Blogged Arteries

By James G Baker, MD
Member, TMA Council on Science and Public Health

If a patient asks you to sign a letter supporting his emotional support dog, should you do it?

For a canine to be designated as someone’s emotional support dog, the person seeking such an animal must have a note from a physician or other medical professional stating that (1) the patient does have a psychiatric disability, and (2) the emotional support animal provides a benefit for the patient beyond the simple need for companionship. The most common reason for the letter request is that emotional support dogs legally are viewed as a “reasonable accommodation” in apartments that have a “no pets” rule.

The idea of using a dog as emotional support would seem to make perfect sense. After all, who wouldn’t benefit from having a four-legged friend at his or her side? Assuming you are the patient has a disability, here are a couple of considerations when assessing the benefit to your patients.

First, while there is good research showing the benefits of service assistance dogs for people with physical disabilities, there is little evidence for the use of service assistance dogs, let alone emotional support dogs, in mental illness. How are service dogs and emotional support dogs different? Service dogs are trained intensively by professionals for many months to perform specific tasks for people with disabilities. For example, service dogs are trained to open doors and turn on lights for people with physical disabilities. They might serve as ears for the hearing-impaired or as eyes for the visually impaired. Service dogs can also be trained as skilled companions for people with intellectual disabilities or mental illness. By contrast, an emotional support dog is not trained to do any specific tasks related to a disability, but rather provides a therapeutic benefit to its owner through companionship.

Second, the lack of specific training requirements for an emotional support dog is problematic. Hopefully the patient’s dog is friendly, calm, and without unexpected behaviors, especially in public. But due to the lack of training, an emotional support dog may bark, act aggressively if it feels threatened, or be intrusive of others in public. By contrast, a service dog is trained to ignore distractions and cause minimal imposition to its surroundings. At very least, an emotional support dog should have formal obedience training sufficient to obtain a canine good-citizen certificate, but longer-term obedience training would be even better. Ideally, the dog would be a skilled-companion service dog trained in skills and tasks to help mitigate the patient’s specific disability.

Hopefully in the not-too-distant future there will be an evidence basis for recommending emotional support dogs for people living with mental health challenges. For example, the Department of Veterans Affairs is participating in a three-year study to compare service dogs and emotional dogs in the management of post-traumatic stress disorders. But until there is evidence to support the use of dogs, it is important to steer patients towards treatments that show evidence-based benefit for their specific challenges.

Peaberry, Dr. Baker's current assistance pup-in-training.

Dr. Baker and his wife, Janet, serve as volunteer puppy-raisers for Canine Companions for Independence, a nonprofit organization that enhances the lives of people with disabilities by providing highly trained assistance dogs at no charge to the recipient. Dr. Baker also is associate chair of clinical integration and services in the Department of Psychiatry at Dell Medical School and systems chief medical officer at Integral Care, the public mental health authority for Travis County.

By James Baker, MD
Austin Psychiatrist
Member, TMA Council on Science and Public Health

It takes a community to prevent adolescent substance abuse, and physicians can play an important part in that community effort.

While parents are the most important role models for their children, as physicians, our goal should be to help delay the age when teens first use alcohol or drugs. In addition to all of the problems related to underage drinking — sexual assaults, accidents, poor school performance — research suggests that teens who start drinking early are much more likely to have an alcohol use disorder as adults.

How can physicians help?

Prevention requires a community focus on the many risk factors that often lead to early drinking and drug use. Physicians can be mindful of these factors when they see teens in their practice. Here are some things physicians can look for and, when present, encourage teens and their parents to get help for:

• Family history of drug or alcohol use,
• Family problems or disruptions,
• Low motivation at school,
• Behavior problems at school, and
• Friendships with other teens with problem behaviors.

When these issues are present, doctors can encourage interventions to address them. For example, poor school performance warrants an evaluation for undiagnosed learning disorders. Family issues warrant an evaluation to see if family therapy is recommended. Motivation issues and behavior problems might indicate an underlying mood or other emerging psychiatric disorder. The local community mental health center is a good resource for all of these problems.

In addition, physicians can adopt the practice of routinely screening for alcohol and drug abuse in their young patients. Screening for depression, anxiety, stress disorders, and substance use ought to be just as routine as taking vital signs. One possible screening tool is CRAFFT. CRAFFT is just six questions shown to be effective in assessing whether a referral is indicated for a longer evaluation of alcohol or drug use. CRAFFT stands for:

Car (Have you been in a car with a driver — including yourself — on drugs or alcohol?),
Relax (Do you use drugs/alcohol to relax?),
Alone (Do you use drugs/alcohol while alone?),
Forget (Do you forget things while on drugs/alcohol?),
Friends (Are your friends concerned about your drugs/alcohol use?), and
Trouble (Have you gotten into trouble while on drugs/alcohol?).

Finally, because they are community leaders, physicians can encourage the entire community — parents, teachers, coaches, and religious and civic leaders — to give children the same messages discouraging alcohol and drug abuse, starting very early in childhood.

We can help teens — and their families — avoid long-lasting consequences of alcohol and drug use through a collective and consistent message, universal screening, and early and aggressive intervention.

Dr. Baker is associate chair of Clinical Integration and Services in the Department of Psychiatry at Dell Medical School and systems chief medical officer at Austin Travis County Integral Care.