From the Editor
Are children experiencing more mental disorders than before, or are we simply getting better at screening for them? Many have opinions and there is debate among psychiatrists and within our society.
In a new JAMA paper, Janet R. Cummings (of Emory University) and her co-authors provide new data shedding light on this issue. Drawing on US government databases covering 22 states and from 2010 to 2019, they looked at diagnoses and demographics among economically disadvantaged children. “This observational study found that the percentage of publicly insured children diagnosed with any mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 16.5% in 2019.” We consider the paper and the accompanying Editorial – and wonder if this reflects better screening or more illness.
In this week’s other selection, we look at the life and career of Dr. Mary Seeman, who died in 2024. In an obituary for The Canadian Journal of Psychiatry, Dr. Robert B. Zipursky (of the University of Toronto) and his co-authors note her many contributions to psychiatry. “Although Mary was 89 years old at the time of her death, her passion, humour, curiosity, and productivity had not abated. It endures now in the legacy of her scientific work, in her teaching and clinical care and in the many people she inspired to follow her example.”
DG
Selection 1: “Trends in Mental Health Diagnoses Among Publicly Insured Children”
Janet R. Cummings, Xin Hu, Jordan Marchak, et al.
JAMA, 24 April 2025
Concern about child mental health has increased in recent years. A US national survey of parents in 2016 found that 25% of children had been diagnosed with a mental health, behavioral health, or developmental disorder at some point in their life by a health care professional. Since the 2020 onset of the COVID-19 pandemic, concerns about child mental health have increased. Data have shown increases in anxiety and depression as well as in diagnosed learning disabilities and developmental delays. Furthermore, research has reported increasing percentages of mental health-related emergency department visits and higher numbers and percentages of mental health-related hospitalizations among children. In 2021, 3 health professional organizations that serve children, including the American Academy of Pediatrics, declared an emergency in child mental health, and the surgeon general released a report on child mental health that highlighted these worrisome trends.
In the US, 16% of children live in poverty, which is associated with increased risk of mental health disorders and poor mental health outcomes. Public insurance programs, such as Medicaid and the Children’s Health Insurance Program (CHIP), covered 38.8% of US children in 2023, including those from families with low incomes, with disabilities, or living in the foster care system. To date, there is limited data examining trends in mental health diagnoses among publicly insured children.
So begins a paper by Cummings et al.
Here’s what they did:
- They conducted a “serial, cross-sectional study used administrative claims data from 22 states to test trends from 2010 to 2019 in the percentage of publicly insured children aged 3 to 17 years with mental health or neurodevelopmental disorder diagnoses.”
- They drew on two government databases: Medicaid Statistical Information System Analytic eXtract and Transformed Medicaid Statistical Information System Analytic Files, both from the Centers for Medicare & Medicaid Services.
- “Regression models included a dummy variable for each year, controlled for child demographics, county-level metropolitan status, median household income, and US Census region.”
- Main outcome: “Any mental health or neurodevelopmental disorder diagnosis in the calendar year, and any diagnosis in 1 of 13 specific diagnostic categories.”
Here’s what they found:
- There were 129 306 637 child-year observations (29 925 633 unique publicly insured children) included.
- Demographics. 41.8% were aged 6 to 11 years; 36.5% were aged 12 to 17 years. 50.9% were male. In terms of race, 20.2% were Black; 38.4%, Hispanic; 35.3%, White.
- Percent diagnosed. “The percentage of publicly insured children with any diagnosed mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 16.5% in 2019; this change remained significant after adjustment for covariates (adjusted risk difference [aRD], 6.7 percentage points)…”
- Diagnoses. “Statistically significant increases were also observed in 9 of the 13 diagnostic categories examined. The largest absolute increases were observed for attention-deficit/hyperactivity disorder…”
- Demographic groups. “Statistically significant increases in the percentage of children diagnosed with any mental health or neurodevelopmental disorder were observed in each demographic subgroup…”
A few thoughts:
1. This is a good paper, drawing on a robust dataset, focused on a practical question, and published in a major journal.
2. The main finding in two words: way up. To be a bit more detailed: the percentage change in rates was up by more than 60%. (!)
3. Needless to say, the authors see clinical implications:
“The increases in the number and percentage of publicly insured children who received 1 or more of these diagnoses may signify increasing need for appropriate services. Higher need combined with documented gaps in access to outpatient and inpatient care, shortages of mental health professionals, and declining psychiatrist participation in Medicaid may contribute to the adverse outcomes observed in recent studies, including increasing percentages of mental health-related emergency department visits, duration of boarding in emergency departments, and increasing mental health-related hospitalizations.”
4. The paper runs with a thoughtful Editorial from Vikki Wachino (of the Health and Rentry Project) and Richard G. Frank (of the Brookings Institute), “Mental Health Diagnoses Among Publicly Insured Children.”
They note that the paper has some surprising findings. Start here: “The unadjusted rates of diagnosis of autism increased more than 5-fold over the study period; the rate after adjusting for demographic and environmental (local income, urbanization) factors was closer to 4-fold.”
Vikki Wachino
How to explain the increase in so many disorders? “These findings raise questions about what underlies the increase in rates of treatment of diagnosed mental illness in children. How much of the increase in those rates was due to changes in prevalence of illness in the population, and how much was due to rising rates of screening, case identification, and treatment? The authors suggest that underlying changes in prevalence may be key. Yet the rates of diagnoses made in clinical settings grew less quickly than did the underlying prevalence of illness.”
Wachino and Frank write further: “There is also reason to believe that access to screening and diagnostic services grew between 2010 and 2019. Pediatrician awareness of behavioral health issues and improved screening methods may have contributed to an enhanced ability to identify and treat mental health problems. Likewise, an expanded role for nurse practitioners and greater awareness and resources in schools likely contributed to more screening and case identification.”
That said, they forward a reasonable position: “The increase in mental illness diagnosis rates is concerning, whether it reflects prevalence of illness, better screening, or both factors.”
They argue that US policymakers have made good and important decision in recent years. “Policymakers of both political parties and at different levels of government, as well as insurers and providers, have expanded policies to increase access to mental health services, especially for children. These policies leverage Medicaid, grant funding to states, and private insurance to expand access to services in primary care settings and schools, as well as strengthen crisis response, among other areas.” They add: “Additional investments in the mental health and well-being of children and their families are badly needed.”
The full Editorial can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2833199
The full JAMA paper can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2833199
Selection 2: “Mary V. Seeman: In Memoriam”
Robert B. Zipursky, Neil Seeman, David S. Goldbloom
The Canadian Journal of Psychiatry, March 2025
It is sad but fitting that this special issue of the Canadian Journal of Psychiatry, devoted to improving understanding of and care for people with schizophrenia, be dedicated to the late Mary V. Seeman, who died on April 23, 2024, after a brief illness – and after a long, productive, and ongoing career in psychiatry.
Generations of psychiatrists and other mental health professionals, as well as national and international colleagues, knew Mary as an inspiring teacher, a caring mentor, an indefatigable researcher and writer, and a compassionate clinician. Mary always thought broadly about patients, from their neurobiology to their social role function and adaptation. From the earliest days of her training and career, she focused on the needs of people with severe and persistent mental illness.
So begins an obituary by Zipursky et al.
They note her incredible productivity. “Mary loved writing. Since her first peer-reviewed publication in 1959, Mary authored or coauthored just under 600 scientific papers and commentaries, primarily focused on schizophrenia – but also more personal reflections on her career path and experience.” They also note her larger role in psychiatry. “Mary’s generosity in mentorship permeated all aspects of her career as an academic psychiatrist.”
Her early years were hard, touched by war and escape. “Mary was born in 1935 in Lodz, Poland, into a Jewish family with a rich cultural and intellectual tradition. Her father, Aleksander Szwarc, was a chemist and inventor. Her mother, Sonia Brzezinska Szwarc, had studied literature at the Sorbonne before her marriage. When she was 4 years old, Mary, together with her parents and her older brother, George, were able to escape Nazi-occupied Poland in a harrowing journey through Italy and France to safety in Portugal… They lived as refugees in Lisbon for 9 months before sailing across the Atlantic to arrive at Ellis Island en route to their new life in Montreal.” She found comfort in the achievements of another Polish-born woman. “Mary would read and reread every biography she could find of Marie Curie…”
She studied at McGill University (language) before further studies at Sorbonne, and then back to McGill for medical school and residency at Columbia.
They note the unique moment in psychiatry that coloured her career: “Delay and Deniker published the first reports of the efficacy of chlorpromazine in psychotic patients in 1952, and it was introduced into clinical practice in the USA in 1954; the move to the deinstitutionalization of psychiatric care was also in full swing.”
The authors describe several of her most important papers. Here, we focus on three.
“Management of the schizophrenic patient”
The Canadian Medical Association Journal, 1979
“She reported observations made following 135 outpatients with schizophrenia. Of particular note, Mary described differences that were apparent in women compared with men with schizophrenia. Women were more easily accepted by their families, more likely to live with their parents, and more likely to be married. She concluded that ‘for men and for women the sequelae of schizophrenia are somewhat different.’ This appreciation of the differences in the impact of schizophrenia on women compared to men became the central focus of Mary’s academic career…”
“Gender differences in schizophrenia”
The Canadian Journal of Psychiatry, 1982
“Mary first outlined her views on gender differences in schizophrenia and the potential mechanisms underlying them. The differences observed in women included later age of onset, better response to treatment, lower recurrence rates, better social and work functioning, higher likelihood of being married, and lower risk of suicide. While these findings reflect the contributions of many investigators, Mary conceptualized the factors that could be contributing to these differences with a degree of breadth and depth that has been extremely generative. She proposed that these could include genetic factors, intrauterine and perinatal factors, psychosocial stressors, differential exposure to alcohol and drugs, and stressors that are specific to male primates during adolescent development.”
“The role of estrogens in schizophrenia gender differences”
Schizophrenia Bulletin, 1990
“She summarized research from rodent and primate models of fetal development. She proposed that sex differences in the human brain, including differences in hormone and neurotransmitter receptor number, distribution and affinity states, may contribute to functional differences relevant to the expression of schizophrenia. She hypothesized that differences in the levels of gonadal hormones during critical periods of fetal development may initiate a chain of events leading to gender differences in brain maturation, which may contribute to the earlier onset of schizophrenia in males at genetic risk for the disorder. She described the potential protective effects that high oestrogen levels may have in delaying the onset of psychosis in women at risk for schizophrenia…”
They mention some of her many leadership roles. “Mary took on leadership responsibilities at the hospital and university levels, serving as both Chief of Psychiatry at Mount Sinai Hospital and Vice-Chair of the Department of Psychiatry of the University of Toronto.” They also comment on the many honours, including the Order of Canada.
Mary Seeman, with her husband Philip
A few thoughts:
1. Dr. Seeman had a remarkable career.
2. This is a great obituary – yes, it notes important life details, but it also summarizes her research and passion.
3. Dr. Seeman began doing research and practice at an incredible moment in the history of psychiatry, as the authors note, with the development of antipsychotics and the push for deinstitutionalization. She was perfect for the moment – with the right blend of curiosity and compassion, allowing her to thrive as a researcher, clinician, and administrator.
4. As is noted in the obituary, The Canadian Journal of Psychiatry special issue on psychosis is dedicated to her. For the record, the issue is terrific. (The Editorial by Dr. Zipursky is particularly thoughtful, by the way.) You can find it here:
https://journals.sagepub.com/toc/CPA/current
5. Dr. Seeman’s writing has been featured in past Readings. In a 2003 paper for The American Journal of Psychiatry, she reflects on her work with a patient, noting the decades-long connection between doctor and patient. “Her faith in me keeps me coming into work each morning, often tired and achy, sometimes trying unsuccessfully to remember the comforting word I want to be able to say.” You can find that paper here:
The CJP obituary can be found here:
https://journals.sagepub.com/doi/abs/10.1177/07067437241298375
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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