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Depression: Insights and Strategies · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm thrilled today because here in the podcast studio is Dr.
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Jessica Sandoval, and you're on the front lines. You've been doing a lot with
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CPAN, which I know is a game changer for a lot of pediatricians,
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a program where they can get through and talk to psychiatrists.
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Thank you so much for being here today, first of all, on Pediatrics Now. You're very welcome.
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Thanks for having me. And we're talking about a tough topic,
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depression, and the epidemic that's happening.
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And our listeners are also on the front lines where they see this happening.
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And I know that a lot of times it's so overwhelming.
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And we're going to talk about a tough case in particular.
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Off the bat, what is your number one piece of advice for our listeners who are
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trying to help kids who have depression?
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I think I would say that you don't have to know it all and you don't have to know everything.
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You just need to be able to listen. And I think if you are going into your practice
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with kind of that authentic self and willingness to hear, you know, the kids out,
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that you'll figure out what you need to know to help them.
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How do you know, you know, in those precious few moments in the exam room,
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if a child, if it could be something more serious or if it's regular teenage anxiety?
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I think, honestly, you have to ask them, right?
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You have to ask them a little bit about their experience.
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The big thing that we want to know when we're talking about,
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is this just normal, developmentally appropriate? What would we expect versus
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a disorder is, is it something that's pervasive?
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And is it something that's interfering with function?
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And that can be either the level of distress. They feel so sad all the time,
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you know, that they just really can't manage it. Or it could be,
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again, a function at school.
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Their grades are slipping, things are changing, they're not going out with their
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friends, right? Things like that.
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And there's a screening test that pediatricians, of course, are already using.
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Can you tell me more about that and how important it is to use?
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Yeah. So let me take a step back. So when we talk about depression,
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the other thing that's really important to think about when we think about is
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this just, again, sadness or typical depression, people will use that term.
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But when we talk about it clinically, we're talking about a disorder.
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And again, a disorder is marked by a certain number of symptoms and functional impairment.
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So if we're talking about a depressive episode, for example,
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which is required or which is the criteria that's required to say somebody has
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major depressive disorder, we're talking about a youth who, you know,
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primarily either feels sad or is irritable or has anhedonia,
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you know, really not interested in things and then has a number of other symptoms, you know, with it.
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Maybe they're sleeping too much or sleeping too little, they're eating too much or eating too little.
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They're feeling guilty and helpless and worthless.
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They might be, you know, really slow and not moving as much as before, low energy.
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They may be having thoughts of suicide, right? So if they're having those symptoms
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and at least five, and this has been going on for most of the time for two weeks,
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we'd consider that a depressive episode.
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There are other depressive disorders like pervasive depressive disorder where,
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you know, they may not quite meet those criteria, but at the same time are sad
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most of the time without any major breaks over the course of a year or two,
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depending on how old they are.
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And so those things make it different than, I feel sad now, but then I'm fine in a little bit, right?
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It's the pervasiveness of it and how impacting it is.
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Because, of course, the last thing any of us wants is for a child to be put
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on medication he or she doesn't need.
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Right, right, absolutely. We want to be able to kind of navigate through this
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is something we expect versus this is illness that needs to be treated.
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I mean, if it's not indicated, then they may just experience the side effects, right?
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And they're not going to, if we're not treating something, they're not going
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to have the benefit that would outweigh potential side effects they might have. So let's take a case.
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14-year-old child goes to the emergency room, survives a suicide attempt,
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is admitted to the hospital, and then recovers and is released and now is going
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back to her pediatrician.
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What would you do? So I first want to say that we are so grateful to our pediatricians
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on the front line who are receiving those kids and are continuing the medications
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that they need, because that is crucial.
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You know, if they receive their 30-day supply of medication and run out,
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we're back to the start, right?
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And so, again, we're super grateful to our colleagues.
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So the big starting point is, again, continuing the medications that were started in the hospital.
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And the hospital doesn't have any, you know, special magical qualities.
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And I say that with sincerity, like this is a place where they can be monitored,
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you know, 24 hours a day in the acute setting, but they're going to continue
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to have those depressive symptoms possibly.
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And so while you're in your outpatient setting, you're continuing to monitor those symptoms.
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And so, So, you know, using a screen like the PHQ-9 helps you to follow the
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improvement of those symptoms or the lack of improvement.
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And then that kind of dictates, you know, your adjustment of the medications.
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Typically, when they're first, you know, in the hospital, they're started on
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the lowest dose of the medication because we have to make sure that they tolerate it.
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But it's not uncommon for that not to be sufficient to address their symptoms.
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And so we're going to need to adjust it to a therapeutic range.
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And so I would think about, you know, that perspective is kind of following
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the symptoms so that we can continue to treat their depression in the outpatient setting.
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So that would definitely be step number one. I know that I understand,
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you know, for some pediatricians, just the idea that this child has ever had
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the suicidal thoughts, you know, may be very anxiety provoking and may,
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you know, feel very onerous.
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And so, you know, what I'd say to that is...
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A lot of kids have these thoughts. And so the fact that this particular child
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is sharing them with you is so important and is such a great step,
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right, for treatment rather than the opposite of them not disclosing and them
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not, you know, talking to us about it.
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And so, you know, as we're treating, you know, we would continue to scream for
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things like suicidal ideation and know that for some kids, those thoughts are going to be there.
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They're going to be there in varying intensity, as well as with different levels
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of how serious they are contemplating acting on them.
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And that's the other really, you know, crucial part is asking them about,
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you know, do they have a plan? Are they thinking about doing things?
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Have they done any sort of rehearsal behavior? Have they been preparing?
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Those would be some of the questions that we would ask about.
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But there are many kids, it's not uncommon with depression for kids to say,
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I just feel like I shouldn't be here.
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I just feel like if I didn't wake up tomorrow, that would be fine and that would be okay.
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So they have these kind of, we call morbid ideation or passive suicidal ideation types of thoughts.
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Those types of thoughts don't require the hospital because again,
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the hospital is for in the acute setting when we're trying to monitor and make
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sure that they're not doing something, you know,
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in that moment in the worst of their, you know, feelings and the worst of their depression.
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So we can expect that they'll continue to have some of those passive suicidal
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ideation or morbid ideation, you know, thoughts.
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One clinician I was talking to said that The patients who have psychiatry issues
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that far and away that takes the most time, time that she usually doesn't have.
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Can you kind of walk us through this? So with this patient, so you ask.
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Have you rehearsed something? What if the answer is yes? So we'd want to know,
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again, about, you know, what kinds of steps have you taken?
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You know, what have you done? Are you thinking about killing yourself?
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You would ask them very directly, you know, very frankly.
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And if they are, those are the things that would escalate that,
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you know, unfortunately, we might say, yes, they need to return,
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you know, back to the hospital. But if they're not, if they say,
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no, you know, I would never do it.
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The other thing that you could do is to try to help that workflow process is
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kind of be prepared and have some resources on hand.
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So, you know, a lot of times we'll do what we call a safety plan.
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You can kind of Google and there are, you know, documents that I'll kind of
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have that I'll outline a basic safety plan that I'll kind of talk about warning
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signs. And so what are my warning signs that I'm starting to feel unsafe, right?
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And they'll be able to tell you, I have a fight with my loved one,
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I get a bad grade on a test, right? They'll kind of cue you in.
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And then, you know, we'll talk about, well, what are the things that you can
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do when you're feeling distressed, right?
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So that they have a tangible reminder of, these are my coping skills,
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these are the things that I can do. And then three adults that they can contact
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so that they know who their social supports are so they can try to find help.
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Because the big thing is moving them out of that despair.
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Again, you know, for a lot of kids who act on suicide, you know,
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they're in these high emotion, you know, times, moments where they feel like things are helpless.
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And so having their safety plan, we kind of help them have some next step things
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that they can do to try to take a step back and alleviate some of that stress.
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We're trying to kind of mitigate some of these dynamic risk factors that they're
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experiencing or that they're having and point them towards more healthier ways of coping.
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Is it important that there be three adults the child can contact?
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I think at least if you have one, one adult. And a lot of times,
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you know, teens will say, well, I don't trust any adults. Can I tell my older
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sister, you know, who's a teenager?
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And we really want to try as best we can to think about an adult.
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Because, yes, their friend might always be there for them and their friend might always listen.
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But we need someone who's going to be able to make the tough decision of this
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is something that I can just sit and be here for you or this is something that
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I need to get a higher level of care. So at least one person.
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And again, a lot of the there are lots of tools that you might be able to find.
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And a lot of times they'll also have, you know, like the suicide hotline.
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You know, teens prefer not to talk, but to text. And they even have crisis text
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lines, you know, now. So kind of having all of those things ready if they're
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not so serious that you need to.
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Enlist emergency services. Jessica, what should a parent do if the child calls
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them or caregiver or they're on that list when that child calls?
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So, you know, the first thing would be just to kind of listen to what they have
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to say, not jumping the gun, not getting excited, not saying,
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you're not going to do this, are you?
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You're going to just hearing them out, right?
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Again, in an acute moment of stress, it may be that they've had a really rough day.
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And in that fleeting moment, yeah, maybe they felt that way,
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but maybe with a little bit more time and remembering things aren't as hopeless,
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or there are these other things to look forward to, there are these other people who care about me,
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you know, the intensity of those thoughts may subside.
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So as the parent, you know, kind of listening.
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And gentle, curious questions, right?
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So if the teen calls and says, Mom, I'm having suicidal thoughts, and I just need to talk.
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Okay tell me a little bit more about what what happened today
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and then letting them you know start there and
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so if they don't kind of get back to the point it's okay to bring them back
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to the point and ask and say you know when you called you said you were having
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some suicidal thoughts i need to understand a little bit more about what what
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does that mean today like what thoughts were you having and try to kind of you
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know get them to tell you in their words right if they just kind of say,
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you know, I don't want to be here today.
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Okay, I hear that today was a really hard day for you, and I hear that it's really, really tough.
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Is there anything that you've been thinking about doing to hurt yourself?
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So I kind of start first with hurt yourself and kind of see,
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you know, what the response is.
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Many teams use, you know, self-injurious behaviors to kind of get through some
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of that high emotion. And so, you know, we would start and we'd ask about that.
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And then if they, you know, say no, you know, we would continue and say,
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okay, so it sounds like you're not feeling like hurting yourself.
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Has there been anything you've been thinking about doing to kill yourself?
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Do I do, you know, and then giving them the opportunity to, to answer.
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And depending on what their answer is and depending on where you are,
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you may need to tell them that you need to keep them on the phone.
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You know, I'm coming right over to you.
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Let's keep talking about X, Y, Z, right? Because if they really are in the midst
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of having a suicidal crisis that does need immediate attention,
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then as a parent, we're going to hope that they're able to go and get them to a safer place.
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And if the answer is yes, a child says yes to self-injury.
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Yeah. This one is probably going to depend on if this is a patient that has
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done this before or hasn't, you know, how aware a parent is or not.
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If they're thinking about it, again, we want to know a little bit more about,
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you know, what, you know, tell me about what you're thinking.
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If they're thinking about doing something like cutting, you might ask,
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is there something else that we might be able to do to get that feeling?
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Taking a step back, you know, in the clinic, things that we will kind of talk
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about are grounding type of techniques, right?
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So holding on to something that's really, really cold, holding on to a thing of ice, right?
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Because sometimes, you know, kids just need that sensation of like,
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I'm really here and they need something that is distracting from the immediate
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thought that they're having, right?
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So we might, you know, offer some of those things, you know,
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can you hold on to a thing of ice?
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Can you, other kids, you know, we might have them wear rubber bands and they
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might snap the rubber band.
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And it kind of still gives that similar kind of pain-like response without having
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to disrupt the skin, right?
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So we'd kind of think about, you know, alternatives.
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So that might be, you know, where we would start. Is that something that you
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recommend pediatric clinicians or listeners, if a patient is talking about self-harm,
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to offer some of those solutions like that?
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Yeah, if in the clinic, you know, you're doing your screening and you're asking
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and they're saying, yeah, you know, I've been cutting.
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You could talk about, well, what does cutting do for you?
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And most often, again, the response will be something like, well,
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I need something to distract me from the pain.
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I need to feel that I'm real. I need to feel that I'm here.
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And so we'll kind of acknowledge that and say, you know, there may be other
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ways that we can kind of get that same sensation.
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Could we try and then offer, you know, some of these other things potentially
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there are going to be some kids that that's what they do and that's what they,
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you know that that's how they operate and so it may be just.
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Counseling, you know, there are better ways and kind of monitoring for hygiene,
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but kind of stay in the course while we're trying to get them in counseling
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where they can, you know, really do more of the nuanced work on what's the underlying
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and, you know, can I do something different?
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How often should the child who was admitted to the hospital and then has survived
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a suicide attempt, And how often should that child be seen by the pediatric practitioner?
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That's a great question. So when they're first coming back to you,
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it's really going to depend on how they're doing.
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But I would say that it probably is going to be seeing them every two to four weeks.
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Probably, you know, four weeks is an okay amount of time while you're making
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adjustments to their medication. We know that the most common medication that
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we use are, you know, the family of SSRIs, and those take time to work.
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And so, you know, while they were in the hospital, they kind of were in the
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period where we would be monitoring for, you know, acute side effects.
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And so you'll have an idea of, did they tolerate, did they not?
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If they tell you well as soon as I started it I
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had a lot of nausea I had a lot of headaches you know that they may
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be a little bit more sensitive and so you either may be
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seeing them sooner to kind of make sure that they tolerate or you may be doing
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smaller increments but you know generally I would say you know every two to
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four weeks in our outpatient you know clinic usually we're seeing them monthly
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you know so I think that's a reasonable expectation while we're trying to get.
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Their symptoms back and stabilized. Should the practitioner try to get this
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patient to be seen somewhere by a trained child psychiatrist, if possible?
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I think, again, the answer kind of depends on how well they're doing.
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Some kids go to the hospital once and never go back again.
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And they may be able to, again, there may be some acute stressor that happens
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that is a wake-up call that, you know, pushes them into treatment.
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And then once they're treated, they may do just fine, right?
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If you have a child who is responding to the adjustments that you're making.
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Right, then they're being treated and they're doing well, right?
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There are a couple steps that every child psychiatrist is going to take as they're,
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you know, implementing the first couple trials that are the same things that
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you can do in a pediatric clinic, right?
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So a trial of one SSRI that's optimized, and then a second trial of SSRI that's optimized.
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And so again, those are steps that are going to be the same exact steps we're going to be taking.
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We want them to be on the fewest number of medications, the lowest dose as possible.
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And so, you know, the likelihood that we would do something fancy,
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you know, from the very beginning and have them on two or three or four different
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things for the same purpose is really unlikely.
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So there would be, again, and this is where CPAN is a great,
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you know, asset because we can kind of guide and say, okay, well,
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this medication that they came out on, they'll need to go up to a dose of about,
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you know, 60 milligrams at the most.
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And if they're still not feeling well, then yes, let's switch it to this other
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medication where it really becomes more important for them to.
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Come to see us as if it's more complicated.
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So if there's psychosis, if there is really kind of worsening,
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things aren't getting better, if things aren't changing.
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But if you're seeing improvement in your practice or in the child who's in your
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practice, they may not need to see a specialist.
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And if you're seeing improvement based on, so this child we were talking about
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who was in the hospital, based on the medication that was prescribed then,
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then just keep it as it is.
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But if they're having bad side effects, not great improvement back off of the
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medication, even in that case, or is it hard to say?
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It's kind of hard to say. If they were having side effects, we may recommend
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to go down a little bit and have a slower optimization.
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That's not uncommon. So some people are just a little bit more sensitive.
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They may be a little bit slower lower metabolizers, you know,
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things that we don't necessarily have a great test for to see, you know, right away.
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And so it may just be that we need a slower entry, but there may be some kids
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who just don't tolerate it.
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So it'll kind of be a little bit of a case-by-case process.
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Jessica, what's your take on the cause or causes of this epidemic?
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Yeah, I mean, taking a step back, I would say, you know, we don't have a great
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understanding of the cause of depression.
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Like there's not like this one thing, is it right?
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There's thoughts that it's related to genetics and to hormones and to immune
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factors, endocrine factors, right? All these other things.
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I think more recently, there's just been a lot of, you know,
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obviously with the pandemic, there was a lot of isolation, right?
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And kids need socialization, right? That's how they learn.
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That's how they understand more about themselves, right?
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What they see reflected in people around them, what they like,
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what they don't like, what they want to be, you know, part of them.
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And so I think they missed a lot of time to build that connection,
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to build that connection, to learn about communication, real communication, right?
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Like face-to-face communication, not just texting acronyms, right? Like to each other.
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I think there's a lot of other, you know, structural factors, right?
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There's poverty and discrimination and kind of all of these other things that
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I think our kids are very aware of, right?
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So I think there are so many things that are kind of all contributing to how
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kids feel and understand the world and see the world.
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But again, that being said, like we talked about, there's a difference between
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kind of the angst and kind of the feelings of unrest and unwell that one might have.
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And then there's a depressive episode, right? And so the other thing that I
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would say is that while we don't have a specific etiology, we do know that there
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are several stressors that may kind of flip the switch, so to speak, right?
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We think a lot about epigenetics and kind of how things all work together.
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And so an acute medical illness, a big social stressor, a big divorce,
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a big move, a big loss, right?
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All of those things can kind of set that cascade into motion.
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You talk about that as parents or as practitioners, we're not there to make the child be happy.
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It's to be there for them and help understand the emotions and help manage the
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situation if possible. Am I saying it right? Absolutely.
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So we had, we talked about two different quotes that I think is really applicable here.
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Brene Brown is a researcher in vulnerability, and I just think she is so wonderful.
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And I love the way that she kind of organizes and explains things.
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And she says, language shows us that naming an experience doesn't give the experience more power.
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It gives us the power of understanding and meaning.
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And she wrote that in Atlas of the Heart. And so I think a lot of times we think,
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oh, we're just not going to talk about how maybe the parent is depressed either.
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We're just not going to talk about how they're depressed because it's going
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to stress them out. The kid knows something is happening, right?
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The kid knows something is not feeling right in the house, right?
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Or they're so smart and intuitive.
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Right, right. Or if the kid is depressed, well, we're just going to ignore it
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because they're fine. They're fine.
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They're fine. But the kid probably feels something is not fine,
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right, and needs to be able to kind of work through it.
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Another person who I kind of listen to their podcast and I like a lot is a woman
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named Dr. Becky Kennedy.
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And she says, kids don't need our help feeling better.
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Kids need our help making sense of things. And so, you know,
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both of those things taken together, I think it's really just so important for
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us to think about being there for our kids,
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being able to communicate and just holding space for them, right?
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So if they are sad and you feel like they shouldn't be sad, you don't get to decide that.
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They feel what they feel, right?
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If we think even about, you know, young kids, like we think about a five or
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a six or a seven-year-old who maybe, you know, they have an ice cream that you
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told them not to go down the slide with the ice cream because it's going to fall.
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And they do. And it falls. And they're disappointed about it. And they're sad.
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You saying, you don't get to be sad. I told you that was going to happen.
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Does nothing for them. They're still sad. Right? And we shouldn't even say,
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I told you so, because they know we told them.
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So that makes me feel worse. Right? Right. My mom did a good job of not doing
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that kind of thing, I must say. I'm very appreciative. Yeah.
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So, you know, being able to just say, like, oh, yeah, it feels so sad right
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now. You really wish that didn't happen.
25:30
It gives them that space to just have that feeling. You're not saying,
25:35
I'm going to get you a new ice cream.
25:36
You're not saying that was a good decision.
25:40
You're just being there with them, right? And in the same way,
25:43
if you have a child who's really, really depressed, and you as a parent,
25:46
And, you know, you've talked to your pediatrician and they say,
25:49
you know, this is clinical depression and, you know, we really need to treat this.
25:53
You know, even if you feel like, what do they have to be depressed about or
25:56
why are they, they have all these great things.
25:59
Again, you're not in their space, right? So if they're telling you that they
26:03
feel extremely sad, you can be there with them in their sadness.
26:08
Yeah, I see that you're feeling really sad.
26:11
And you can say what you really feel. I wish I could do something to help it.
26:16
And you can just speak that wish, right? You as a parent are not going to have
26:21
all of the answers, are not going to have all of the tools, but being there
26:24
with them is going to be really helpful.
26:28
They may not tell you as a teen. They're not going to say, well,
26:30
thanks, Mom. Thanks for validating my feeling. I'm so glad they said that.
26:34
But over time, if more, you know, your response is validating,
26:39
they will remember that.
26:41
And that pattern of you being there for them in validation will make it more
26:45
likely that they'll tell you about the bigger feelings and the harder feelings
26:49
and the other things that are happening, right?
26:51
Going back to us talking about that five or six or seven-year-old,
26:55
if you're telling them that their feelings are wrong, that's confusing, right?
27:00
You're sending signals to this child that I don't actually know what I'm feeling.
27:04
My mom is really smart, so she must know what I'm feeling, so maybe this isn't sadness.
27:08
And then that introduces kind of a host of other complicated things when they're
27:13
out, again, trying to make other relationships with other people.
27:17
You know, trying to build connection, kind of do other things, right?
27:21
They like may learn that they shouldn't trust their feelings,
27:25
even if they're in a situation that is not ideal or not, you know,
27:30
safe or emotionally abusive, right?
27:32
But there's that kind of, well, I thought I knew what I felt,
27:35
but I didn't, because this person who I care about is telling me this is what I should feel like.
27:41
And so again, just being able to hold that space is really important.
27:46
And you don't have to agree.
27:48
You don't have to necessarily understand completely. But the hope would be that
27:53
if you are there in that space with them, that they'll kind of help you understand.
27:57
They'll kind of talk to you a little bit more about it.
28:00
The inner workings of kind of the things that have been happening for them.
28:03
It feels like there's this pressure to be happy or for my child to be happy at all times.
28:08
And kids are rewarded for being happy.
28:12
Right. And the reality is most of us are not, quote unquote,
28:16
happy all the time. Right.
28:18
We may be content and satisfied, and those are good things to strive for, right?
28:24
Like it's unrealistic to think that we're all going to be happy,
28:27
you know, all the time. Our brains don't work that way, right?
28:31
You went to Rice University and then you did your med school and training here
28:36
at University of Texas Health Science Center or UT Health.
28:39
What inspired you to go into child psychiatry? And I know you're doing so much to help children.
28:46
It's funny because I would say the road to child psychiatry was a very windy one.
28:52
When I was growing up, I'm originally from the Valley. I have a very large family.
28:58
And on my dad's side of the family, he was one of nine.
29:01
And they did migrant work. And, you know, I remember so vividly my uncles talking
29:08
about, you know, their time,
29:10
you know, in the fields and about how their circumstances influence their dietary choices.
29:20
And I remember them talking about how all these doctors just don't get it and
29:24
they just don't know and they don't understand what we've been through.
29:27
And so my journey to medicine really was kind of born from that.
29:31
I thought I'm going to be a family medicine doctor who is going to be,
29:35
you know, culturally aware of the things that my community, you know,
29:40
has experienced and needs.
29:42
And when I came into medical school, I didn't know a lot about mental health.
29:46
I did my psychiatry classes and, you know, they were interesting,
29:50
but it was really in the wards that I just was so fascinated and so, you know, intrigued.
29:57
And child psychiatry was just so fun. And I hesitate to say fun because we definitely
30:02
do work with a lot of very difficult situations, right? We work with a lot of
30:09
trauma. We work with a lot of family conflict.
30:12
But kids can be so resilient. And I love the idea that in child psychiatry,
30:20
if I was able to treat the child, I also had a front row seat to the family unit.
30:29
And part of what we do is medication, but there is a lot of therapeutic work
30:34
that we do, and there is a lot of communication work that we do.
30:37
And so if I'm able to work with this one child and help the communication that
30:43
they have with their parent,
30:44
the likelihood is that parent's going to have these better tools and skills
30:49
to use with their other children that might have an even greater full impact for their family.
30:56
And I just really loved that idea and being able to see families kind of over
31:02
the course of time grow and kind of learn and understand.
31:07
And again, even if the communication is not perfect, they may come to a point
31:11
where they're able to have a conversation that they weren't able in the beginning.
31:16
And that's so gratifying. And it was funny because as I was going through,
31:20
you know, I thought about, is this really what I want to do?
31:25
Like, I had this whole vision of I need to be informed in there for my community.
31:31
And then I realized that there were all these other mental health things that
31:34
were happening growing up that I had no idea because it was so stigmatized and
31:38
we weren't talking about it.
31:39
I had an uncle who has schizoaffective disorder and my grandmother completed
31:44
suicide and all these things that we hadn't talked about. Thank you.
31:48
And I realized, no, this is where I need to be. This is where I need to be culturally
31:52
informed and kind of in a position to kind of help families navigate this and understand.
31:59
And so here I am. Hmm. And does the memory of your grandmother,
32:05
does that help inspire you to do this difficult work every day?
32:11
Or can you tell me more about that?
32:13
Yeah. I mean, even outside of how she died, she was a huge inspiration.
32:18
She was just this beautiful woman who cared about everyone, who was just a really,
32:24
you know, giving soul. And so in that way, I hope that that is how I operate
32:31
my practice, right? Being there for others, being of service.
32:34
And certainly, you know, our experience with everything that happened with her
32:38
was very eye-opening for me in terms of, you know, kind of the system and things
32:44
that I wish would have happened, could have happened.
32:46
And so, so yeah, from that perspective, you know, I think that's,
32:50
that's part of where I think the family system and kind of collaboration is
32:55
really important in my practice and in my work.
32:58
For our listeners in South Texas and here in San Antonio in general,
33:03
so you see patients at Clarity, but you're focusing, is it all of your time
33:07
or most of your time right now on this special research project?
33:11
So right now I kind of am a little bit of a hybrid. So my office is technically
33:15
at Clarity, but I'm not physically seeing any patients there.
33:18
So I'm supervising fellows over at the Center for Healthcare Services.
33:22
I supervise fellows down at, there's a nonprofit called Roy Moss Youth Alternative.
33:27
And we have several partnerships with them, and we have a community clinic over
33:32
on West Avenue. So I supervise there as well.
33:35
Is that somewhere where pediatric practitioners can send patients?
33:40
Yeah, at RMYA, one of the big stipulations is that it is a relatively smaller
33:46
clinic, and they do have to be enrolled with the counselors there to be able
33:52
to have access to our clinic.
33:53
It's kind of an embedded partnership.
33:56
So if they already have a counselor, they wouldn't be eligible to see us there.
34:01
But if they're in need of a counselor and they enroll there,
34:05
then yes, potentially they would have access to us.
34:07
Do you know where they're accepting new counseling patients?
34:11
I think they are. It's the Roy Moss Youth Alternative. For kids with depression, anxiety?
34:17
Yeah. So generally, you know, we see kids with depression, anxiety.
34:20
We see kids with ADHD there. At that particular clinic, some of the higher-intensity
34:25
kids may not be as good of fits as our clinic is.
34:32
They have trainees in the counseling center, and so they may be limited in some
34:38
of the higher-acuity caseloads that they can take, but you can always call,
34:43
and they can tell you. Okay.
34:45
And Jessica, this is all so insightful. It's such an honor to be here with you today.
34:50
Let's go back for the pediatric practitioners to say this is their 35th patient
34:56
of the day with several more patients in the exam room, and this family is coming in,
35:01
and this 11-year-old boy, the mom says he's feeling really sad and anxious lately.
35:09
What would you say to that? What's the next step? So we would ask about kind
35:14
of pervasiveness. We would ask about, you know, how long has this been happening?
35:20
We would ask about if there's been any other like big behavior changes, right?
35:27
So we're trying to get the functional impairment part of things,
35:31
right? Have grades been dropping?
35:32
Have there been, you know, other getting in trouble for other reasons?
35:36
Or for a depressive episode, it really only is required to be a two-week,
35:42
again, assuming that it's most days more often than not.
35:46
And so if they're saying, you know, this has been a really, really rough,
35:49
you know, time, you know, obviously we would also ask, like,
35:52
has there been any big, you know, stressor, any big event, any big change?
35:59
If the answers are yes, and we get this kind of, you know, mild to moderate
36:04
depression, again, during that time, you could have them do the PHQ-9.
36:07
So we kind of have a little bit, you know, more of a screen and more of a number.
36:11
You would ask about, you know, suicidality. If there's no suicidality and,
36:16
you know, there's been significant symptoms, you could take that first step
36:21
and say, you know, I'd really like for you to see a counselor, right?
36:24
So first line for mild to moderate depression could be counseling or medication.
36:29
And so if it's been that short of a time, we might think about counseling first,
36:35
you know, see how they respond.
36:38
But if it is pretty profound, the impairment that they're having,
36:42
and if the parent is saying, you know, they just, you know, can't get out of
36:47
bed, they're sleeping all day, we would ask about substance too and roll that out.
36:52
You know, but then we could consider, you know, whether a medication at that
36:56
point, again, depending on the severity, would be appropriate.
36:59
One pediatric clinician was saying to me, a family came in the other day and
37:05
she said, and her nine-year-old daughter is bipolar, like that there's these,
37:09
so early on, there's these labels.
37:12
Do you see that? And what do they do about that?
37:16
And she asked the family, like, how do you, has the child been clinically diagnosed?
37:21
And it was really the and the mom I you
37:24
know I know she is because she has I looked at all
37:27
the symptoms and so my daughter's bipolar now what is
37:30
the next step kind of thing so what are your thoughts there yeah so
37:33
the bipolar thing I think and I'm putting that in
37:36
quotes you can't see that on the air you know it's really difficult because
37:39
a lot of times people take words that we use and kind of shift the meaning and
37:46
I think a lot of times when people say bipolar they mean their child has a lot
37:50
of mood liability and frustration tolerance, right?
37:54
And that's kind of what you're saying is that it can be really hard to tease
37:56
out, are they using it in this kind of colloquial way versus.
38:01
In the way that we would need more rapid, right, treatment.
38:06
And so for bipolar disorder, you know, we'll remind you that it's a discreet period.
38:15
And, you know, euphoria or extreme irritability coupled with the most like cardinal
38:23
symptom is decreased need for sleep. So they're not really sleeping.
38:26
You know, they're sleeping only two hours, three hours, you know,
38:29
much less, you know, than they had been. And those are good initial screeners
38:34
that, you know, you could ask about.
38:38
So that would be the primary thing to kind of say, is this mania?
38:41
Is this, you know, hypomania? There are also other screeners for bipolar disorder as well.
38:46
But if what the parent is describing is, you know, they are,
38:52
you know, every time I say no, they just tell me, they curse at me.
38:57
And every time I say no, they explode and they have a tantrum.
39:00
You know, those types of things are not bipolar disorder, right?
39:05
And so trying to elicit, you know, do they have a manic episode?
39:10
If it doesn't sound like remotely like that, again, the likelihood is that it's
39:15
more these kind of mood lability issues.
39:19
Of course, if there was any question that remained, if there was a family history
39:24
of bipolar disorder, there would be a higher risk that the child would also.
39:31
And so those could be potential things to refer for.
39:36
Blanking on the name of the screener for the bipolar disorder.
39:42
But most often, the trouble that happens with the screening also is that the
39:46
parents are not answering as one discrete period. They're answering, has this ever happened?
39:53
And most often, like most other symptoms, you will have some of those symptoms some of the time.
39:59
But it's the question of, is it happening kind of, you know,
40:03
all at once? And again, most often these kids, what they're really saying is
40:07
they're moody, they're angry, and they get frustrated, you know, really easily.
40:13
And so is it important to explain to the parent that what you're saying?
40:18
So it's, it sounds like it's more like this, that it's.
40:22
Not bipolar disorder? Yeah, you know, we would talk about, depending on the
40:28
age of the child, right, is it developmentally appropriate, right,
40:31
for them to be having tantrums at that age, for them to be having those,
40:35
you know, difficulties.
40:36
We would give them the education that, you know, bipolar disorder is this very
40:40
specific constellation of symptoms that happens. And while, you know,
40:45
you're describing some of those things, it doesn't quite meet the picture.
40:49
That doesn't mean that it's not concerning.
40:51
That doesn't mean that it's behavior that we would like to address,
40:54
but it just may not require this diagnosis or these types of medications.
40:58
And then a lot of times, like, that's a good thing, right?
41:02
This is a disorder that can be very debilitating, that can be very hard to treat,
41:08
that, you know, can result in a lot of distress and impairment.
41:13
So, you know, we try to give them that information and, you know,
41:17
we could talk about, again, and referring for counseling, referring for family
41:21
therapy, you know, those types of things.
41:24
But even in our offices, we get that a lot is, you know, families coming in,
41:28
and that's the first thing that they say, you know, my child's bipolar,
41:30
or they'll come in and say they've been bad.
41:32
And you can make poor decisions and poor choices that are not mental illness.
41:37
And you can have difficulty controlling your emotions and your frustration that's
41:42
not mental illness. Yes.
41:44
And what if the pediatric practitioner is feeling pressure from the parent that
41:49
the parent wants something prescribed to make their child be good or be happy?
41:55
Yeah. I mean, I think that's such a difficult feeling to have,
42:01
but you just stick to your medical, do no harm. There's not a reason.
42:07
There's not a clear reason to have a medication. And right now the benefits
42:15
wouldn't outweigh the risks, right?
42:17
And you just kind of unfortunately agree to disagree. We've had those hard conversations
42:22
several times as well. So another term that seems to be thrown around a lot,
42:29
maybe it's much more in adults, but like narcissist.
42:33
Is that something you come across where parents think the child seems to be
42:37
having narcissistic tendencies?
42:38
Or is there anything you want to say on that topic as raising children,
42:43
red flags we should look for where we're guiding them in a different direction
42:47
so they don't become a narcissist or what? Any thoughts there?
42:51
Let's see. I have multiple thoughts. I think my first thing would be that
42:54
again everything that we talk about has
42:58
some it is on a spectrum right
43:01
and so we all have some inherent narcissism sometimes in certain contexts because
43:10
that's preservation like that's you know so so that that's kind of the first
43:16
thing that i i think about when you say that.
43:20
But it takes a lot for the diagnosis, right, to your point.
43:23
So it may not be helpful necessarily, right, to kind of be throwing around, you know, labels.
43:30
Is that a diagnosis that kids get? Is it a? No. It's like, okay, I didn't think so. Yeah.
43:36
Yeah. Personality disorders generally are reserved for after the age of 18.
43:40
Not because there's a magical thing about 18, but it really,
43:44
a personality disorder is a longstanding pattern of a very specific kind of
43:52
maladaptive coping style that has certain implications for your relationships.
43:57
And during your teenage years, you're figuring it out.
44:00
You're trying to understand what is going to keep that best friend or what is
44:06
going to hurt people and take things back or I can't take that back, right?
44:10
So during that time period, you're trying to go through all the different ways
44:15
that you would cope with things and understand, you know, what means the most
44:20
to you and to your relationships and your communication style.
44:24
So generally is reserved, you know, for adult.
44:27
In terms of raising, you know, kids and warning signs, I guess,
44:34
you know, I would think about the ability to, you know, do things for others, right?
44:41
Most teenagers are going to be a little bit selfish, right? Like we talked about.
44:45
But there should be some ability to give and take, so to speak, right?
44:50
There should be some ability or expectation for them to help around the house,
44:55
to contribute, you know, to the things that you guys are doing as a family,
45:00
you know, to your values.
45:03
So I think for most, again, it would be a very rare to meet the kind of diagnostic patterns.
45:13
I think the bigger thing is kind of demonstrating as a parent, right, also that we're,
45:20
working as a team and kind of helping others and things like that.
45:23
And so that's the other thing that I would think about is, are you demonstrating
45:26
in your day-to-day life some of the things that your children are demonstrating
45:32
or doing and they're watching us? Right.
45:36
So I think it would be a good paper or a book, How Not to Raise a Narcissist.
45:42
I think there may be some out there like that. Are there? Yeah.
45:46
Because yeah, truly like, you know, Or you see the parent who,
45:49
don't hit your brother and then whap, you know?
45:52
Right. Did that just make sense? Right. Right. So thinking about your values
45:56
and are we sharing with others? Are we doing things for the greater good?
46:01
Are we, right? And depending on how you're doing that or how you're not doing
46:04
that, again, reframing, your child is in that context.
46:10
And our children are often the center of our worlds, but then that doesn't mean
46:15
they're going to become narcissists, right? if we do whatever we can for them.
46:19
Right. We're showing giving to others, right?
46:22
Right. But with rules and limits and boundaries, right? Like we talked about
46:25
with the ice cream and with the lollipop, right?
46:27
If their expectation is always, this is going to be for me, this is going to
46:32
be done for me, this is, that also is problematic, right? So it's about kind of balance.
46:36
And yeah, I mean, and yeah, my daughter has a friend who, she does not do any chores at home ever.
46:43
Like it's not ever expected. I mean, I think she's 12 now and it's not like ever.
46:51
So then when she comes to our house to play, it's like awkward.
46:53
She's standing there watching us like empty the dishwasher and clean up.
46:57
And, you know, it's like, I don't really see the benefit of that.
47:01
But anyway, chores are good. Yeah.
47:05
Back to, though, the pediatric practitioner. Anything else you want to say about
47:09
putting something, you know, in the moments that we have left, like,
47:13
into their tool bag. If you see that, you know, is there something you see that's
47:18
often missed or be sure to look at this or anything that you want to say there about depression?
47:26
I think the biggest thing that I would want to emphasize and make sure that
47:32
they're aware of is that sometimes it presents us irritability.
47:36
And so we think about depression as depressed mood, as sad, but kind of going
47:44
on our earlier conversations that we had, sometimes it's not,
47:48
society makes it not feel safe to be vulnerable, not feel safe to be sad.
47:55
And so in particular for younger kids who, again.
48:00
Don't have the language and the tools to say, I'm feeling really depressed and I hate myself and I,
48:08
you know, my self-image is, you know
48:11
all these negative things they may not be able to really express
48:15
that or explain that the younger they are the more
48:18
kind of you know risk of irritability as
48:21
a symptom for really anything depression anxiety kind of everything because
48:25
they're not able to to tell you what they need right and and they're frustrated
48:30
but i'd say the same is true for males right i'd say the same is true for minoritized populations.
48:40
Anywhere where it's kind of more frowned upon or not expected for somebody to
48:44
be able to express that vulnerability, we may see kind of irritability present.
48:50
And so if you have someone, a parent who says they're just cranky all the time,
48:55
they're just upset all the time, to remember that that could be a warning sign
48:59
that they're depressed and to ask a little bit more about, are they also feeling sad?
49:05
Are they not enjoying anything? Do they have any sort of pleasure activities
49:11
that they do, right, and kind of screening to make sure that it's not depression?
49:15
If the child is more irritable than normal and is 13 or 14 or 12,
49:21
but also has things he or she loves and lots of times of joy,
49:28
and that's not a warning sign thing. That's normal.
49:33
If they have long periods of time, again, where they are able to be happy and
49:39
feel joy and it's not an all-the-time thing, yes, could be normal.
49:43
And there's also kind of low-grade irritability, right, like oppositional teens.
49:49
And I think maybe that's kind of what you're getting at. So in the absence of
49:53
all the other symptoms, yes, kind of a low-grade cranky can be common,
49:58
you know, for teens. But we're really looking for those additional symptoms, right?
50:03
Is their self-esteem really awful? Are they really, you know,
50:06
low energy? Are they not sleeping?
50:08
Are their grades dropping?
50:11
The other really key thing that I should have mentioned that we didn't talk
50:14
about earlier is if they have no interest in friends plus the mood stuff, right?
50:21
Most kids may not be that interested to hang out with you as a parent as they get older.
50:26
Right and so if you're kind of painful so if
50:30
you say oh let's go to the movies let's go to the s house let's
50:33
you know do these things and they're like no if the parent reports that they're
50:37
not interested in those things that doesn't raise my you know antennae so to
50:42
speak as much as it does that they used to go out with their friends to the
50:46
movies and all of a sudden they don't want to do that they used to have friends
50:50
over but now they don't do that they used to text or call.
50:54
Or play video games.
50:56
They used to do all these things, but now they're just laying in bed in their
51:00
room and they're not doing those things.
51:01
So the absence of kind of the desire and the pleasure to socialize with peers
51:06
their age as they get older is also kind of something that we'd be listening
51:11
for or thinking about. And you talked about counseling.
51:14
Anything else to try before medication in terms of lifestyle?
51:20
If they are meeting kind of depressive episode, the standards of care and treatment
51:29
would be, yes, counseling and medication.
51:32
So there are other adjunctive things possibly that you could suggest,
51:36
but are not going to be like the.
51:40
The end of it are not going to be the things that kind of alleviate, right?
51:44
So adjunctive things, you know, you could encourage, you know,
51:47
to try to have a little bit more sunlight, kind of time outside, natural light, right?
51:54
Things like that. You could encourage them, you know, to exercise.
51:57
A lot of kids that are really depressed don't have the energy to exercise,
52:01
don't have the energy to kind of do those things.
52:03
And so, you know, in counseling, some things that they'll do is kind of,
52:08
they call it behavioral activation.
52:10
So they'll try to kind of get them closer to that.
52:14
So, okay, you don't go for a walk, but at least put your shoes by the door.
52:18
Can you at least put your shoes by the door? Okay.
52:21
And then the next day, can you just put them on?
52:24
And so we're trying to get them like closer to engaging in that actual activity.
52:29
Definitely those things, you know, we could try to encourage,
52:32
but for a true like depressive episode, you know, counseling and medications
52:37
would be the treatment that we'd be thinking about.
52:41
Anything, Jessica, you want to say about nutrition? Could junk food and hot
52:46
Cheetos and all of that that kids like today, could that be causing depression?
52:52
Or is that something that comes up as a psychiatrist?
52:56
So I don't think that it could cause depression per se.
53:01
And, you know, anytime that they look at studies for like, you know,
53:06
nutrition and autism or nutrition and ADHD and, you know, things like that,
53:10
it typically doesn't, you know, bear out.
53:12
That being said, I imagine, you know, if someone has a really,
53:17
you know, high fat, high carb diet, you know,
53:21
just any of us that are only eating those kinds of foods may feel more tired,
53:25
may feel more fatigued, may, you know, be putting on weight and things that
53:32
might make us not feel as well. So.
53:37
It could be helpful to have a healthier diet, but again, I'm not sure that that
53:41
would be like the primary thing I would be emphasizing to change necessarily. Okay.
53:48
Is there anything else you want to mention for pediatric practitioners about the screening tool?
53:53
There is another screening tool called the mood and feeling questionnaire.
53:59
Most pediatricians don't like that one as much though, because it's not designed.
54:03
The PHQ-9 is designed to have the symptoms of depression.
54:08
So it's a little bit easier to kind of pick out. The mood and feelings questionnaire
54:12
asks questions in a little bit of a different way and kind of frames it a little
54:18
bit separately, but can be helpful as well and kind of track over.
54:23
Is there anything else you want to say to pediatricians about depression in general?
54:28
I do know that it's difficult to spend that extra time. Like,
54:32
I completely appreciate that because, you know, our outpatient appointments
54:36
are built to, you know, have the time to explore and kind of,
54:41
you know, try to address a lot of these things.
54:43
And so, you know, I definitely hope that it doesn't come across as us saying
54:48
it's easy. You should just be able to figure it out.
54:50
Like, respectfully, you know, we definitely appreciate that there are so many opportunities.
54:55
Layers of things that pediatricians are working with. And we wish it was easier
55:00
and we wish there were more of us.
55:02
You know, pretty much all of Texas is in what they categorize as severe shortage
55:07
for childless and psychiatrists.
55:10
Yes, like a psychiatry desert, basically. Yeah. So I definitely wish that there were more of us.
55:15
But I think it's so, so important for treatment to be early.
55:19
So if there are kids who it's, again, you know, run-of-the-mill,
55:24
lower grade depression, it's going to be so much better for them to get treated
55:28
sooner rather than later and have to delay.
55:32
And it also leaves more space for us to take the more complicated cases of the
55:37
patient with bipolar disorder or the kiddo like you were talking about who maybe
55:42
doesn't have bipolar disorder but still has a lot of very significant irritability
55:47
and impulsivity and kind of other things that,
55:50
you know, we would be managing in our clinics.
55:52
And so, you know, I think we kind of work together for the better of the community
55:57
to try to navigate the ones that, you know, they can in their practices.
56:01
And we really, really appreciate that.
56:05
And anything you want to say to us, some pediatricians have said that they love
56:09
CPAN, but they don't have time to call.
56:11
Like they would need to go through the whole case scenario and they've got patients waiting.
56:17
What might be helpful is if they call and they say, I have five minutes.
56:21
And if they're very clear from the beginning, this is as much time as I have,
56:25
then that might lead to a different questioning approach.
56:29
That might lead to, you know, whereas some pediatricians that call have lots
56:34
of questions. And I think I spent like 30 minutes one time with somebody because
56:38
they wanted to go through all the items.
56:40
And so as the person on the other end, we don't always know what the expectation is.
56:46
And so that's one thing that I'd say that could be helpful up front is saying,
56:49
I have five minutes, I have, you know, high level, you know,
56:54
overview, and then go from there.
56:57
But I definitely appreciate that it can be really tough to do.
57:02
And so we try our best to be available at the moment that the call comes in, at least, you know, so.
57:11
I think some pediatricians will have the like an ancillary staff call in with
57:19
at least the initial information, but then be available when the child psychiatrist
57:24
is available on the phone.
57:27
And of course, it's important for all of us to take care of ourselves and our
57:31
pediatric practitioner listeners
57:33
who have so much coming at them in a high stress, high burnout career.
57:38
Do you want to mention what you'd like to do in your spare time?
57:40
I know, has your daughter turned 11 yet?
57:43
She did. She turned 11 on the 30th. Oh, tell her happy birthday.
57:46
Thank you. I appreciate it. In my spare time, so we like to go for walks.
57:50
I have a dachshund named Domino.
57:52
And so we like to take him for walks. We also like to watch shows together.
57:57
And so, you know, we'll watch, we just finished the WandaVision sequel, the Agatha.
58:03
So, you know, we watch that together. It's on Disney+.
58:07
So we watch that together and then, you know, kind of talk about it.
58:11
And then we like to do crafts. So we do a lot of crafts together.
58:14
That's great. And your special project's research about translation in medicine.
58:20
So we're going to be looking at families who have limited English proficiency
58:25
and a preferred language of Spanish who require interpreters during our psychiatric evaluations.
58:31
And so we'll be looking at the quality of the interpretation and whether that
58:37
impacts their outcomes.
58:39
I really appreciate you talking here today, and I hope that it helps inspire
58:44
our listeners to keep up the great work that they're doing that's so tough,
58:49
helping kids with depression.
58:51
And yeah absolutely and again we're we're so grateful
58:54
you know for all of our colleagues and the collaboration and
58:58
you know we're just a call away and hopefully other states and other parts of
59:03
the country have things like c-pan where you could call and no call is too small
59:07
and we'll put the number in for texas dr jessica sandoval child psychiatrist
59:13
at ut health san antonio thank you for being here today on pediatrics now.