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Mental health risk higher for transgender youth

A new study suggests that transgender and gender non-conforming children and adolescents may be more likely to develop depression and other mental health conditions, compared with individuals whose gender identity matches their assigned gender at birth.

a sad woman sitting by a window

The research was conducted at the Kaiser Permanente Southern California Department of Research & Evaluation in Pasadena. Study co-author Tracy A. Becerra-Culqui, Ph.D., and colleagues recently reported their findings in the journal Pediatrics.

According to Becerra-Culqui, previous studies that investigated the mental health of transgender and gender non-conforming individuals only looked at a small number of people, and any symptoms of mental health disorders were self-reported.

For this latest study, however, the team gathered data from the electronic medical records of 1,347 children and teenagers — aged 3–17 years — who were transgender or gender non-conforming.

Of these individuals, 44 percent were transfeminine (their assigned gender at birth was male), and 56 percent were transmasculine (their assigned gender at birth was female).

Between 2006 and 2014, the researchers looked at the prevalence of mental health conditions, such as depression, anxiety, and attention deficit disorder, among these youths.

The study revealed that the risk of developing a mental health condition was three to 13 times higher for transgender and gender non-conforming youth than youth whose gender identity corresponded with their assigned gender at birth, also referred to as cisgender.

Diagnoses of depression and attention deficit disorder were the most common mental health conditions among children and teenagers who were transgender and gender non-conforming, the researchers report.

In fact, the risk of attention deficit disorder was three to seven times greater among these individuals, compared with those who were cisgender; and, the risk of depression was four to seven times greater.

Around 15 percent of transfeminine and 16 percent of transmasculine youth were diagnosed with attention deficit disorder, while depression was diagnosed among 49 percent of transfeminine and 62 percent of transmasculine youth.

Becerra-Culqui and colleagues are unable to pinpoint the precise reasons behind their findings, but they believe that gender dysphoria may play a role.

Gender dysphoria is a condition wherein an individual experiences distress because of a disconnect between their biological sex and the gender with which they identify.

Additionally, the team notes that many transgender and gender non-conforming individuals are subject to prejudice and discrimination, which can cause stress and potentially lead to mental health problems.

Becerra-Culqui says that she hopes that this research “creates awareness about the pressure young people questioning their gender identity may feel, and how this may affect their mental well-being.”

She adds that clinicians should be aware of the heightened risk of mental health conditions that transgender and gender non-conforming youth may have.

“It is also crucial they have the knowledge necessary to provide social and educational support for their young patients who are figuring out their gender identity,” Becerra-Culqui adds.

Study finds high rates of stress events, suicidality among college students

September 6, 2018, Brigham and Women’s Hospital

Credit: Kaitlyn Beukema

For college-bound students and their families, the start of the school year can be a time of excitement and optimism, but a new study brings to light that the college years are also a time of increased risk of stressful events and a wide range of accompanying mental health challenges, including risk of suicide. Published online today in Depression & Anxiety, a study of more than 67,000 college students from across more than 100 institutions has found that while racial/ethnic, sexual or gender minorities are especially vulnerable, high rates for stress events, mental health diagnoses and the risk of suicide or suicidal thoughts were reported among all students surveyed.

“Colleges and family members who are sending students off to need to remember that this is a phase of life where young people are confronted with expectations from new relationships and living situations and other encounters that are stressful,” said lead author Cindy Liu, Ph.D., of the Departments of Pediatric Newborn Medicine and Psychiatry at BWH. “Some stressful events cannot be prevented and, in some cases, are completely normal. But for others, a plan should be in place for family, friends, and colleges to provide support. Our study highlights an urgent need to help students reduce their experience of overwhelming levels of stress during college.”

Liu and her colleagues analyzed results from a survey conducted in the spring of 2015 by the American College Health Association-National College Health Assessment (ACHA-NCHA). The survey asked students a variety of questions related to depression and anxiety, including whether they had been diagnosed or treated for a mental issue; if they had engaged in self harm, considered or attempted suicide; and how many they had experienced in the last year.

Stressful life events, defined as exposures that the felt were traumatic or difficult to handle, included academics, career-related issues, death of a family member or friend, family problems, intimate relationships, other social relationships, finances, health problem of family member or partner, personal appearance, personal health issue and sleep difficulties.

The team reports the following:

  • Rates of stressful life events were high and associated with . Three out of four students reported having experienced at least one stressful life event in the last year. More than 20 percent of students reported experiencing six or more in the last year. Stress exposure was strongly associated with mental health diagnoses, self-harm, and suicidality.
  • Mental health diagnoses and suicidality were common. One in four students reported being diagnosed with or treated for a mental health disorder in the prior year. One-fifth of all students surveyed had thought about suicide, with 9 percent reporting having attempted suicide and nearly 20 percent reporting self-injury.
  • Sexual minorities showed elevated rates of and suicidality/self-injury. Transgender students showed particularly elevated rates of all outcomes, with approximately two-thirds reporting self-injury and more than one-third attempting suicide. Over half of bisexual students reported suicidal ideation and self-harm, with over a quarter reporting attempted suicide.
  • Rates of concerning mental health symptoms are higher now than they were the last time the survey was given. Among gay/lesbian and bisexual students, rates were higher than the 2009 administration of the survey for suicidal ideation (57.8 vs. 47.7 percent), suicide attempts (27.6 vs. 25.3 percent) and self-injury (51.4 vs. 44.8 percent).
  • Mental health issues may be underreported for racial/ethnic minorities. Despite a higher likelihood of and suicide attempts, Asian students reported a lower rate of diagnosis compared to white students. Black students showed a lower likelihood of reporting all outcomes compared to white students.

The authors note that all these rates are based on self-report, and that there may be a response bias among those who received the online surveys. While the 108 colleges in the survey were diverse in setting and included minority-serving institutions, each elected to participate, and their results may not be generalizable to all schools across the U.S. Additional research is needed to determine if there is increased vulnerability among students who belong to an intersection of identities (for instance, students who identify as both a sexual and racial/ethnic minority).

Explore further: LGBQQ college students face barriers to campus mental health services, study finds

More information: Cindy H. Liu et al, The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: Implications for addressing disparities in service use, Depression and Anxiety (2018). DOI: 10.1002/da.22830

Improve Mental Health Access: Collaboration, Integration, and Telepsychiatry

Sep 1, 2018 Volume: 35 Issue: 9

information of the Mercy Kids/Mercy Virtual - Behavioral health program

Mercy Kids/Mercy Virtual – Behavioral health program

Image of Massachusetts Child Psychiatry Access Program

Figure

Perhaps pediatricians should consider telepsychiatry

Perhaps pediatricians should consider telepsychiatry

Every day, pediatricians encounter children and adolescents in need of mental health services. We usually refer these patients to mental health professionals who can provide diagnosis, counseling, or medication management. In many circumstances, unfortunately, mental health providers have limited availability. This article will detail ways we can provide services within the walls of our practices. As you will see, pediatricians are quite capable of caring for both the physical and mental health of patients.

The problem

According to Best Principles for Integration of Child Psychiatry into the Pediatric Health Home, published by the American Academy of Child and Adolescent Psychiatry (AACAP) in 2012:1

·      20% of all children in the United States have a mental health problem, but only 20% of them receive treatment.

·      13% of children aged 8 to 15 years have a mental illness that impairs daily living. In the group aged 13 to 18 years, the percentage rises to 21%.

·      50% of lifelong mental illness begins by age 14 years; 75% by age 24 years.

·      The average delay between symptom onset and intervention is between 8 and 10 years.

Even more impressive are the statistics reflecting the lack of mental health services for our patients. According to the AACAP website, the current need for child and adolescent psychiatrists (CAPs) is 30,000, but only 8300 are practicing, and this pool is shrinking. Because of the severe shortage of child psychiatrists, 75% of all mental health services are provided by pediatricians.1

Practice-based mental health access

Pediatricians have identified several barriers to providing mental health services on their own. These include lack of mental health training, time restrictions, and reimbursement concerns, as well as lack of mental health resources in many communities. Nine years ago, the American Academy of Pediatrics (AAP) Committee on Psychosocial Aspects of Family Health and the Task Force on Mental Health recommended that pediatricians integrate mental health screening into routine practice and provide office-based mental health services whenever possible. The policy stated that pediatricians should partner with mental health specialists to petition insurers to improve payment for mental health services, and collaborate with community mental health specialists to improve provider knowledge and skills, with the goal of providing mental health services within the “medical home.”2

There are 2 ways pediatricians can provide on-site mental health care. One involves embedding services directly into a practice, while the other involves seeking collaboration with existing community mental health professionals for training and support.

Integrative mental health care

To facilitate provision of mental health services for patients, you might consider embedding one or more mental health professionals in your practice. You may choose to employ a prescribing mental health nurse practitioner and/or a psychologist/psychotherapist. Alternatively, you can provide office space to these professionals who may prefer to remain independent. This would be a very attractive option, especially for those who are building their practices, as it provides immediate access to a large referral base. Having mental health professionals in your office under a rental agreement enables provision of services on a sliding scale for uninsured or underinsured patients. This may be difficult for pediatricians to do on their own due to restrictions imposed by insurance contracts.

Another integrative approach is to incorporate telepsychiatry into your practice. Via telepsychiatry, parents and patients can participate in a virtual face-to-face visit with a mental health professional in a room equipped with a televideo setup. There are several nationwide telepsychiatry services available, and these can be implemented at little or no cost to your practice. In many ways, telepsychiatry may be the easiest and most expeditious method for practices to expand their behavioral health capabilities (see “Perhaps pediatricians should consider telepsychiatry”).

Collaborative mental health care

Another way to improve practice-based mental health services is to form an alliance with a child and adolescent psychiatrist (CAP) in your community. One can invite motivated CAPs to join your practice for “lunch-and-learn” sessions. Over time, these will improve your ability to render mental health services independently.

There are many states that have implemented programs that facilitate mental health access. In 2003, the University of Massachusetts Medical School in Worcester initiated a pilot program to provide support services to pediatricians who wanted to provide behavioral health services within their practices. A year later, with funding from the state, the program, then called the Massachusetts Child Psychiatry Access Program (MCPAP), expanded statewide. The MCPAP improves an enrolled pediatrician’s ability to assess patients and to treat patients with anxiety, mood disorders including depression, and substance abuse problems (Figure). The program also facilitates referrals and care coordination for patients who need community-based specialty services.

The MCPAP uses 6 hubs to effectively cover 95% of the children in Massachusetts. The Massachusetts Department of Mental Health receives a $3.1 million annual appropriation from the commonwealth to fund the project. The MCPAP website (www.mcpap.org) has numerous resources for pediatricians including webinars on diagnosis and management. As a result of the program, the screening rate of children for behavior health problems who had Medicaid insurance increased from 17% at program onset to 80% as of 2014.3,4

The success of the MCPAP has led to the creation of similar programs throughout the country. Currently there are similar Child Psychiatry Access programs operating in 28 states. These programs are coordinated via the National Network of Child Psychiatry Access Programs (NNCPAP). The NNCPAP website (www.nncpap.org) lists state-by-state resources as well as contact information.

Time to decide

As discussed earlier in this article, pediatricians have many options regarding expanding the ability of their practices to provide direct mental health services to patients, even in communities where resources may be wanting. It’s time for pediatricians to be proactive and either integrate mental health services into the medical home or upgrade skills so we can assume responsibility for patients in need.

References:

1. American Academy of Child and Adolescent Psychiatry. Best Principles for Integration of Child Psychiatry into the Pediatric Health Home. Washington, DC: American Academy of Child and Adolescent Psychiatry; 2012. Available at: https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/best_principles_for_integration_of_child_psychiatry_into_the_pediatric_health_home_2012.pdf. Accessed July 3, 2018.

2. Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Policy statement—The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics. 2009;124(1):410-421.

3. Sarvet BD, Ravech M, Straus JH. Massachusetts Child Psychiatry Access Project 2.0: a case study in Child Psychiatry Access Program redesign. Child Adolesc Psychiatr Clin N Am. 2017;26(4):647-663.

 

4. Straus JH, Sarvet B. Behavioral health care for children: the Massachusetts Child Psychiatry Access Project. Health Aff (Millwood). 2014;33(12):2153-2161.