Dr. Gabrielle Cerda’s job is to treat mental illness in kids, but she often finds herself tangling with another enemy: stigma.
Cerda, clinical director of outpatient psychiatry at Rady Children’s Hospital San Diego, mainly treats children of the poor who have public insurance or none at all and come to the hospital because they have nowhere else to go for treatment. She says many parents feel confusion and shame, especially if they come from other cultures where mental illness isn’t as commonly treated as it is here.
Cerda, a UCSD graduate who grew up in Chula Vista, also battles the world of medicine at large. She is an outspoken advocate for mentally ill kids and speaks to groups about how the system often leaves them without access to proper care.
In an interview, Cerda talked about the conditions she sees, the cultural hurdles she faces on the job and the lure of medication as a quick fix.
What are the big problems that people come to you about?
Usually people come for different kinds of behavior problems — at home, at school. A lot of those diagnoses turn out to be things like depression, anxiety and attention-deficit/hyperactivity disorder.
What are you seeing more of these days?
A lot of autism disorders and a lot of maternal depression. My lifelong dream was to be able to treat the mothers of the children I see, and in recent months I’ve been able to do that on a small scale. If we treat the mom when it’s appropriate, especially today when we have concerns about so many medications and their effects on kids, this can be an effective intervention to address kids’ problems.
What do you see in poor kids that you wouldn’t if, say, you were a child psychiatrist in La Jolla?
The diagnoses probably aren’t different. What is different is the resources to manage them and for parents to be able to take time off work, bring them to treatment. Having money for a car, gas and transportation. Having money to pay for medications. The other thing that’s different is that these families often have less access to internet resources and often have lower educational levels. It might be more difficult to fully comprehend what is going on with the kids. And they have less money to pay for tutoring or babysitters so they can come to appointments.
You speak Spanish and see a lot of Latino patients. Is stigma toward mental illness especially common in the Latino community?
One of the things we struggle with is countering the stigma of mental illness enough so that they come to get diagnosed and stick with treatment. It can be difficult to see mental illness as another illness like hypertension or diabetes as opposed to something that you should be able to control yourself.
Psychiatry and psychologists are such a big part of our culture. Is it different in Mexico?
Yes, absolutely. There are many fewer resources in terms of mental health, and people usually don’t go to see a psychiatrist. There’s often a lot of expression of stress in physical illness: people will have recurrent aches and pains, stomachaches and body aches that they’ll go to their regular doctors about. That’s how it’s expressed in a more culturally acceptable fashion.
So there’s no Mexican equivalent of the neurotic, shrink-happy Woody Allen?
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No! But certainly more and more there are ongoing campaigns to make mental illness something that’s not so shameful and something you can be more open about. But when you compare the culture of Mexico to the U.S., it’s much more shame-based with stigma. With Latinos in particular, they have language barriers and lack of knowledge about the system. The parents absolutely do not have knowledge of their rights in the schools and what resources are available. They’re not able to ask or fight for these, so a lot of what we do is advocacy work. They need special support in this area.
How about other cultures? How do they look at mental illness?
It seems that most cultures have a sense of stigma. One of our goals is to do a lot of education in terms of talking about mental illness in a way that it doesn’t mean that you’re crazy or there’s something bad that needs to be hidden.
How does the stigma affect your work with these people?
With the groups that require an interpreter, there is a sense that their ethnic community is so small, and the sense of coming to a mental health clinic is associated with such a negative stigma, that they’ll often refuse an interpreter specifically because they don’t want their business known. The other issue that comes up is that kids go without necessary treatment, even when they’re dangerous and psychotic, because it’s so unacceptable to have a mental illness and receive treatment. Sometimes kids have to go through serious consequences before families will see the need for treatment, and this can take years.
How do you treat the very young kids?
For the under-school-age kids, a lot of the work is teaching parents to manage the children. The younger they are, the more time they’re spending at home and the greater the impact of the home environment.
Kids in the pre-kindergarten ages are being prescribed more medications these days, right?
Unfortunately. It’s very concerning that people are jumping straight to medication. It’s frightening what I’ve seen in kids under 5. I’ve seen 2-year-olds started on anti-psychotics, 3-year-olds on regimens of three, four or five medications.
What about overdiagnosis of mental illnesses? Is that a serious problem?
Absolutely. We’re often very quick to diagnose something that is just typical behavior that we don’t like. For example, there are kids whose personality is to be active, loud and intense. Does that mean you have ADHD? Not necessarily. It also has to do with how people are quick to call something a problem instead of stopping to think about managing the child differently.
Is it hard to find a quality child psychiatrist?
It can be a challenge to find one who can spend the necessary time to evaluate children, particularly young children. Today’s society wants a quick fix, and that usually involves medication. It may be cheaper to just give the kids some pills instead of invest in the time that therapy takes to achieve results. And consumers aren’t always fully aware of the side effects of medications. On the other hand, I believe there is absolutely a role for medication, usually in conjunction with other therapies.
What about the cost of a child psychiatrist?
There are waiting lists everywhere because there are so few child psychiatrists. And a lot of the top psychiatrists are cash-only. The problem is that most insurance companies reimburse so poorly that many of the best child psychiatrists don’t work through them. A quality child psychiatrist could cost within the range of $300-$400 an hour and not take insurance.
How can a parent find a good psychiatrist?
I would find a good provider by asking for recommendations from their own primary care physician and people they trust.
Interview conducted and edited by Randy Dotinga. Please contact him directly at randydotinga@gmail.com and follow him on Twitter: twitter.com/rdotinga.