinois Violence Prevention Authority. She readily admitted that the ICMHP's draft plan served as the first prototype of at least a segment of what the NFC was advocating. "What is happening in Illinois is a testing ground for the President's New Freedom report goals," she told Psychiatric Times.
Shaw argued that the opposition in the state to the draft's support for screening of children and pregnant women was based on a misunderstanding of the kind of screening being advocated and, perhaps more broadly, on a mistrust of the mental health establishment in general. The ICMHP is promoting mental health screenings for children as part of their regularly scheduled physical well-child checkups. "We are advocating social and emotional screenings which point out areas of developmental support a child may need, from their parents for example, in areas such as coaching to remediate aggressive behavior," she explained. "We want to step in so we can prevent more serious mental problems from developing."
But critics of the recommendations--a vocal minority according to Shaw--misconstrued the screening recommendation to imply that the ICMHP wanted all children to undergo mandatory screening with troubled children being labeled as "mentally ill" and being pushed, by schools or the state, into medication regimens. "These are people who feel the schools have no place futzing with their children's mental health," she explained. "They also distrust psychotropic medications."
Nada Stotland, M.D., professor of psychiatry at Rush Medical College in Chicago and secretary of the American Psychiatric Association, pointed out that the objective of the original state law was to help children whose mental difficulties were getting in the way of their learning. "We wouldn't expect teachers to ignore kids who were wheezing because of asthma, would we?" she asked PT in wonderment. Moreover, she is amazed that anyone could object to mental health screening for pregnant women.
Several major medical societies have advocated screening for pregnant women. "We screen pregnant women for diabetes and hypertension," said Stotland. "Why wouldn't we screen them for depression? I mean, come on, we have seen women jumping out of windows, drowning themselves, killing their babies. It is nothing more than a manifestation of a stigma that we wouldn't want to screen these women.
"This whole hysteria in Illinois seems to be the same kind as got currency from the New Freedom Commission report recommendations," she added.
Michael F. Hogan, Ph.D., chairperson of the NFC and director of the Ohio Department of Mental Health, said the NFC did not recommend universal screening of children or adults, pregnant women or otherwise. "We said children should be screened in settings where children of high risk are known to be present, such as in juvenile detention settings," Hogan told PT. "We also recommended expansion of mental health screening in schools and early childhood settings."
But Hogan added that public school screenings of the general population have to be done selectively and carefully. Ohio, for example, is one of a number of states with pilot sites participating in a Columbia University program. However, that program includes a number of important components such as parental notification, a 100% expectation that children who screen positive for mental issues see a physician very quickly and placement of those children in a system where they receive the care they need. The program uses three screening models. The first is a 10-minute paper-and-pencil questionnaire that asks youth about depression, substance use, and suicidal thinking and behavior--the most significant predictors of suicide risk in adolescents. The results of this screening allow staff to identify youth who could benefit from the additional screening. The DISC Predictive Scales (DPS) is a pre-screening device that shows whether a youth needs to be sent on for more detailed screening with the Voice Diagnostic Interview Schedule for Children (DISC) or for clinical evaluation. The DPS differs from the questionnaire in that it assesses a broader range of potential problems--from eating disorders to anxiety and mood problems. The DISC is a computerized program that "speaks" questions to the youth through headphones and can be customized to screen for any combination of the 30+ disorders it is capable of identifying. The program uses DSM-IV criteria.
Hogan noted that, nationally, of the children red-flagged by a Columbia pilot as needing psychiatric follow-up, only 9% are currently receiving any care. Hogan himself has strong feelings about the need for much more thorough screening of children. But he acknowledged that "science and public opinion" have not advanced to the point where universal mental health screening is acceptable.
The current controversy about links between selective serotonin reuptake inhibitors and suicide has also contributed to the second thoughts about the Illinois law and screening in general. There is a concern that antidepressant drugs have not been tested adequately. Information posted by the U.S. Food and Drug Administration on its Web site in late August bolstered that impression. That information included an FDA analysis that suggested some antidepressants pose a greater risk of suicide in children than adults. The data seemed to support a view that fluoxetine (Prozac) posed the smallest risk for kids, and that venlafaxine (Effexor), for example, was a very suspect choice. According to the Wall Street Journal, the FDA analysis reported that the agency's analysis of Wyeth's clinical trials with Effexor showed that children who took that antidepressant were nearly five times as likely to have suicidal thoughts or actions as those who took a placebo pill. The Journal quoted Alan Metz, North American medical director for GlaxoSmithKline, the manufacturer of paroxetine (Paxil), a drug the FDA also found as having the potential to cause suicidal thoughts in kids (2.65 times more likely than placebo), as underlining the fact that the data cited by the FDA did not rise to the level of statistical significance.
Those kinds of reports are helping to fuel fears about widespread screening of kids. "There are foes out there," Hogan admitted.
Hogan conceded that "we in the field" would have an easier time convincing the public of the need for at least broader, if not universal, screening if the CMHS had published the NFC Action Plan that has been delayed. In a number of addresses earlier this year, Power, director of CMHS, stated that the Action Plan was on the cusp of publication. On March 3 she told a conference in Baltimore:
Our Action Agenda, which will be released in the next few weeks, lists specific steps that we will take to implement each of the goals and recommendations of the report. Our current inability to adequately address the mental health needs of our citizens is precisely why the recommendations of the New Freedom Commission carry so much urgency.
"I am personally frustrated that the Action Plan has not been published," stated Hogan. "It should have been out no later than the one-year anniversary of the New Freedom report." But" he was sympathetic to the bureaucratic problems he believes Power is facing in getting Bush administration approval for the Action Plan, which has to be signed off by numerous federal agencies. "I'm glad the federal agencies are finally working together, at least," Hogan said. "It is about time."
Mark Weber, director of communications for SAMHSA, told PT it is taking time to get "buy-in" from the six federal agencies involved in developing the action plan, which will lay out a strategy for an "unprecedented" reform of the nation's mental health system. He explained, "We could have rammed out an action plan with no buy-in. But it would have gone nowhere." Reading between the lines of Weber's comments, some federal agencies and departments are being asked to give up mental health programs they have administered. "Everything is being put on the table," stated Weber.
Weber also noted that even in the absence of an action plan, the Bush administration has moved forward with some mental health reform initiatives. He cited the "Money Follows the Person--Rebalancing Initiative." He also mentioned that the Bush administration has proposed an increase in the budget of CMHS from $862 million in the current fiscal 2004 to $912 million in fiscal 2005. That increase compares very favorably with the static budgets proposed for most other domestic health agencies. Included in the $912 million is $30 million in new funding for state mental health transformation grants, which would total $43.8 million in 2005. Congress is yet to approve a 2005 CMHS budget.