Child Psychiatrists Hope to Improve Primary Care Interactions

Data presented during the annual meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), held in Toronto in October, indicate that“ treatment as usual” for youth with emotional disorders seen in the primary care setting continues to be “often nonexistent or inadequate.”

In addition, for children who are referred to specialty mental health care providers, fewer than 35 percent receive any mental health treatment in the six months following their referral.

The data, presented by John Campo, M.D., an associate professor of psychiatry and pediatrics at the University of Pittsburgh, and his colleagues at Western Psychiatric Institute and Clinic, provided stark contrast to numerous upbeat AACAP meeting sessions devoted to the interplay of child psychiatry with pediatrics and primary care.

Several AACAP meeting sessions focused on detailed descriptions of novel service-delivery models wherein child psychiatrists actively consult to or successfully locate in collaborative practices with pediatricians or other primary care providers.

Other presentations described what some deemed “diagnosis mills”—mental health clinics to which children are referred by primary care providers only for a diagnostic evaluation and are then referred back to primary care with detailed treatment recommendations. While no treatment is given in this clinic model, more severely ill children are typically referred directly to other outpatient mental health care providers or to inpatient services if appropriate.

Still other presentations during the AACAP meeting detailed efforts across the country to place mental health specialists—ranging from clinical social workers to psychiatric nurse practitioners—directly into schools to serve as “front-line triage specialists.” From within the school walls, these specialists can identify children with mental health issues and refer them for evaluation and possible treatment.

Regardless of the specific model, though, each of the presentations centered around the need, demonstrated by the data presented by Campo and several others, to improve access to quality mental health services for all children. Yet the wide variety of models presented also speaks to the enormous challenge faced not only by AACAP, but by the American Academy of Pediatrics (AAP).

The two academies have been working together in some formal capacity on the issue for nearly 15 years, said Frances Wren, M.D., director of the Child and Adolescent Depression Clinic at Stanford University School of Medicine.

Wren, who co-chairs the AACAP Committee on Liaison With Primary Care and interacts with several AAP components, said the academies have been working more closely and with much more coordination over the last few years. Two things, she said, have spurred this increased activity.

“First of all, there has been more contact within the leadership of AACAP and AAP,” Wren told Psychiatric News, “and secondly, there has been more grassroots interest from [both organizations'] membership,” especially following recent FDA warnings regarding use of antidepressant and stimulant medications in children and adolescents. But the need for support tools for pediatricians with patients who have mental health concerns, Wren added, existed “long before the black box [label warnings].”

The increased collaboration between the academies and the increased concern among AAP members led the pediatric academy to list access to, and quality of, mental health services as one of AAP's five strategic objectives. As a result, Wren said, last year AAP formed its Mental Health Task Force, charged with developing tools to support pediatricians in the care of children in which mental health issues are a concern.

Wren, as the AACAP liaison to AAP, is a member of the task force. The task force is addressing four specific goals: development of “patient engagement strategies” that make the pediatric office more conducive to parents talking about mental health concerns, development of patient tracking tools (including support of electronic health records) and tools for interpractice communication, development of tools that support diagnostic and referral decisions, and development of strategies to address barriers related to organization and financing of care.

Today, Wren said, “there is certainly a real understanding between the two groups. It is my hope that these projects will lead to an expansion of the focus of both specialties beyond the narrow issue of identification and referral. These are two important issues, yet in between lies the whole world of collaborative care.” ▪