Until a few years ago, I used to spend a few days a year helping psychiatrists prepare for their oral board exams. The exam involved, among other things, interviewing a patient while examiners watched. After the interview the candidate for board certification presented the case in a structured format, following which the examiners would ask her questions. The candidate would be rated on her interview skills and on her knowledge. About half the candidates would fail this part of the exam, at least partly because of performance anxiety getting in the way of both proper interviewing and responding to oral exam questions.
In the board review course where I was faculty, candidates participated in mock interview sessions that were meant to help practice the test. After the mock exam, I would give them feedback on things they could do to improve. Psychiatrists who took the course were often those who had not taken the exam right after residency, leading them to feel rusty. They came from different practice settings.
Early in my mock oral exam faculty career, I had a candidate who forgot to ask the patient any substance use history. During the feedback session, I asked her why. She said that she was a child psychiatrist in a well-to-do suburb and given that her patients did not have addiction problems it wasn’t her usual practice to ask about it. I was surprised.
Dual diagnosis – presence of a mental illness and substance use disorder – is fairly common, even among teens. The National Survey of Drug Use and Health (NSDUH 2014) shows that 1 in 8 of the teenagers with depression in a given year also had a substance use disorder during the same year. It also shows that 1 in 3 of teenagers who used illegal drugs in a given year suffered from depression at the same time. To add to that, per the National Institute on Alcohol Abuse and Alcoholism the average age of initiation of alcohol use is 14 years. By age 16, 1 in 2 teens admits to having had more than a couple of sips in the past year and by age 18, 2 in 3 teens admits to it. The National Institutes Health call addiction a developmental disease given that most adults who have addiction problems usually started using regularly in their teens. The National Institute of Alcohol Abuse and Alcoholism recommends universal screening of kids starting at age 9.
Unfortunately, I found that the experience I had with that one candidate repeating itself a few times over my mock exam faculty career. These psychiatrists, both those specializing in child psychiatry and those doing general adult psychiatrists, but always from well-to-do towns believed that their adolescent patients didn’t have addiction and acknowledged that they either did not routinely ask about addiction in their practice or did so cursorily. It’s a classic case of what the mind doesn’t believe that eye doesn’t see.
While it is true that poverty and many of its consequences increase the risk of various mental health problems, including addiction, it doesn’t mean that the well-off or their children don’t suffer from it.
As noted in my post last week, 41% of people with addiction who don’t seek help don’t do so because they are not ready to stop using. If it’s because they don’t think their addiction is causing problems, I’m sure their physicians’ assumptions about who is at risk and who is not doesn’t help. If we just followed the experts’ advice and made universal annual screening part of normal practice, it would potentially help close the addiction treatment gap.
