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.
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 (www.mcpap.org) 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 (www.nncpap.org) 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: https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/best_principles_for_integration_of_child_psychiatry_into_the_pediatric_health_home_2012.pdf. 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.