We need more doctors like this. From an op-ed at the Boston Globe:
ON A RECENT episode of the HBO series “In Treatment,” a CEO of a major company describes with complete absence of emotion the death of his 16-year-old brother when he was 6. When Paul, his therapist, suggests that his panic attacks may be related, he leaves the office, saying he will ask his doctor to prescribe medication now that he has a diagnosis. Paul gently suggests that they continue the important work they have begun. I am eager to see how this plays out. I am quite certain, however, that in the real world, the CEO would find many doctors to prescribe medication, enabling him to eliminate the symptom without the hard work of grieving.
This episode reminded me of a case in my pediatric practice (with the details changed to protect privacy). A 5-year-old girl was referred by her kindergarten teacher for evaluation of attention deficit hyperactivity disorder, with a strong recommendation that medication be considered. Her behavior had been disruptive since preschool, but was now affecting her ability to learn. There was concern that she might not be able to move on to first grade. Before I even saw the patient, armed with standardized forms and psychological testing, I was quite sure that she would meet diagnostic criteria for ADHD and that medication would be a reasonable consideration.
I met with her parents, who described classic symptoms of ADHD, including prolonged battles at home around such simple tasks as getting dressed for school. About halfway through the visit, I began to ask, as I always do, about past history. “How was your pregnancy with her?” There was a pause, during which the parents exchanged looks. “Actually, I’m not her biological mother.”
Now it was my turn to pause, as I was quite shocked to receive this important piece of information so late in the evaluation process. With some reluctance, they went on to tell me that the girl’s mother was seriously mentally ill, had been intermittently involved in her life, and had disappeared completely two years earlier. But, they assured me, she never talked about her mother and it wasn’t an important issue.
This story has a happy ending. I agreed that medication could be helpful, but, building on the trust they had developed with me as their pediatrician, I suggested that the loss of her mother was actually very important and needed to be addressed. They accepted my referral to a therapist. I am fortunate to have an excellent colleague across the street who accepts their insurance. He wisely explained to them that children do grieve, and now the whole family is engaged in working with him around this painful and difficult task. This child is now thriving in first grade.
For this one positive outcome, there are hundreds that do not end this way. Children who have experienced terrible loss do not have the opportunity this girl had. They are aggressive and disruptive, and their symptoms are medicated away. They continue to struggle, often failing in school. Some of the reasons this path is chosen are lack of time, limited access to mental health services, and resistance to doing this hard work.
I recently received a letter from the state with the alarming statistic that 37 percent (nearly $190 million) of the MassHealth pharmacy budget is spent on behavioral health medication. The letter asks for input regarding possible ways to improve patient care while reducing costs.
I proposed that we as a society recognize that grief and loss cannot be medicated away. As one friend who recently lost her husband so eloquently put it, “Grief is a powerful release that validates your loss, relieves stress, and helps you heal.” Certainly medication may be an adjunct, particularly when people are so incapacitated by their symptoms that they are unable to function. But if we as a culture validate the experience of grief, if we offer the time and space and resources to support people through the difficult process, I am quite certain that in the long run we will not only spend less on medication, but will help people to heal and return to being productive members of society. It is with children that this investment will have the greatest return.
Dr. Claudia Meininger Gold, a pediatrician, practices in Great Barrington.