Catch or Release: Gatekeeping in Mental Health

Last week a long time patient asked me about my blog. He had been reading it, but wondered why I focused on writing about teens and young adults. Why not write about some of the issues we were working on for him: relationships, divorce, or PTSD? After all, he said, he is no longer a young adult (he’s 35) and I still treat him. Why not write about midlife?

I considered his question for a long time. Why focus primarily on teens and young adults?

The care of young people, often new to the mental health system, presents special issues. The decisions mental health professionals make regarding these young people have big consequences. On the one hand, if the system can help a kid after he tries heroin the first time, and not wait until his third ICU stay from overdose; or likewise treat a college student with depression when it begins, and not wait ten years until hopelessness has robbed her of the ability to function and left her perpetually wishing for death, offering early treatment can save lives.

Yet it’s not just prevention that makes the care of young people distinctive. Screening folks in or out of care is unique to newcomers into the system. Young people come into mental health care, brought by families, and decisions we make will determine whether they stay in care or move on to have lives free of mental health contact. Young patients may have transient problems or the beginnings of lifelong illnesses. Our assessments and diagnoses, the education we provide families, and the expectations we set as clinicians can influence long-term outcomes profoundly.

Many young people come in to the system due to worried parents and stage of life bumps in the road, and their care must be approached differently. Unfortunately, many professionals are using a cookie cutter approach to all patients who enter the mental health care system. Teens and twenty-somethings are given too much medication, given serious and scary diagnoses and prognoses, and when the treatment is excessive, the patients deteriorate rather than recover. Mental health care involvement for healthy young people is essentially making things worse.

Early detection and early treatment can drastically improve outcomes for those with real illness, but early treatment can worsen outcomes for the bumpy stage of life group. Mental health practitioners and advocates need to re-think an overly inclusive model of mental health care. We need to protect healthy young people from excessive care, and make room in the strapped mental health care system for the people who truly need the vital but limited resources. We need to allocate the resources to the right place.


Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.



Posted on September 8, 2014 .