Dr. Sheila Marcus, Pediatrics Director and Consulting Psychiatrist for MC3, was featured on the Pediatric Meltdown podcast titled “Need a Child Psychiatrist’s Help? Phone a Friend!”
Original article written by Estelle Slootmaker and published by Second Wave Michigan on Jan., 13, 2022.
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This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.
Across the country, more kids than ever are struggling with mental illness. 20% live with a diagnosable mental illness and 10% are experiencing a significant impairment. Over the past 10 years, twice as many teens and young adults have had major depressive episodes, and suicide is now the second leading cause of death for Americans aged 15-19. To make matters worse, more than 33% of Michigan’s littles, adolescents, and young adults with mental health issues do not have access to care.
In 2012, Dr. Sheila Marcus and her colleagues at Michigan Medicine launched a program to address this mental health epidemic: Michigan Child Collaborative Care (MC3). MC3 helps primary care providers (PCPs) address their young patients’ mental health by offering same-day phone consultations, scheduling telepsychiatry sessions with patients, connecting families to local mental health resources, and providing educational opportunities for PCPs to expand their expertise in diagnosis and treatment. In addition, MC3 has expanded its reach to women experiencing mental illness during pregnancy and postpartum.
Marcus, a clinical professor at the University of Michigan (U-M) and section chief for child and adolescent psychiatry at Michigan Medicine, says MC3 aims to improve access to mental health care, as well as PCPs’ “competence and confidence.”
In addition to drawing upon Michigan Medicine’s psychiatry department, MC3 collaborates with the Michigan State University College of Human Medicine, which provides group case consultations and educational programming, and the Michigan Department of Health and Human Services (MDHHS). Since launching in 2012, MC3 has enrolled approximately 3,500 PCPs and provided about 18,000 consultations.
“I became aware of the increasingly dire straits of mental health care for children, young adults and women in the state of Michigan,” Marcus says. ” … MC3 was designed to leverage getting mental health expertise from big academic centers into the communities. The goal is to provide diagnostic clarification to clinicians who are really puzzled by what they’re seeing in front of them and are not sure what to call it — and to improve evidence-based treatments, including advice about psycho-pharmaceutical medicines as well as psychotherapies.”
For example, Marcus notes that pediatricians may misdiagnose children who have experienced trauma as having bipolar illness or ADHD. When those pediatricians consult with an MC3 psychiatrist, they are equipped to make better diagnoses.
“We’re providing access to people who otherwise would not have access,” Marcus says. “We’re seeing high rates of trauma among the population that we serve, high rates of suicidality — patients who have been hospitalized and are coming out, or patients who have some degree of suicidality. When they went to the emergency room, they were not severe enough to be admitted. So they come back to the PCP office.”
“I was bowled over.”
One of those PCPs, Dr. Lia Gaggino, practiced as a pediatrician with Bronson Rambling Road Pediatrics – Oshtemo for 33 years. She joined the MC3 program when Marcus, whom she did not know at the time, recruited her via Facebook in 2012.
“At the time I trained, we basically learned how to manage ADHD, which I think pediatricians are really good at. I was always interested in mental health, so I took psychopharmacology courses, went to lots of conferences, did lots of reading, and worked with some other pediatricians that were really gifted,” Gaggino says. “When Dr. Marcus described that MC3 could be a support, that I could talk to a child psychiatrist on the same day [of a patient’s visit], I was bowled over. Even if she had said, ‘We can get back with you in two weeks,’ I would have been ecstatic because prior to MC3, I had to manage everything without a psychiatrist.”
Gaggino’s retirement from active practice launched her into her role with MC3, where she now consults with, educates, and recruits Michigan pediatricians, family practice doctors, and obstetricians into the program.
“Now more than ever, mental health is a significant concern for kids. Both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry have declared a mental health crisis,” Gaggino says. “Behavioral health concerns account for well over a third of patient visits. … For most pediatricians it is a daily occurrence.”
Gaggino says those patient visits reveal that too many kids live with anxiety, depression, and suicidal ideation. Parents may bring kids in because they have chronic stomach aches, chronic headaches, or sleep disturbances. When physical causes are ruled out, their doctor can quickly consult with an MC3 psychiatrist and receive guidance the same day.
“We are finding that much of the time, PCPs are just unsure about what to call things,” Marcus says. “Children who have trauma backgrounds are often being misdiagnosed with bipolar illness or ADHD. We’re trying to rectify some of that.”
A phone conversation with a child psychiatrist helps clarify the diagnosis and sets the child on the way with the correct medication and treatment plan. That plan might include a telepsychiatry visit with one of MC3’s behavioral health consultants, referral to a local mental health resource, or simply continued follow-up with the PCP. MC3 also consults with over 75 school-based health centers and provides educational programming to PCPs as well as schools.
“The MC3 behavioral health consultants are all regionally dispersed and are very knowledgeable about which resources exist in the home community,” Marcus says.
Mental health help for the youngest among us
With funding from the MDHHS Healthy Moms, Healthy Babies initiative, MC3 has expanded its reach to Michigan’s perinatal providers, who serve new moms in the weeks immediately before and after birth. Dr. Maria Muzik, who leads the U-M psychiatry department’s Zero to Thrive women and infant mental health programs, shared her insights in a September 2019 State of Health series story on new moms and mood disorders.
“These are natural points where moms are being seen by the medical professionals,” Muzik said. “We know this is a time when women are vulnerable for mental health issues and that preexisting conditions are exacerbated by the hormonal changes, sleep deprivation, and birth trauma.”
Through MC3, pregnant women identified as at risk for mental health issues receive brief interventions and same-day access to virtual counseling and care coordination through remote behavioral health consultants. In some cases, MC3 sets up telepsychiatry consultations with psychiatrists who focus on the perinatal period. When mothers have access to mental health services, infants and children are better poised to experience better mental health in the future as well.
Through COVID and beyond
COVID-19 has hit Michiganders’ mental health especially hard, especially in families who have lost jobs or found themselves food-insecure. And, for both rural and urban residents, the long-term mental health outlook is not bright. Delivering virtual care for years before the pandemic struck, MC3 has been a shining example of how mental health care can be expanded to meet this increasing need.
“There is no question that there is ‘a surge after the surge’ during COVID,” Marcus says. “There are increased rates of suicidality, especially among teens. There are increased rates of trauma. If you think about families who are quarantined together with their aggressor, that’s a huge issue. There are issues with children with special needs, like autism and developmental disorders, who have had their primary treatments interrupted.”
Because of MC3, Michigan communities lacking mental health services or a practicing psychiatrist have an alternative. Organizers hope that as this model of care becomes more broadly recognized, health care systems and payers will step up with funding to expand it – and reduce reliance on grant dollars.
Gaggino says MC3 made her a better clinician and “totally changed” her prescribing habits.
“You do the best you can, but you can do better when you have help,” she says. “MC3 is really brilliant in being able to amplify that support.”
Dr. Sheila Marcus photo by Doug Coombe.
Dr. Lia Gaggino, Consulting Pediatrician for MC3, published an op-ed article in The Detroit News titled “Tackle mental health and gun violence together.” The article is behind a paywall, but here are some quotes from it:
[…]
“Pediatricians can and should be counseling families about safe storage. Parents are the first line of defense to keep children safe. Statistically, we know a home without a firearm is the safest for kids. However, if there are firearms in the home, parents can take simple measures to ensure their children’s safety:
► Firearms should be stored and locked.
► Ammunition should be locked separately from the gun.
► Seek help if there are concerns for a mental health issue such as depression, suicidal ideation, cutting or anxiety.”
[…]
MC3 Consulting Psychiatrist Dr. Nasuh Malas was interviewed on WXYZ Detroit about how to help kids deal with grief and trauma after the Oxford High School shooting on November 30.
Speaking openly about feelings of pain, uncertainty and grief is an important step in helping children process their own emotions, says Dr. Malas. “It can be simply checking in and asking how things are going, how they are experiencing recent events,” he said.
Watch the interview below:
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Dr. Zakia Alavi, Consulting Psychiatrist for MC3, was featured on the Pediatric Meltdown podcast titled “School Shootings: The Aftermath and Prevention.”
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MC3 Consulting Psychiatrist Dr. Joanna Quigley offered tips on how to talk with kids about a school shooting in a Michigan Advance article, “How should you talk with kids about a school shooting?”.
“Parents obviously don’t want to burden their kids with more fear and worry based on what they are experiencing, yet I also think it’s important for parents to name their own feelings to some degree,” Quigley said.
MC3 Pediatrics Director Dr. Sheila Marcus was interviewed on the Paul W. Smith radio show, commenting on the mental health implications for the November 30 Oxford High School shooting. She also explained what MC3 and how primary care providers in Michigan can sign up. Listen to the interview below:
This article, written by Kara Gavin, originally appeared on the M Health Lab website.
Raising or educating kids in a pandemic with cases surging and the winter holidays approaching was already hard enough for Michigan parents and school staff.
And then the school shooting in Oxford, Michigan happened on Nov. 30, 2021 – the first one in the state in decades, and the first one to claim multiple young lives in the U.S. since the start of the pandemic.
Now, parents and educators find themselves having to help children and teens process the news and navigate the trauma.
That may take days or weeks, but resources from local and national organizations can help, says Joanna Quigley, M.D., a child psychiatrist at Michigan Medicine, the University of Michigan’s academic medical center.
“The biggest things that adults and our communities can do right now are to provide consistency and structure, to keep open lines of communication, and to find time each day to check in with one another,” she said. “Make it clear you’re available to answer questions about what happened, but make sure the child isn’t overexposed to the media coverage of the event, or to social media posts about it.”
Stepping away from news and posts on screens large and small is important for avoiding an effect called retraumatizing, which brings up the negative emotions that the initial shock of the event prompted.
She highly recommends giving older children and teens a resource from the National Child Trauma Network called “When Terrible Things Happen”, which can help young people recognize the effects of major traumatic events and work to reduce them or avoid making them worse.
For parents, she recommends the disaster, violence and trauma resources from the American Academy of Child and Adolescent Psychiatry, the Resources for Families site from the federal agency known as SAMHSA, as well as the resources developed for coping during COVID-19 by the U-M Department of Psychiatry.
Routines, communication
The stress of a sudden major trauma on top of the underlying stress of living through a pandemic – especially at this time in Michigan – makes it especially important for families to spend time together, focus on healthy eating, sleeping and activity habits, and keep regular schedules.
School is an important part of that, giving kids a safe and familiar environment and keeping their minds and bodies active. With teachers, school counselors and school nurses already stretched thin by the stress of educating during a pandemic, this may be especially hard, but she recommends the tips contained in this resource from the NCTN.
Even though it may be tempting, kids, teens and adults shouldn’t try to avoid thinking about or talking about what has happened or how they’re feeling.
In fact, says Quigley, “Grownups should name the emotions they’re feeling about this situation, especially with teens. Sometimes older children and teens aren’t ready to name the emotions they’re feeling or discuss them proactively, but if they hear that others are feeling them, they may.”
This may take some time, she added. “Even if say they don’t have questions or don’t want to talk right now, let them know you have an ‘open door policy’ if they do want to talk, which could be a week or two from now, or may be prompted by more information coming out about the incident. It’s important for them to know that the adults in their lives are available to them on an ongoing basis.”
If you suspect or see a problem
For both children and adults, it’s important to recognize when stress, feelings and emotions have started to interfere with normal relationships, ability to enjoy favorite activities, and regular daily tasks.
Today’s children and teens are more equipped than previous generations to talk openly about their mental health. But some may still bottle it up for fear of being labeled or stigmatized.
Teen and young adult years are peak times for the start of many mental health conditions, from depression to schizophrenia, Quigley notes.
Adults and peers who notice someone’s behavior or personality has changed should speak up and try to guide them to help.
Anyone in Michigan, including students, who is concerned about a school safety issue should contact the OK2SAY Tip Line at 1-855-565-2729, text to 652729, or email to [email protected].
Parents with concerns about their own children should start by expressing their concern to their child’s pediatrician, family physician or nurse practitioner, Quigley emphasized.
She and colleagues help these primary care providers care for the mental health needs of their young patients through the MC3 program.
For families that own guns, it’s always important to follow safe practices to keep lethal means from being readily available to anyone during stressful times. The U-M Injury Prevention Center’s resource for families is a good one to refer to, Quigley says. She emphasizes that gun violence is a public health issue, not strictly a mental health issue.
If someone has urgent concerns that someone might hurt themselves, the National Suicide Prevention Lifeline is available at 1-800-273-8255 or through web chat on its site. Each county in Michigan also has a crisis line; they’re listed here.
MC3 Consulting Psychiatrist Dr. Joanna Quigley was quoted in a Medscape article about the recent declaration of a pediatric mental health emergency by the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association:
“It’s very powerful that these three groups came together and made a joint effort and statement to really highlight how serious this problem is across the country.”
The following article was written by Dr. Richard Dopp, a Consulting Psychiatrist for MC3. It was published by the bphope magazine.
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Balancing the benefits and risks of taking psychotropic medications during pregnancy is a hard but necessary task. You should always discuss treatment decisions thoroughly with your psychiatrist or other prescribing practitioner, as well as your obstetrician, to make the best personal choice.
Should I continue my bipolar meds if I’m pregnant?
First and foremost, any changes to your medication regimen must be worked through with your practitioners for the safest outcome. Raising the topic early on—preferably when still considering getting pregnant—is the best plan. And it helps to be proactive: Read up on your medications and bring any concerns to your care providers.
Recent research suggests that risks associated with continuing your pharmacotherapy during pregnancy have been overstated. Several studies over the past five years have found no significant differences in newborn health between mothers with bipolar who remain on meds and mothers without a psychiatric disorder.
Lithium, a mood stabilizer that is among the “first line” of medications prescribed to treat bipolar disorder, has a reputation for affecting fetal development. Findings from large-scale studies in the U.S. and Europe now indicate that negative outcomes are lower than previously thought.
However, treatment guidelines suggest lowering doses of lithium during the first trimester, when risk of miscarriage is generally higher and much of fetal heart development occurs.
With second-generation antipsychotic medications, also commonly used to treat bipolar disorder, recommendations call for lowering dosage in the third trimester. Nursing mothers should also consult with their prescribing practitioner about the likelihood of medication passing into breast milk.
What are the risks of not taking my meds?
Going off your prescribed medications increases the likelihood of having a depressive or manic episode. Depression and mania impose their own consequences for self-care during and after pregnancy, as well as for providing the attentive, 24/7 care required by a newborn.
An extensive review of previous studies, published in 2019, reported that 70 percent of women who discontinued treatment with lithium during their pregnancy experienced recurrence of mood episodes. Among women who continued on lithium while pregnant, that figure dropped to 23 percent.
Higher risk of depression, mania and psychosis continues after the baby is born, often complicated by hormonal changes and sleep deprivation. Postpartum mood episodes may affect the process of mother-child bonding, which is important to long-term child development.
Dutch researchers found that nearly 60 percent of new mothers admitted to the hospital for postpartum depression reported impaired bonding. Over the course of treatment, however, decreases in both depressive and manic symptoms correlated with improved bonding.
What else should I consider?
Create a treatment team.
You should strongly encourage your obstetrician, prescribing practitioner, and psychotherapist to connect. A team approach, known as “collaborative care,” is the best way to get all your questions answered and your concerns addressed while keeping everyone on the same page regarding medications, supports, and reasonable monitoring.
Seek counsel(ing).
If you are not already in psychotherapy, give some thought to recruiting that extra support while you’re pregnant or considering pregnancy. Talk therapy gives you a dedicated opportunity to parse all the practical or emotional issues that come up along the way.
Respect your changing body.
The usual interventions and self-care strategies for bipolar management apply during pregnancy. However, you may want to adapt your activities over the months as your ligaments soften, lung volume decreases, and center of gravity shifts.
If you do yoga, for example, be aware that some poses should be modified during pregnancy. It’s a good idea to find a yoga instructor with training in prenatal yoga, or at least research this topic online.
Whether you are continuing or starting an exercise regimen—a vital contribution to both physical and emotional health—it’s wise to check in with your care providers over the months to assess personal safety levels for aerobic exercise and weight training.
If you don’t get the go-ahead for vigorous types of physical activity, walking can be an excellent substitute. If you have access to a pool, water walking or swimming at a gentle pace provides a lower-gravity alternative as your belly grows.
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