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Mental health risk higher for transgender youth

A new study suggests that transgender and gender non-conforming children and adolescents may be more likely to develop depression and other mental health conditions, compared with individuals whose gender identity matches their assigned gender at birth.

a sad woman sitting by a window

The research was conducted at the Kaiser Permanente Southern California Department of Research & Evaluation in Pasadena. Study co-author Tracy A. Becerra-Culqui, Ph.D., and colleagues recently reported their findings in the journal Pediatrics.

According to Becerra-Culqui, previous studies that investigated the mental health of transgender and gender non-conforming individuals only looked at a small number of people, and any symptoms of mental health disorders were self-reported.

For this latest study, however, the team gathered data from the electronic medical records of 1,347 children and teenagers — aged 3–17 years — who were transgender or gender non-conforming.

Of these individuals, 44 percent were transfeminine (their assigned gender at birth was male), and 56 percent were transmasculine (their assigned gender at birth was female).

Between 2006 and 2014, the researchers looked at the prevalence of mental health conditions, such as depression, anxiety, and attention deficit disorder, among these youths.

The study revealed that the risk of developing a mental health condition was three to 13 times higher for transgender and gender non-conforming youth than youth whose gender identity corresponded with their assigned gender at birth, also referred to as cisgender.

Diagnoses of depression and attention deficit disorder were the most common mental health conditions among children and teenagers who were transgender and gender non-conforming, the researchers report.

In fact, the risk of attention deficit disorder was three to seven times greater among these individuals, compared with those who were cisgender; and, the risk of depression was four to seven times greater.

Around 15 percent of transfeminine and 16 percent of transmasculine youth were diagnosed with attention deficit disorder, while depression was diagnosed among 49 percent of transfeminine and 62 percent of transmasculine youth.

Becerra-Culqui and colleagues are unable to pinpoint the precise reasons behind their findings, but they believe that gender dysphoria may play a role.

Gender dysphoria is a condition wherein an individual experiences distress because of a disconnect between their biological sex and the gender with which they identify.

Additionally, the team notes that many transgender and gender non-conforming individuals are subject to prejudice and discrimination, which can cause stress and potentially lead to mental health problems.

Becerra-Culqui says that she hopes that this research “creates awareness about the pressure young people questioning their gender identity may feel, and how this may affect their mental well-being.”

She adds that clinicians should be aware of the heightened risk of mental health conditions that transgender and gender non-conforming youth may have.

“It is also crucial they have the knowledge necessary to provide social and educational support for their young patients who are figuring out their gender identity,” Becerra-Culqui adds.

“We Need to Normalize Mental Health Care in the Black Community”

A USC professor shares her personal story of mental illness to shatter the stigma and inspire others to get help.
Image courtesy of Smartboy10/ Getty Images
Image courtesy of Smartboy10/ Getty Images

I am a PhD, a book author, a professor at USC. I work with organizations to create healthier and happier workplaces by reducing stress and building emotional resilience. And yet, until very recently, I have been reluctant to share my own story.

It is a story of mental illness, recovery and resilience, a story of bipolar disorder. And I have been hesitant to share it because I did not want to experience the stigma associated with mental illness.

I used to joke that I didn’t want to be the embodiment of “the nutty professor,” but the joke stopped being funny when the stigma against mental illness — particularly in the black community — negatively impacted my professional and personal life. In previous roles, I learned that it wasn’t acceptable for me to have a mental illness in my professional setting, and that it definitely was not okay to talk about it. My competence was questioned, even though I no longer had symptoms and was given a clean bill of health from my psychiatrist, and I was asked to not ‘out’ myself as having bipolar disorder to my students. That is why I’m sharing my story publicly: I hope to inspire my students to fight their way through their own mental health challenges.

Even with all my degrees, even with my understanding of the healthcare system, finding affordable and accessible mental health services has often been a challenge for me. Even though I know what it’s like to have supportive family, friends and colleagues, and a fantastic healthcare team, I have struggled. These experiences have inspired my activism and advocacy for a world where using mental health services is no different than getting care for any other illness.

Let me start with a little-known statistic: African Americans are 20 percent more likely to experience serious mental health problems than the general population, according to the Office of Minority Health. And yet: only about 25 percent of African Americans seek mental health care as compared to 40 percent of whites, according to the National Alliance on Mental Illness.

The reasons for this discrepancy are plentiful: lack of health insurance, distrust of mental health care system, misdiagnosis of symptoms, lack of cultural competence, and stigma. Addressing these challenges for African Americans entails three parts: taking care of our mental health should be acceptable, accessible and affordable.

Allow me to explain.


We live in a society where it is not socially acceptable to talk about one’s mental illness. It is much easier to say you are in recovery from addiction or in remission from cancer than to say you are in recovery from bipolar disorder or to speak of your depression or anxiety freely. There is no token to reward me and no norm for saying how long I have been symptom-free.

We live in a culture that does not support mental health and well-being. We work too hard for too long with too little respite. The United States is the only industrialized nation with no national paid maternity leave and no federally required vacation. In Europe the norm for sick leave is 2 to 4 weeks, with 5 to 6 weeks of paid holidays. Americans often feel as if we are in a competition to see who can work longer hours and take fewer breaks, and the result is higher and higher rates of chronic health conditions such as heart disease, hypertension, high cholesterol and obesity — and its related co-morbidities.

And for African Americans, the never-ending onslaught of the stress of systemic and personal racism and discrimination — both at the macro and micro levels — exacerbates what regular life in America brings. Stereotypes such as the “Angry Black Woman” or the “Black Superwoman” are based in a reality in which black women are expected to do everything perfectly and all at once, and that we should fight back every time we think we have been racially wronged. There is this sense that “black don’t crack,” emotionally or mentally (and not just in reference to our reputedly wrinkle-resistant skin).

The stigma of mental illness in the African American community goes something like this: “We made it across the Atlantic in the hold of ships and survived slavery, so now, we can survive whatever comes our way.” And even when we feel as if maybe things are getting too much, we have another narrative that says, “Take it to the Lord in prayer.”

Faith and spirituality are excellent supports of mental health and can reduce isolation and extend life. But if we approve of people taking medications for hypertension, or getting dialysis for kidney failure, then we should approve of people getting treatment for brain disorders. Having a therapist DOES NOT MEAN that people are weak or not enough of a Christian. We shouldn’t have to literally swallow our troubles into obesity, and associated chronic illnesses like hypertension and diabetes and unacceptably poor maternal and child health outcomes.

Recently, New York State became the first state to require mental health education in all its K-12 public schools, which hopefully means that the next generation will be more likely to find mental health acceptable to talk about. It is also great to see men like Jay-Z talking about going to therapy, but it is still a long way from being normalized, especially for African American men.

Mental health care is marginalized within the healthcare system. It is not usually a component of annual primary care visits. Medical practitioners often say they don’t have enough time, but there are many ways to get this done. It can be a simple paper form given in the waiting room or done on a tablet of some sort. It could even be done electronically before we show up for our annual visit. This would make the most basic of mental health care ACCESSIBLE and make mental health more ACCEPTABLE to talk about.

So let’s say you are one of the small minority of people whose primary healthcare provider completes a mental health assessment, and it is determined that you need specialized mental health services. Then what? Now you have to find a mental healthcare provider. It is not so easy to find a mental health provider who is both taking clients and taking health insurance. There are not enough mental health care providers and the trends in medical training reveal that there will be even fewer psychiatrists than we need in the near future. A primary reason is that nationwide, more than 50 percent of psychiatrists and more than a third of psychotherapists are over the age of 60.

For many African Americans who may want to discuss the impact of racism on their mental health and physical well-being, finding a mental health practitioner who is also culturally competent is important to their healing. There are significant inequalities in care, from misdiagnosis to overuse of medications to misunderstanding cultural expressions of mental distress. But it is not easy to find mental health professionals trained in anti-racist practice and other anti-oppressive strategies, especially outside of major urban areas. Only 2 percent of psychiatrists and a little more than 5 percent of psychologists are African American, according to estimates. To address this accessibility issue, there needs to be more recruitment and training of African American mental healthcare providers, and training of more providers in culturally competent methodologies. (It is important to note that being African American does not by default make one skilled in anti-racist practice.)

With almost 20 percent of African Americans not having health insurance, cost is a significant factor in being able to access mental health services. By including mental health assessments in primary care, there will be a reduced need for expensive specialized care; especially if the assessments are used to do early intervention, such as lifestyle changes and medications, before there is need for acute care. There also needs to be monitoring, advocacy and activism connected to how mental health care will fare if the Affordable Care Act gets dismantled. We need to continue to advocate for expanded health insurance coverage and the provision of low-cost mental health services.

Solutions to the affordability issue also include options like having support groups that are both community-based and faith-based, which will also solve a lot of the accessibility and acceptability issues as well. Courses like mental health first-aid will assist communities and professionals in early detection and referral to services that will reduce mental health crises that can have negative lifelong impacts.

Making mental healthcare accessible and affordable for African Americans requires coordinated efforts across healthcare systems, and advocacy and activism in the policy arena. Making it acceptable for African Americans to talk about mental health requires ongoing conversations across sectors such as places of work, places of worship and the media. The more it is done, the easier it will be.

This op-ed is adapted from a keynote delivered at the health luncheon of the NAACP national convention on July 16, 2018, in San Antonio, TX.

13 Reasons Why We MUST Talk About Teen Mental Health

By  August 31st, 2017 ACEs and Resilience, Mental Health Awareness

Last year, the New York Times reported that the suicide rate in the United States had hit a 30 year high, particularly affecting adolescent girls. Suicide is the third leading cause of death for young adults ages 15-24, and reports state that most teens who completed suicide have some type of coexisting mental health condition, such as depression, anxiety or drug and alcohol abuse.

The time to talk about teen mental health issues is now, and the place to start is with open conversation.

Perhaps it makes sense why 13 Reasons Why is one of the most popular shows on Netflix this year. It tells the story of a high school student named Hannah Baker, who through a series of tapes, offers a rationale for why she decided to take her own life. There is an ongoing debate on whether or not such graphic details were constructive or destructive to reveal, but what we know is that regardless, being able to identify and address warning signs and symptoms of mental health issues is very important.  Having this knowledge may very well save lives.

Toxic Stress Affects Teen Mental Health

There is a common denominator that we see in our work, toxic stress that occurs in childhood.  The 1998 landmark Adverse Childhood Experiences (ACEs) Study by the Centers for Disease Control and Prevention and Kaiser Permanente provides insight on types of toxic stress that results from childhood trauma (e.g. abuse, neglect, family dysfunction) that are predictive of mental health outcomes, such as depression and anxiety, suicide attempts and drug abuse. Our focus is on how we can help minimize the impact of adversity, bolster strengths to build resiliency, and in many cases change the trajectory of young lives.

In 2016, we conducted a review of the impact of ACEs and their relationship with collaborative youth mental health services. We sought to determine the relationship between our integrated and collaborative mental health services and mental health outcomes, specifically with children who were exposed to multiple adverse childhood experiences. The goal was to further our development of evidence-based practices and present a case for support for widespread understanding of ACEs as part of mental health treatment and prevention strategies.

The content of our report shows:

  • ACEs pose a threat to proper brain development.
  • More than half of the adults in California have at least one ACE.
  • Individuals with four or more ACEs are seven times more likely to have mental health problems and 11 times more likely to attempt suicide than individuals with zero ACEs.
  • Without intervention, the estimated weighted annual community cost per child is $18,856 in one community.
  • Western Youth Services is addressing ACEs with nearly every research-recommended strategy.

Teen Mental HealthOur Version of 13 Reasons Why

Over the course of the next few months, we will be publishing a series of articles addressing the most prevalent 13 adversities and/or teen mental health conditions that our clients experience. It is our hope that the overview below and the accompanying articles in the series will serve as an informative resource to increase awareness, reduce stigma, cultivate healing, strengthen communities, and most importantly to change lives.

1. Abandonment 
Whether through divorce, death, distant parents or caregivers, or a falling out among friends, abandonment issues create emotional conditions that are not conducive for healthy development. Young adults who have been the victims of abandonment may struggle to trust others, inadequately express their needs, and experience disproportionate feelings of shame, low self-esteem and the like.

2. Abuse 
Abuse is an umbrella term for any act that aims to “diminish one’s sense of identity, dignity, or self-worth.” Abuse can be verbal, physical, sexual, or emotional, and can occur whether or not the abuser is aware that they are negatively harming someone.  Abuse can be inflicted by parents, friends, neighbors, acquaintances or strangers. Teen dating abuse and violence is a particularly big issue for adolescents and young adults today.

3. Anxiety and Depression
Although anxiety and depression are not mutually exclusive, they can both be characterized by the persistent and excessive presence of worry, sadness, irritability or unwanted/intruding thoughts. The conditions, which can often occur in tandem, may present as irrational worry, withdrawal, isolation, disinterest in activities and family/friends, changes in appearance, irritability or moodiness. Anxiety and depression are the leading causes of suicidal ideation. Over 90% of young adults who report experiencing suicidal thoughts are also being diagnosed with one or both.

4. Bullying and Cyberbullying 
Bullying is unwanted or aggressive behavior that creates a real or perceived power imbalance. Bullying can include, but is not limited to: teasing, name-calling, threatening to cause harm, leaving someone out on purpose, spreading rumors, publicly embarrassing, hitting, kicking, tripping, stealing, or insulting someone. Cyberbullying is bullying that occurs using electronic technology, and can include, but is not limited to: mean texts or emails, rumors posted publicly, embarrassing photos or videos, and the creation of fake profiles used to mock or steal the identity of an individual.

5. Drug and Alcohol Abuse
Drug and alcohol abuse is the usage or over-usage of illegal or prescription drugs or excessive alcohol intake. Studies show that there is a link between drug and alcohol abuse and suicide in teens, and some of the warning signs include having a sudden change in friends, being secretive or withdrawn from family, dropping grades, paying less attention to hygiene and new or odd behavior.

6. Eating Disorders
Eating disorders are the use of restriction, binging or purging in association with negative body image and self-esteem, or the desire to change one’s body. Behaviors may include restricting meals, not eating for long periods of time (anorexia), binging and then purging (bulimia), exercise addiction (orthorexia), overeating to the point of feeling sick (binge eating), or a combination of these. Some causes may be related to genetics, traumatic experiences, peer pressure, bullying, or having a friend or family member with an eating disorder.

7. Embarrassment and Shame 
Shame is the emotion of feeling “lesser than,” bad, wrong, or unworthy. Embarrassment is the feeling that accompanies having your individuality or inadequacy (whether real or perceived) made a point of public attention. These emotions occur often in young adulthood, as teens are developing their sense of self and finding their confidence. Research notes that it is during this time of life that our propensity to compare ourselves to others, self-reflect and feel sensitivity toward other people’s opinions is at a high. Feeling embarrassed or ashamed of oneself is one of the most overlooked connections to suicide or suicidal ideation.

8. Family Dysfunction  
There are a wide range of issues that are considered familial dysfunction.  Most people associate it only with big events such as witnessing violence at home, living through a parental divorce, separation, or death, drug or alcohol abuse, physical abuse, and family members with mental, physical, or emotional illness. There are also adversities that may seem small or even go unnoticed, yet they cause traumatic stress that can lead to depression or anxiety that negatively impacts a person for life.

Teen Mental Health - Western Youth Services9. Social Isolation and Withdrawal 
Social isolation and withdrawal are classic signs of depression and possibly suicidal ideation. It occurs when the discomfort and stress of being around other people becomes so unbearable that one prefers to be by themselves more often than not. Children and young adults who struggle to fit in and feel accepted are more prone to experiencing bouts of withdrawal than adults.

10. Learning Disabilities
Young individuals with learning disabilities reportedly experience more abuse, neglect, challenging family dynamics, peer bullying, and exclusion than anyone else. Studies state that persons with learning disabilities “are likely to be at increased risk for undetected suicidal thoughts and behaviors.” This can be due, in part, to feeling misunderstood and isolated, different thought and conversation patterns, and struggling with tasks and responsibilities that seem to come more easily for others.

11. Neglect 
Though neglect falls under the umbrella of abuse, it is different from it in that it is the failure of a parent, caregiver or other guardian to care for a child under 18. Neglect can be physical or emotional, and it also includes failure to protect against sexual abuse, as it relates to the disregard for a child or young adult’s well-being. Studies show that over half of individuals who are admitted for care due to neglect show suicidal behavior.

12. Peer Pressure
Peer pressure is the influence that individuals within the same age group or social circle project onto one another. Often, it is actually the pressure to feel perfect or to perform in a way that is out of alignment with one’s true wants, desires or values that pushes the correlation between peer pressure and suicidal thoughts or behavior. 

13. Self-harm and Suicide 
Self-harm, suicide, and other forms of intentional self-mutilation affect 15% of adolescents in the US, and 17%-35% of college-aged students, according to The Journal of the American Board of Family Medicine. Self-harm is the umbrella term for any behavior that involves intentionally harming one’s body, such as cutting or burning. It is typically a sign that a young adult does not have the coping mechanisms to deal with such intense feelings of pain or dread, which is also what drives some to feel that there is no other way to “escape” than to end their own life.

Suicide is never a solution. It is an irreversible choice regarding a temporary problem. There is help. If you are struggling with thoughts of suicide or know someone who is, talk to a trusted adult, call 1-800-273 TALK (8255), or text “START” to 741741.

Since 1972, we have aimed to advance awareness and redefine mental health to include mental health and wellness services for children, teens, and families. We are acutely aware of the signs and symptoms of intensive mental health needs.  Through our decades of work, we are knowledgeable of the common precursors to crises and the risk factors associated with mental health conditions.  We are also experts in mitigating the ravaging effects of childhood trauma through our evidence-based and evidence-informed practices and treatment.  Our 3-tiered approach provides a wide range of prevention strategies, targeted intervention and clinical treatment for those with intensive mental health needs.

We have countless stories of healing and recovery to share, in which our clients have minimized the impact of adversity, developed their resiliency muscles, and gone on to lead happy, fulfilling lives. We recognize that each story began with a conversation, and we hope that the following series provides a starting point for more families, schools, and communities to have the knowledge and resources to start talking to the young people in their lives about what’s really going on in their hearts and in their minds.

The time to talk about teen mental illness is NOW.

Lorry Leigh Belhumeur PhD, CEO of Western Youth Services on Blog - Western Youth Services (WYS) Orange County - the hub of mental health care and wellness solutions for kids in Orange County, CA

Lorry Leigh Belhumeur, Ph.D.
Chief Executive Officer
Western Youth Services

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.