Proposing Psychiatric Referrals in Primary Care Pediatrics

Primary care pediatricians often encounter children or parents presenting with physical symptoms who are resistant to considering a psychiatric cause or the emotional sequelae of a chronic physical illness. Sometimes a physical symptom is the child’s only solution to an emotional problem that is very hard for the family to face. Sadly, the stigma that still attaches to mental illness can make it easier for patients to seek help from their primary care physician than from a mental health provider. So, this month, we are discussing how to approach referral for two of the most common presentations in primary care: postpartum depression and psychosomatic disorders. We are not discussing the task of finding an appropriate clinician, but instead how to help your patient or their parent agree to see a therapist or psychiatrist to better understand or treat their symptoms. It sounds simple but is not always easy.Perinatal Depression It is estimated that between 10% and 20% of women will experience perinatal depression, defined as occurring during pregnancy then up to 1 year after childbirth. This is not the “baby blues,” in which the same depressive symptoms (tearfulness, anxiety, depressed mood, low energy, and fatigue) occur within a few days of childbirth but resolve within 2 weeks without treatment. While stressful, baby blues generally do not interfere with functioning or cause morbid or suicidal thoughts. Susan D. Swick, MD, MPHPerinatal depression, on the other hand, is a serious complication of pregnancy. Without treatment, it can lead to higher rates of pregnancy-related death and suicide in mothers, and higher rates of preterm birth, low birth weight, and stillbirth. When new mothers experience untreated depression in their baby’s first year of life, that baby faces an increased risk for poor attachment, delayed cognitive and linguistic skills, and impaired emotional development and substantial risk for behavioral problems and psychiatric illness in childhood, adolescence, and adulthood. Perinatal depression is not more difficult to treat than other types of depression, but it can be more challenging to engage patients in treatment. This is where the pediatrician comes in.The American College of Obstetricians and Gynecologists estimates that 40% of new mothers miss their postpartum checkup (between 3 and 8 weeks after delivery) with their obstetrician, whereas the American Hospital Association estimates that closer to 60% fail to follow up with their obstetrician. This is not surprising, given the challenges of learning to care for a new baby. But the frequency of missing appointments with that new baby’s pediatrician are much lower — closer to 10%, according to the American Academy of Pediatrics. This is why the American Academy of Pediatrics recommends that pediatricians screen new mothers for depression with the Edinburgh Screening Instrument at the 1-, 2-, 4-, and 6-month well-child visits. This is a 10-item self-report instrument that is completely free and well-validated. The mother is not your patient, but a functioning mother is essential to the health and development of your patient and she will listen to you.If your patient’s mother has a positive screen, or if you have a high degree of clinical suspicion for depression, what next? Try starting with whatever concerns the new mother has brought you. Is this just the first well-baby visit? Does she have questions about nursing? Sleep? Is she tearful? Anxious? Follow her lead, and in discussing the baby’s needs, acknowledge that having a baby is a very stressful event, a revolutionary change in routines and responsibilities for the new parents. Even when it is a welcome and happy event, it also creates enormous challenges as parents adjust.Michael S. Jellinek, MD If the mother relaxes into this acknowledgment, you are on the right track. Then you might ask about how she is doing overall; sleep, appetite, and energy are always affected by childbirth. Have they been able to stay in touch with friends or family? Do they still enjoy anything --- their favorite television shows? Music? Time outside? Can they experience any delight or joy with their newborn? If they are overwhelmed, do they feel hopeless? Guilty? Are they having morbid thoughts? Suicidal ones? Do they have a history of depression and does depression run in the family? Remember, asking about these serious symptoms will not cause them. On the contrary: A new mother experiencing them is likely to feel very isolated and grateful that you are trying to understand and address her suffering. Your questions can open the door to connection and compassion, to the possibility of feeling better. Tell your patient so directly — that postpartum depression is very common. It is not the same as the baby blues all her friends in the new mothers group seem to have recovered from so quickly. It needs treatment and is very treatable. The best way for her to take good care of her newborn is to take good care of herself. Of course, it will feel difficult (depression makes every effort feel difficult). Find out who else can join the conversation: her spouse, an adult sibling, or her own parent. When you have a positive screen, but no time for this discussion, jump to this step. Activate her immediate support network, and inform them of your concerns and the need for her to have more support to help her care for the newborn and herself. You are in a unique position to help her build the team to treat her depression and protect both her and her newborn.Somatic Symptoms in a ChildHow many times have you had a sick child in your office and concluded that the underlying problem was psychiatric? Psychiatric illness in childhood and adolescence is very common (affecting between 20% and 25% of youth by the age of 18 by recent CDC estimates), so it is a likely explanation for any new symptoms. Some youth — and some parents — are going to be less comfortable with a psychiatric diagnosis than with a medical one. At the extreme, these children will continue to present with a complex array of vague somatic concerns (headache, stomachache, dizziness, etc.) and high levels of distress. This can lead to extensive, expensive workups, which are not always benign. It also leads to frustration for caregivers and developmental stasis for the child. In the worst case, children will feel utterly powerless and hopeless about rejoining the world of their peers.Whether you are seeing a child with new symptoms that are more suggestive of an anxiety disorder than a gastrointestinal illness or dealing with a frustrated family who is searching for an elusive medical explanation for years of vague symptoms, how you approach this patient and their parents can make all the difference. Start with a posture of genuine curiosity. Let the child tell you the story of their symptoms, and then let the parent add to that story. Don’t make assumptions or jump to conclusions. Ask only questions that help them provide more detail. These details can include external stressors, sleep, activity level, energy, concentration, and normal developmental milestones. Be sure you have enough time for this visit to listen to their concerns. You may develop a new theory about a medical cause of their symptoms (even rare disorders do happen). But the key is to invite a description of all symptoms: physical, cognitive, and emotional.The critical next step is to acknowledge how stressful (for both child and parents) it can be to be sick, especially when no one can figure out why. If they are receptive to your compassionate stance, proceed. If not, back up and ask them to tell you more about their experience so you can better understand it.Acknowledge that medicine is imperfect, and that our workups are frequently inconclusive. Offer the idea that there may be a medical cause for their child’s symptoms that we don’t yet understand or know how to look for. Offer that the good news is that you have ruled out the dangerous causes for their symptoms, and the bad news is that uncertainty is burdensome. Focus on the strain of chronic symptoms, frequent medical visits, and inconclusive tests. State clearly that all of that stress can cause further problems: disrupted sleep, poor energy, panic attacks, even full-blown depression. The key is to frame the idea that two things can be true: There can be both an underlying medical cause for symptoms and a psychiatric diagnosis, including one caused by the stress of the physical symptoms. The key is that the child (and more commonly, the parents) do not feel that they have to give up the medical diagnosis for the psychiatric one. Then it can be straightforward to explain that the psychiatric symptoms have very clear recommended treatment, which you expect to be effective. Treating those symptoms will make it easier (or just possible) to manage their physical symptoms and to resume their lives in the meantime. Without this frame, patients and parents might feel that a psychiatric explanation just means that they are “crazy” or imagining their symptoms. This is one arena where stigma remains powerful around mental illness. When you can help your patients fully describe their symptoms and accept that even part of treatment could be psychiatric, you create a path forward for that family. Usually, the best approach is to continue some appropriate treatment of the physical symptoms such as physical therapy in parallel to the psychiatric referral. Remember, two things can both be true!