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Trained or not, family doctors and pediatricians are on the front lines of mental health care

, Nashville Tennessean


Here are some tips to help recognize a mental health crisis and how to help. Ayrika L Whitney, The Tennessean

When a sick kid steps into the pediatrician’s office, it could be for just about anything: an ear infection, a twisted ankle or an upset stomach. And sometimes, behind all those outward symptoms, there is something deeper that needs attention.

Pediatricians and family doctors have long served a crucial but largely undefined role in American mental health care, diagnosing and treating depression and anxiety in addition to everyday physical injuries and common diseases.

But amid rising concern about mental health and gun violence in America, experts say these primary care doctors could do more to spot red flags among their patients.

Dr. Nathaniel Clark, chief medical officer at Vanderbilt Behavioral Health, described the task of primary care doctors as challenging: They are the Swiss army knives of medicine, expected to do a little of everything, but also a front-line defense in a growing mental health crisis.

“As health care has become more complicated, the pressure on family care providers to do it all has increased exponentially,” Clark said.

“But what’s also happened is there is a growing awareness of how common behavior health disorders are. And the challenge for family practitioners and pediatricians is partly that, while they have excellent training, it’s not necessarily focused on behavioral health.”

Psychiatrists are in short supply throughout Tennessee and nationwide, so the vast majority of mental health disorders are diagnosed and treated by primary care doctors. Nearly all these doctors studied mental health at one point because a psychiatry rotation is mandatory in most medical schools. But once school is done, the amount of continuing education they get in the field of mental health varies broadly.

More: Clergy not prepared to meet congregations’ mental health needs

More: When we have mental health crises, are our schools, churches or doctors offices prepared?

But now a relentless drumbeat of deadly mass shootings — including Nashville’s own Waffle House shooting — has spurred a nationwide desire to prioritize mental health and expanding training options for primary care doctors.

In Tennessee, the governor’s office has led an initiative called “Building Strong Brains,” funded with $1.25 million from state lawmakers the past two years, including grant funding for mental health education for pediatricians and other doctors.

Training primarily focuses on the link between early-age childhood trauma, officially known as “adverse childhood experiences,” and teenagers with behavioral and physical health problems.

In addition to the Building Strong Brains program, the Tennessee Chapter of the American Academy of Pediatrics has launched the Behavioral Healthcare in Pediatrics training program, or BeHIP, in which doctors learn from real cases of children with complex mental health diagnoses.

The program started small, uniting about five pediatricians in the state’s northeast corner, but is now expanding into Knoxville. Organizers hope to expand it statewide, said Dr. Michelle Fiscus, BeHIP medical director.

Participating doctors discuss challenging mental health cases within Tennessee’s children protective services system, Fiscus said. That experience should make the doctors’ interaction with other patients with depression or attention deficit disorders “much less intimidating.”

“It makes perfect sense that a pediatrician could be a great resource and manager of behavioral health concerns for our patients,” Fiscus said.

Fiscus, a Franklin pediatrician, said she envisioned the BeHIP training program in part because of an uncertainty she felt when treating mental health patients years ago. Too many other doctors, she said, still feel the same way.

“Across the state, it’s not the biggest topic that pediatricians want to treat,” Fiscus said. “Because it’s so large and so broad, sometimes they don’t know where to start when it comes to mental health.”

Jessica Bliss contributed to this report.

Study finds high rates of stress events, suicidality among college students

September 6, 2018, Brigham and Women’s Hospital

Credit: Kaitlyn Beukema

For college-bound students and their families, the start of the school year can be a time of excitement and optimism, but a new study brings to light that the college years are also a time of increased risk of stressful events and a wide range of accompanying mental health challenges, including risk of suicide. Published online today in Depression & Anxiety, a study of more than 67,000 college students from across more than 100 institutions has found that while racial/ethnic, sexual or gender minorities are especially vulnerable, high rates for stress events, mental health diagnoses and the risk of suicide or suicidal thoughts were reported among all students surveyed.

“Colleges and family members who are sending students off to need to remember that this is a phase of life where young people are confronted with expectations from new relationships and living situations and other encounters that are stressful,” said lead author Cindy Liu, Ph.D., of the Departments of Pediatric Newborn Medicine and Psychiatry at BWH. “Some stressful events cannot be prevented and, in some cases, are completely normal. But for others, a plan should be in place for family, friends, and colleges to provide support. Our study highlights an urgent need to help students reduce their experience of overwhelming levels of stress during college.”

Liu and her colleagues analyzed results from a survey conducted in the spring of 2015 by the American College Health Association-National College Health Assessment (ACHA-NCHA). The survey asked students a variety of questions related to depression and anxiety, including whether they had been diagnosed or treated for a mental issue; if they had engaged in self harm, considered or attempted suicide; and how many they had experienced in the last year.

Stressful life events, defined as exposures that the felt were traumatic or difficult to handle, included academics, career-related issues, death of a family member or friend, family problems, intimate relationships, other social relationships, finances, health problem of family member or partner, personal appearance, personal health issue and sleep difficulties.

The team reports the following:

  • Rates of stressful life events were high and associated with . Three out of four students reported having experienced at least one stressful life event in the last year. More than 20 percent of students reported experiencing six or more in the last year. Stress exposure was strongly associated with mental health diagnoses, self-harm, and suicidality.
  • Mental health diagnoses and suicidality were common. One in four students reported being diagnosed with or treated for a mental health disorder in the prior year. One-fifth of all students surveyed had thought about suicide, with 9 percent reporting having attempted suicide and nearly 20 percent reporting self-injury.
  • Sexual minorities showed elevated rates of and suicidality/self-injury. Transgender students showed particularly elevated rates of all outcomes, with approximately two-thirds reporting self-injury and more than one-third attempting suicide. Over half of bisexual students reported suicidal ideation and self-harm, with over a quarter reporting attempted suicide.
  • Rates of concerning mental health symptoms are higher now than they were the last time the survey was given. Among gay/lesbian and bisexual students, rates were higher than the 2009 administration of the survey for suicidal ideation (57.8 vs. 47.7 percent), suicide attempts (27.6 vs. 25.3 percent) and self-injury (51.4 vs. 44.8 percent).
  • Mental health issues may be underreported for racial/ethnic minorities. Despite a higher likelihood of and suicide attempts, Asian students reported a lower rate of diagnosis compared to white students. Black students showed a lower likelihood of reporting all outcomes compared to white students.

The authors note that all these rates are based on self-report, and that there may be a response bias among those who received the online surveys. While the 108 colleges in the survey were diverse in setting and included minority-serving institutions, each elected to participate, and their results may not be generalizable to all schools across the U.S. Additional research is needed to determine if there is increased vulnerability among students who belong to an intersection of identities (for instance, students who identify as both a sexual and racial/ethnic minority).

Explore further: LGBQQ college students face barriers to campus mental health services, study finds

More information: Cindy H. Liu et al, The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: Implications for addressing disparities in service use, Depression and Anxiety (2018). DOI: 10.1002/da.22830

Improve Mental Health Access: Collaboration, Integration, and Telepsychiatry

Sep 1, 2018 Volume: 35 Issue: 9

information of the Mercy Kids/Mercy Virtual - Behavioral health program

Mercy Kids/Mercy Virtual – Behavioral health program

Image of Massachusetts Child Psychiatry Access Program


Perhaps pediatricians should consider telepsychiatry

Perhaps pediatricians should consider telepsychiatry

Every day, pediatricians encounter children and adolescents in need of mental health services. We usually refer these patients to mental health professionals who can provide diagnosis, counseling, or medication management. In many circumstances, unfortunately, mental health providers have limited availability. This article will detail ways we can provide services within the walls of our practices. As you will see, pediatricians are quite capable of caring for both the physical and mental health of patients.

The problem

According to Best Principles for Integration of Child Psychiatry into the Pediatric Health Home, published by the American Academy of Child and Adolescent Psychiatry (AACAP) in 2012:1

·      20% of all children in the United States have a mental health problem, but only 20% of them receive treatment.

·      13% of children aged 8 to 15 years have a mental illness that impairs daily living. In the group aged 13 to 18 years, the percentage rises to 21%.

·      50% of lifelong mental illness begins by age 14 years; 75% by age 24 years.

·      The average delay between symptom onset and intervention is between 8 and 10 years.

Even more impressive are the statistics reflecting the lack of mental health services for our patients. According to the AACAP website, the current need for child and adolescent psychiatrists (CAPs) is 30,000, but only 8300 are practicing, and this pool is shrinking. Because of the severe shortage of child psychiatrists, 75% of all mental health services are provided by pediatricians.1

Practice-based mental health access

Pediatricians have identified several barriers to providing mental health services on their own. These include lack of mental health training, time restrictions, and reimbursement concerns, as well as lack of mental health resources in many communities. Nine years ago, the American Academy of Pediatrics (AAP) Committee on Psychosocial Aspects of Family Health and the Task Force on Mental Health recommended that pediatricians integrate mental health screening into routine practice and provide office-based mental health services whenever possible. The policy stated that pediatricians should partner with mental health specialists to petition insurers to improve payment for mental health services, and collaborate with community mental health specialists to improve provider knowledge and skills, with the goal of providing mental health services within the “medical home.”2

There are 2 ways pediatricians can provide on-site mental health care. One involves embedding services directly into a practice, while the other involves seeking collaboration with existing community mental health professionals for training and support.

Integrative mental health care

To facilitate provision of mental health services for patients, you might consider embedding one or more mental health professionals in your practice. You may choose to employ a prescribing mental health nurse practitioner and/or a psychologist/psychotherapist. Alternatively, you can provide office space to these professionals who may prefer to remain independent. This would be a very attractive option, especially for those who are building their practices, as it provides immediate access to a large referral base. Having mental health professionals in your office under a rental agreement enables provision of services on a sliding scale for uninsured or underinsured patients. This may be difficult for pediatricians to do on their own due to restrictions imposed by insurance contracts.

Another integrative approach is to incorporate telepsychiatry into your practice. Via telepsychiatry, parents and patients can participate in a virtual face-to-face visit with a mental health professional in a room equipped with a televideo setup. There are several nationwide telepsychiatry services available, and these can be implemented at little or no cost to your practice. In many ways, telepsychiatry may be the easiest and most expeditious method for practices to expand their behavioral health capabilities (see “Perhaps pediatricians should consider telepsychiatry”).

Collaborative mental health care

Another way to improve practice-based mental health services is to form an alliance with a child and adolescent psychiatrist (CAP) in your community. One can invite motivated CAPs to join your practice for “lunch-and-learn” sessions. Over time, these will improve your ability to render mental health services independently.

There are many states that have implemented programs that facilitate mental health access. In 2003, the University of Massachusetts Medical School in Worcester initiated a pilot program to provide support services to pediatricians who wanted to provide behavioral health services within their practices. A year later, with funding from the state, the program, then called the Massachusetts Child Psychiatry Access Program (MCPAP), expanded statewide. The MCPAP improves an enrolled pediatrician’s ability to assess patients and to treat patients with anxiety, mood disorders including depression, and substance abuse problems (Figure). The program also facilitates referrals and care coordination for patients who need community-based specialty services.

The MCPAP uses 6 hubs to effectively cover 95% of the children in Massachusetts. The Massachusetts Department of Mental Health receives a $3.1 million annual appropriation from the commonwealth to fund the project. The MCPAP website ( has numerous resources for pediatricians including webinars on diagnosis and management. As a result of the program, the screening rate of children for behavior health problems who had Medicaid insurance increased from 17% at program onset to 80% as of 2014.3,4

The success of the MCPAP has led to the creation of similar programs throughout the country. Currently there are similar Child Psychiatry Access programs operating in 28 states. These programs are coordinated via the National Network of Child Psychiatry Access Programs (NNCPAP). The NNCPAP website ( lists state-by-state resources as well as contact information.

Time to decide

As discussed earlier in this article, pediatricians have many options regarding expanding the ability of their practices to provide direct mental health services to patients, even in communities where resources may be wanting. It’s time for pediatricians to be proactive and either integrate mental health services into the medical home or upgrade skills so we can assume responsibility for patients in need.


1. American Academy of Child and Adolescent Psychiatry. Best Principles for Integration of Child Psychiatry into the Pediatric Health Home. Washington, DC: American Academy of Child and Adolescent Psychiatry; 2012. Available at: Accessed July 3, 2018.

2. Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Policy statement—The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics. 2009;124(1):410-421.

3. Sarvet BD, Ravech M, Straus JH. Massachusetts Child Psychiatry Access Project 2.0: a case study in Child Psychiatry Access Program redesign. Child Adolesc Psychiatr Clin N Am. 2017;26(4):647-663.


4. Straus JH, Sarvet B. Behavioral health care for children: the Massachusetts Child Psychiatry Access Project. Health Aff (Millwood). 2014;33(12):2153-2161.

What’s Driving ‘Whole Health’ For Children?

By Monica E. Oss


A couple weeks ago, I hosted our first annual OPEN MINDS Children’s Services Executive Summit. In the opening session, The 5 Key Trends Driving Change In Children’s Services, I discussed how the push for “integrated care” is changing the financing and delivery for children’s services—much like it is with health care overall. But, the issues for children are unique, and the “integration” is spanning not just health care and services for children with disabilities, but also child welfare and special education services.

This market shift is illustrated by the launch of the Whole Child Model Program in California, which integrated most services in the California Children Services (CCS) program with the health plans in select areas of the state. The CCS program, which provides services to children with special needs and disabilities, previously delivered and financed services fee-for-service. The program also requires health plans to report on a series of quality measures including emergency room utilization, family satisfaction, mental health visits, and inpatient stays (see California Medicaid Launches Whole Child Model Program).

And, a recent assessment of the New Hampshire child welfare system by Public Consulting Group (PCG) called for more integration of mental health, addiction treatment, and preventive services to better support youth and families. It even included a recommendation to contract with Medicaid managed care organizations to create and support a continuum of community-based services for youth with complex needs. PCG also called for “continuous accountability, quality improvement, and data mechanisms to track, monitor and manage the achievement of system of care goals, fidelity to the system of care philosophy, and quality and effectiveness at the geographic, agency, system, and individual level” (see New Hampshire Child Welfare Assessment Recommends Integrating Behavioral Health & Preventive Services).

There is good reason for this push for better coordination of services for children—there are wide variances in state performance on measures related to child health. My colleague, Athena Mandros, recently took a look at the Child Medicaid Core Set for behavioral health and found that the median state score on 30 day follow-up after a mental health hospitalization was 44.7% and the median state score on 30 day follow-up after an ADHD medication was newly prescribed was 48.8%. And state scores on these measures ranged by 82.5 percentage points and 72.9 percentage points, respectively (see Are The Kids All Right?).

And other recent research results illustrate the “gaps” in serving children in the U.S. health and human service system.

Only one-third of children receive the developmental screening and surveillance that is recommended during early childhood, meaning that of the estimated nine million children aged 9 through 35 months, only 30.4% received developmental screening and only 37.1% were reported to have received developmental surveillance (see A Third Of Children Receive Recommended Early Childhood Developmental Screening & Surveillance).

A 2018 lawsuit filed against the California Department of Health Care Services (DHCS) alleges that the state Medicaid program (called Medi-Cal) fails to provide adequate in-home nursing care for children with disabilities, with at least 29% of authorized Medi-Cal nursing hours going unstaffed (see Lawsuit Alleges California Medicaid Fails To Provide Adequate In-Home Nursing Care For Children With Disabilities).

Children who experience a traumatic brain injury (TBI) commonly have unmet treatment needs during the two years after the injury—over 25% of children with “complicated mild TBI” had unmet service need for speech therapy, mental health, services, educational services, and psychiatry services (see Unmet Therapy Needs Common In Children With Traumatic Brain Injury). And, about 20% of children hospitalized for TBI never return for outpatient follow-up treatment. Of those that do return for outpatient follow-up, 27% miss appointments (see Many Hospitalized Children With TBI Do Not Return For Follow-Up Care).

While each of these stories represents a narrow view of the market, I think they are pieces of a long-running trend where the need for services is misaligned with the services actually received. This arises from the siloed funding and service mentality that defines most of the market. For more on the children’s services market, check out these resources:

  1. Los Angeles County Contracts With A Second Chance, Inc. To Address Foster Family Approval Process Backlog
  2. Texas DFPS Selects Family Tapestry For Bexar County Foster Care Management Contract
  3. New Integrated Child Health System Goes Live In Wales
  4. Homelessness During Infancy: Associations With Infant & Maternal Health & Hardship Outcomes
  5. Apricot Case Management Software Receives $59 Million Investment
  6. ACF Launching EBP Clearinghouse For Family First Prevention Services Act
  7. Parents With Adverse Childhood Experiences More Likely To Have Children With Behavioral Health Problems
  8. Iowa Agrees To Change Special Education Requirements
  9. Maine Medicaid To Cover Youth Psychiatric Residential Treatment Facility Setting
  10. Settlement In Kentucky Lawsuit About Faith-Based Foster Homes Ruled Unenforceable

Want to keep up on all the latest news about the children’s service market? With one click, you can customize the market intelligence that comes to your inbox and receive our monthly market intelligence report on children’s services. Update your email preferences today to receive this monthly report—a summary of all of OPEN MINDS’coverage of the children’s service market.

Need a refresher on the metrics that are driving all improvement in health care service delivery? Join us at The 2018 OPEN MINDS Technology & Innovation Institute on October 23 in Philadelphia for the session: “Mapping Performance To Manage Value: The Clinical Data You Need To Manage The Risk Of Value-Based Reimbursement”, featuring OPEN MINDS Senior Associate Joseph P. Naughton-Travers; Vinfen President & Chief Executive Officer, Bruce L. Bird, Ph.D.; and Project Transition Chief Executive Officer, Luke Crabtree, J.D., MBA.