Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

The moderation effect of mental health services use on the relationship between exposures to adverse childhood experiences and mental health outcomes among US adolescents

BACKGROUND

The prevailing exposure to Adverse Childhood Experiences (ACEs) among youth is associated with adolescents' mental health. However, few studies have examined whether receiving help from mental health services affects mental health outcomes among adolescents with ACEs. Therefore, this study examines the moderated effects of mental health services use on the relationship between exposures to ACEs and mental health outcomes among US adolescents.

METHODS

The sample was restricted to adolescents aged 11-17 using data from the National Health Interview Survey (NHIS) from 2019, 2021, and 2022. Multivariate logistic regressions and descriptive analyses were performed to estimate the moderation effect of mental health services use.

RESULTS

Using mental health services buffered the associations between ACEs and severe anxiety and depressive symptoms. Receiving counseling/therapy moderated the impact of ever living with an individual who had severe anxiety (Adjusted Odds Ratio, AOR: 0.58, p < .05) and depressive symptoms (AOR: 0.38, p < .01) among adolescents. Furthermore, counseling/therapy moderated the effect of ever living with an individual with a history of alcohol or drug abuse on severe depressive symptoms (AOR: 0.49, p < .05) and the effect of being a victim or witness of violence on severe anxiety symptoms (AOR: 0.45, p < .01). In addition, taking prescription medication moderated the effect of the experience of incarcerated family members on severe anxiety symptoms (AOR: 0.41, p < .05).

CONCLUSION

Our findings suggest that policy and practice need to encourage access to mental health care for vulnerable adolescents with ACEs to reduce the detrimental effect of their experiences on their mental health problems.

Digital Platform for Pediatric Mental Health Support During Armed Conflicts: Development and Usability Study

Background

The prevalence of mental health disorders among children and adolescents presents a significant public health challenge. Children exposed to armed conflicts are at a particularly high risk of developing mental health problems, necessitating prompt and robust intervention. The acute need for early intervention in these situations is well recognized, as timely support can mitigate long-term negative outcomes. Pediatricians are particularly suited to deliver such interventions due to their role as primary health care providers and their frequent contact with children and families. However, barriers such as limited training and resources often hinder their ability to effectively address these issues.

objectives

This study aimed to describe the rapid development of a digital mental health tool for community pediatricians, created in response to the urgent need for accessible resources following the October 7th terror attack in Israel. The goal was to create a comprehensive resource that addresses a wide range of emotional and behavioral challenges in children and adolescents, with a particular focus on those affected by armed conflict and significant trauma exposure. In addition, the study aimed to evaluate the platform's usability and relevance through feedback from primary users, thereby assessing its potential for implementation in pediatric practice.

Methods

A digital platform was developed using a collaborative approach that involved pediatricians and mental health professionals from various hospital clinics. The initial framework for the modules was drafted based on key emotional and behavioral issues identified through prior research. Following this, the detailed content of each module was cocreated with input from specialized mental health clinics within the hospital, ensuring comprehensive and practical guidance for community pediatricians. A focus group of 7 primary users, selected for their relevant hospital and community roles, provided feedback on the platform's user experience, content relevance, and layout. The evaluation was conducted using a structured questionnaire complemented by qualitative comments.

Results

Fifteen detailed modules were created, each providing information, including anamnesis, initial intervention strategies, parental guidance, and referral options. The focus group feedback demonstrated high satisfaction, indicating a very good user experience (mean 4.57, SD 0.53), content relevance (mean 4.71, SD 0.48), and layout suitability (mean 4.66, SD 0.52). Specific feedback highlighted the value of concise, actionable content and the inclusion of medication information. Participants expressed a strong willingness to regularly use the platform in their practice (mean 4.40, SD 0.53), suggesting its potential for broad application.

Conclusions

This study demonstrates the effectiveness of a collaborative development process in creating a digital tool that addresses the mental health needs of children in crisis situations. The positive feedback from pediatricians indicated that the platform has the potential to become a valuable resource for early recognition, crisis intervention, and parental support in community pediatric settings. Future research will focus on broader implementation and assessing the platform's impact on clinical outcomes.

Evaluation of a pediatric navigation program within primary care: a quantitative analysis guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework

BACKGROUND

Pediatric Support Services (PSS) is a Patient Navigation Program designed to address barriers from referral-to-service connection from primary care to health system and community-based services and resources. This study aimed to evaluate PSS' implementation for mental health services along the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and identify factors throughout implementation to inform sustainability and delivery.

METHODS

This study included descriptive analysis of all patients referred to PSS to assess reach, with a primary cohort analyses of a subset of patients referred specifically to mental health services. Data collection included triangulation of information extracted from electronic health records, direct contact with patients' caregivers, and follow-up surveys completed by patients' caregivers. Analyses were designed within each construct of the RE-AIM framework, and assessed for their tiered impact on the patient, provider, and system levels.

RESULTS

From October 2019 to June 2023, 13,109 total referrals for 11,214 unique patients were triaged by PSS. The patient population overrepresented younger, Hispanic, female patients compared to the clinical population included in this health system's service area. Of these patients, 3,929 were followed-up by trained navigators at two-weeks for mental health service connection, with 50.6% reported being connected to referred services and an additional 27.1% with pending appointments. There was a significant increase in referral connection rate as age increased and for Black patients, compared to other children. For patients considered connected to or pending services, a satisfaction survey found high satisfaction with PSS and the amount of navigator-patient contact (81.5 and 79.6%, respectively).

CONCLUSION

These findings highlight potential program modifications to optimize quality of care and health for children and families, while enhancing capacity among providers, navigators, and clinics. Further adaptations, including electronic health record integration, patient/family feedback, and automated navigation processes, are suggested next steps for comprehensive navigation.

TRIAL REGISTRATION

This study was approved by the Institutional Review Board for Prisma Health, trial number 1,852,794, with the most recent approval for expanded evaluation received on June 15, 2022 (original application approved in 2016).

Anxiety, Depressive, and Eating Disorders in Adolescents

Adolescent anxiety, depressive, and eating disorders are a worsening population health issue that primary care clinicians play a critical role in addressing. Implementing universal screening into clinical practices for depression at age 12 years and anxiety at age 8 years is the first step to diagnosis. Referencing 5th edition of the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria is essential to making the correct diagnosis after ruling out underlying medical conditions. The evidence-based mainstays of treatment are unique to each specific disorder.

Integrated behavioral health care as a means of addressing common behavioral health concerns within pediatric primary care

Behavioral and mental health concerns are common, with depressive episodes reported by 1 in 5 adolescents and anxiety reported by 1 in 10 adolescents. In 2021, given the growing mental health crisis worsened by the COVID-19 pandemic, a state of emergency was declared in children's mental health and a national suicide prevention crisis hotline number, 988 was established. Despite the elevated rates of mental health concerns, the ability to access treatment is low and critical shortages in the U.S. Child and Adolescent Psychiatry workforce contribute to the lack of access to trained pediatric mental health professionals. Pediatric primary care is a natural setting for evidence-based and innovative primary, secondary, and tertiary prevention models due to universal access to patients. Pediatricians can integrate behavioral health care into their primary care practice though providing patients with care for common mental health issues either alone or collaborating with mental health specialists. However, the majority of pediatric trainees report that they do not feel competent to assess and treat pediatric patients with common B/MH concerns even though they feel that competency in these areas is important. Regulatory changes in pediatric training programs are necessary but change takes time. Integrated Behavioral Health (IBH) is a term used to describe a variety of models of care that can be implemented by teams of primary care and B/MH providers working together. These models use a systematic approach that emphasizes collaboration and communication to provide patient-centered care and improve patient health outcomes through increased access to and delivery of quality behavioral health care. The integration of behavioral health care into pediatric primary care has the potential to reduce disparities by increasing access to needed mental health care in a familiar and destigmatized environment, decrease wait time for services and improve the quality of B/MH care provided in the primary care setting.

Empowering primary care physicians in child and adolescent psychiatry: a needs assessment on collaborative care in Dubai

Background

Child and adolescent psychiatric disorders pose significant public health concerns necessitating prompt intervention. Primary care physicians (PCPs) play a critical role as initial points of contact, facilitating early detection, management, and referral of these conditions. In Dubai, integrating mental health services into primary care faces unique challenges, highlighting the need for systemic reforms and enhanced PCP training.

Objective

This study investigated perceptions, barriers, and systemic challenges encountered by PCPs in managing child and adolescent psychiatric conditions in Dubai's primary care setting. It also assessed family physicians' involvement and preparedness in this domain.

Methods

Using a mixed-methods approach, we conducted a survey among family physicians in Dubai Health facilities and analyzed patient data from family medicine clinics. The survey evaluated formal training, preparedness, encounter frequency, and referral patterns for psychiatric care in young patients. Qualitative insights from open-ended survey questions provided additional understanding of specific challenges.

Results

Findings revealed significant gaps in formal training, with only 33.3% of respondents trained in child and adolescent psychiatry during medical education, and 21.1% participating in Continuing Medical Education (CME). A majority (54.4%) of PCPs felt unprepared to manage psychiatric care in young patients. Patient data analysis showed a predominance of male patients (59.9%) and identified Autism Spectrum Disorder (43.1%) as the most common condition, emphasizing the reliance on specialized care through a high referral rate (63.1%). Major barriers included time constraints, limited psychiatric knowledge, resistance to mental health services, systemic and structural issues, communication challenges, and resource shortages.

Conclusion

Enhanced training and systemic reforms are urgently needed to integrate mental health services effectively into Dubai's primary care. Implementing structured collaborative care models, fostering interdisciplinary collaboration, and addressing systemic barriers are crucial for improving child and adolescent psychiatric condition management. These initiatives promise better patient outcomes and more efficient healthcare resource utilization.

Selective Serotonin Reuptake Inhibitor Prescribing Within an Integrated Pediatric Primary Care Behavioral Health Program

OBJECTIVE

Selective serotonin reuptake inhibitor (SSRI) prescribing is increasingly being integrated into primary care, but few data are available about prescribing patterns by pediatric primary care clinicians (PCCs) following implementation of integrated behavioral health (BH) care.

METHODS

Using administrative claims data, we performed a cross-sectional analysis of SSRI prescribing within a statewide pediatric primary care network over 10 years after the initiation of an integrated BH program, calculating the rate of PCC and specialist SSRI prescribing. Using electronic health record data, we analyzed a proposed set of quality metrics for SSRI initiation.

RESULTS

Over 10 years, SSRI prescribing by PCCs increased from 56 fills/1000 patient-years to 446; over the same time period, prescribing by specialists for the network's patients rose from 233 fills/1000 patient-years to 380. In 2013, PCCs prescribed 19% of all SSRIs, while by 2022, they prescribed 54% of the total (P < 0.001 for change for PCCs compared to specialists). Among 16,272 initial SSRI prescribing events by PCCs, 99.6% prescribed a recommended SSRI; 97.5% used an appropriate starting dose; 55.2% documented a validated symptom rating scale at initiation; 53.4% had a contact within 14 days; 67.8% had a follow-up visit within 60 days; and 37.4% documented a symptom rating scale within 60 days.

CONCLUSIONS

In the first 10 years of a pediatric integrated BH program, SSRI prescribing by PCCs increased over 7-fold and surpassed specialist prescribing for the patient population. PCCs chose medications and starting doses appropriately but could improve their use of validated symptom rating scales and consistent follow-up.

Trends in youth acute care hospital visits for anxiety and depression in Illinois

PURPOSE

This study analyzes the trajectory of youth emergency department or inpatient hospital visits for depression or anxiety in Illinois before and during the COVID-19 pandemic.

METHODS

We analyze emergency department (ED) outpatient visits, direct admissions, and ED admissions by patients ages 5-19 years coded for depression or anxiety disorders from 2016 through June 2023 with data from the Illinois Hospital Association COMPdata database. We analyze changes in visit rates by patient sociodemographic and clinical characteristics, hospital volume and type, and census zip code measures of poverty and social vulnerability. Interrupted times series analysis was used to test the significance of differences in level and trends between 51 pre-pandemic months and 39 during-pandemic months.

RESULTS

There were 250,648 visits to 232 Illinois hospitals. After large immediate pandemic decreases there was an estimated -12.0 per-month (p = 0.003, 95% CI -19.8-4.1) decrease in male visits and a - 13.1 (p = 0.07, 95% CI -27 -1) per-month decrease in female visits in the during-pandemic relative to the pre-pandemic period. The reduction was greatest for outpatient ED visits, for males, for age 5-9 and 15-19 years patients, for smaller community hospitals, and for patients from the poorest and most vulnerable zip code areas.

CONCLUSIONS

llinois youth depression and anxiety hospital visit rates declined significantly after the pandemic shutdown and remained stable into 2023 at levels below 2016-2019 rates. Further progress will require both clinical innovations and effective prevention grounded in a better understanding of the cultural roots of youth mental health.

Mental health clinical pathways for children and young people with long-term health conditions: A systematic review

RATIONALE

Clinical pathways (CPWs) are structured care plans that set out essential steps in the care of patients with a specific clinical problem. Amidst calls for the prioritisation of integrated mental and physical health care for young people, multidisciplinary CPWs have been proposed as a step towards closer integration. There is very limited evidence around CPWs for young people with mental and physical health needs, necessitating a review of the literature.

AIMS AND OBJECTIVES

The aim of this review is to understand how clinical pathways have been used to deliver mental health support to children and young people with long-term physical health conditions and their effectiveness across a range of outcomes.

METHODS

The databases MEDLINE, CENTRAL, PsycINFO and CINAHL were searched from inception to 6 September 2023. Keywords linked to children and young people, mental health, long-term physical health conditions and CPWs were used. Studies using either quantitative or qualitative research designs were included. All studies must have evaluated a CPW to provide mental health support to children and young people (up to 25 years old) with long-term health physical conditions. Both mental and physical health outcomes were considered. Pathways were grouped by integration 'model' as described in the wider literature.

RESULTS

The initial search returned 4082 studies after deduplication. A total of eight studies detailing six distinct care pathways (232 participants [170 children and young people; 50 caregivers; 12 healthcare professionals]) met eligibility criteria and were included in the analysis. Four pathways were conducted within an 'integrated model'; two were a combination of 'integrated' and 'colocated'; and none within a 'co-ordinated model'. Only pathways within an integrated model reported quantitative health outcomes, with improvements across a range of mental health measures. One negative physical health outcome was reported from an integrated diabetes pathway, but this should be interpreted with caution.

CONCLUSION

This review identified a range of CPW designs but most fell under an integrated model. The results suggest that calls for integrated mental health pathways in this population may be appropriate; however, conclusions are limited by a paucity of evidence.

Depression Part 2: Treatment

Depression treatment strategies are within the scope of pediatric practice and among the competencies recommended by the Academy of Pediatrics and The American Board of Pediatrics. Treatments that may be provided through collaborative care include nonpharmacologic therapies such as psychosocial treatments and evidence-based psychotherapies, and pharmacotherapy and monitoring processes for depression. Abundant support and guidance are available to pediatricians in depression care, including mental health consultation and online materials.

Retrospective descriptive analysis of an urban pediatric collaborative care program

OBJECTIVE

The prevalence of mental health conditions in pediatric patients in the United States is approximately 15%. Concerningly, nearly half go untreated, with lower treatment rates among children of color. Collaborative care can increase access to care and has an emerging evidence base for pediatrics. We present retrospective results from a collaborative care program that accepted referrals for a variety of conditions.

METHODS

Pediatric patients seen in an academic, urban collaborative care program from July 2019 to December 2021 were tracked in a registry. Demographics, presenting problem(s), symptoms, treatment, and discharge dispositions were examined. Descriptive data were analyzed, including changes in reported symptoms via paired t-tests.

RESULTS

Three hundred nineteen patients were seen. Racial and ethnic diversity in our clinic's population was similar to that of the surrounding community, with half belonging to a minoritized racial or ethnic group. Symptom comparisons demonstrated clinically and statistically significant improvements from intake to discharge.

CONCLUSION

Collaborative care can improve access to care and outcomes for a diverse pediatric population. Our clinic served racial and ethnic patient populations that were representative of the demographics of the metropolitan area. Further study is necessary to determine if collaborative care increases access for these underserved groups.

Depression Part 1: Evaluation

By young adulthood, 1 in 5 teens will experience an episode of major depression. The second leading cause of death among youths aged 15 to 24 years is suicide, most of which will have been caused by untreated or undiagnosed depression. Depression is a highly heritable condition: depressed children often have depressed parents. Support to caregivers is important because depressed parents can have negative effects on children's development and future mental health. Groups more vulnerable to mental health disorders such as depression include Black, Indigenous, and persons of color and lesbian, gay, bisexual, transgender, or queer/questioning, who in recent years have the highest rate of suicide attempts (Black teens, sexual minority youth), the highest increases in suicide rates (Black children and youths), and the highest suicide rates (American Indian/Alaskan native). They frequently experience more adverse childhood events, which increases the risk of depression and suicide attempts. Pediatricians are most likely to care for these vulnerable youths, who often are less engaged in specialty mental health care for a variety of reasons, including stigma and barriers to access. By offering behavioral and mental health care to vulnerable populations in primary care, mental health equity may be achieved. Screening for depression and assessment for suicide are within the scope of pediatric practice and among the competencies recommended by the American Academy of Pediatrics and The American Board of Pediatrics.

Perspectives on the Practice of Collaborative Care: Topical Themes and Future Directions From the Lens of a Collaborative Care Child Psychiatrist

The increasing shortage of psychiatrists in the workforce is a well-documented and alarming trend. In light of this workforce shortage, psychiatrists bear a professional and ethical responsibility to identify strategies to increase access to mental health treatment and thereby reduce the impact of the psychiatrist shortage on patients and on the greater health system. One such strategy is the collaborative care model (CoCM), which has demonstrated efficacy in the mental health treatment of both pediatric and adult populations. In this article, the CoCM is presented as one effective strategy to address the behavioral workforce shortage. Current themes observed from the clinical practice of psychiatric collaborative care in a pediatric collaborative care setting are discussed with contemplation of future directions.

Comprehensiveness of State Insurance Laws and Perceived Access to Pediatric Mental Health Care

Importance

Many US children and adolescents with mental and behavioral health (MBH) conditions do not access MBH services. One contributing factor is limited insurance coverage, which is influenced by state MBH insurance parity legislation.

Objective

To investigate the association of patient-level factors and the comprehensiveness of state MBH insurance legislation with perceived poor access to MBH care and perceived inadequate MBH insurance coverage for US children and adolescents.

Design, Setting, and Participants

This retrospective cross-sectional study was conducted using responses by caregivers of children and adolescents aged 6 to 17 years with MBH conditions in the National Survey of Children's Health and State Mental Health Insurance Laws Dataset from 2016 to 2019. Data analyses were conducted from May 2022 to January 2024.

Exposure

MBH insurance legislation comprehensiveness defined by State Mental Health Insurance Laws Dataset (SMHILD) scores (range, 0-7).

Main Outcomes and Measures

Perceived poor access to MBH care and perceived inadequacy of MBH insurance were assessed. Multivariable regression models adjusted for individual-level characteristics.

Results

There were 29 876 caregivers of children and adolescents with MBH conditions during the study period representing 14 292 300 youths nationally (7 816 727 aged 12-17 years [54.7%]; 8 455 171 male [59.2%]; 292 543 Asian [2.0%], 2 076 442 Black [14.5%], and 9 942 088 White [69.6%%]; 3 202 525 Hispanic [22.4%]). A total of 3193 caregivers representing 1 770 492 children and adolescents (12.4%) perceived poor access to MBH care, and 3517 caregivers representing 1 643 260 of 13 175 295 children and adolescents (12.5%) perceived inadequate MBH insurance coverage. In multivariable models, there were higher odds of perceived poor access to MBH care among caregivers of Black (adjusted odds ratio [aOR], 1.35; 95% CI, 1.04-1.75) and Asian (aOR, 1.69; 95% CI, 1.01-2.84) compared with White children and adolescents. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to MBH care increased (aORs ranged from 1.68; 95%, CI 1.32-2.13 for 1 ACE to 4.28; 95% CI, 3.17-5.77 for ≥4 ACEs compared with no ACEs). Compared with living in states with the least comprehensive MBH insurance legislation (SMHILD score, 0-2), living in states with the most comprehensive legislation (SMHILD score, 5-7) was associated with lower odds of perceived poor access to MBH care (aOR, 0.79; 95% CI, 0.63-0.99), while living in states with moderately comprehensive legislation (score, 4) was associated with higher odds of perceived inadequate MBH insurance coverage (aOR, 1.23; 95% CI, 1.01-1.49).

Conclusions and Relevance

In this study, living in states with the most comprehensive MBH insurance legislation was associated with lower odds of perceived poor access to MBH care among caregivers for children and adolescents with MBH conditions. This finding suggests that advocacy for comprehensive mental health parity legislation may promote improved child and adolescent access to MBH services.

Adolescent Health in the Post-Pandemic Era: Evolving Stressors, Interventions, and Prevention Strategies amid Rising Depression and Suicidality

Prior to COVID-19, there were already increasing rates of youth with mental health concerns, including an increase in youth presenting to medical emergency departments (EDs) with mental health chief complaints and limited access to treatment. This trend worsened during the pandemic, and rates of youth presenting to medical EDs with suicidal ideation and self-harm increased 50% from 2019 to 2022. This resulted in a "boarding" crisis, in part, due to a lack of inpatient psychiatric hospitalization beds, and many youth were left without access to adequate treatment. Additional study of innovations in health care delivery will be paramount in meeting this need.

Widening Our Lane: How Child and Adolescent Psychiatrists Can Embrace the Full Spectrum of Mental Health

The majority of a psychiatrist's training and clinical attention is devoted to mental illness rather than mental health. This article suggests a broader understanding and application of mental well-being that can benefit both those already struggling with mental health challenges and those trying to stay well. Recommendations for being a well-being-oriented psychiatrist include increasing one's knowledge about well-being and health promotion and adjusting one's practice to incorporate these principles. Recommendations at the level of the field of psychiatry include revising the definition of a psychiatrist, increasing research on well-being and health promotion, improving financial incentives, expanding efforts in schools and community settings, and providing additional training.

Mental health interventions for children and young people with long-term health conditions in Children and Young People's Mental Health Services in England

BACKGROUND

Almost a quarter of children and young people (CYP) in England have a long-term health condition (LTC), which increases the risk of developing mental health difficulties. There is a lack of understanding regarding the routine provision and efficacy of mental health interventions for CYP with LTCs within Children and Young People's Mental Health Services (CYPMHS).

METHODS

This study analysed national service-reported data in England from two secondary datasets. Data were submitted by services between 2011 and 2019. We evaluated data on the presence or absence of a serious physical health or neurological issue, and which interventions were offered.

RESULTS

A total of 789 CYP had serious physical health issues and 635 had neurological issues. The most common interventions delivered to CYP in either group have some evidence in the literature. Most CYP showed improvements across a range of outcomes.

CONCLUSIONS

This study found that prevalence rates and psychological intervention and outcome data were widely under-reported across both datasets, posing questions about their utility for this population. Such data would benefit from triangulation with data from other sources to understand pathways of care for these young people and the extent to which clinical datasets underreport the number of CYP with LTCs.

The impact of public leadership on collaborative administration and public health delivery

BACKGROUND

This research depicts the linkage of public leadership on public health delivery (PHD) and collaborative administration. The research is also focused to examine the effect of public leadership on public health delivery through the intervening variable of collaborative administration by using both social information processing theory and collaboration theory.

METHODS

This research is based on quantitative method. Data was collected from 464 public hospital administration in the context of Pakistan. This study evaluated data using SPSS, AMOS, and PROCESS Macro.

RESULTS

Public leadership has a positive profound effect on public health delivery and collaborative administration, and that collaborative administration significantly promotes public health delivery. The outcomes also exposed that public leadership has substantial influence on public health delivery through intervening collaborative administration.

CONCLUSIONS

Whilst public leadership demonstrated positive outcomes on public health delivery and collaborative administration, there is a need for more rigor studies on collaborative governance leadership, collaborative ethics and collaborative norms in the public health service.

Evaluation of collaborative mental health services in Latin America: Theoretical and methodological basis

OBJECTIVES

Approaches to collaborative mental health care (CMHC) have been implemented in many countries to strengthen the accessibility and delivery of mental health services in primary care. However, there are not well-defined frameworks to evaluate CMHC models. The purpose of this article is to identify, contextualize and discuss relevant health services research approaches, theory, and evaluation models for the development of an appropriate evaluation framework in order to foster effective CMHC in Latin America.

METHODS

A comprehensive literature review informed a critical analysis of relevant theories and alternative methods to be considered in the development of the framework.

RESULTS

Specific health services research frameworks are discussed in the context of evaluating CMHC. Two theoretical perspectives - collaboration theory and systems theory - and three evaluation models- realistic, developmental and collaborative - are analyzed in terms of their relevance. Methodological implications are identified.

CONCLUSION

An appropriate evaluation framework for CMHC in Latin America needs to reflect theoretical and contextual considerations and relevant evaluation approaches and methods, including key dimensions and attributes/variables, core indicators, and recommendations for implementation.

Identifying Risk Factors Associated with Repeated Referrals Within a Pediatric Navigation Program

Approximately 1-in-5 children have a diagnosed mental, behavioral, and/or developmental disorder or delay by age 8 in the United States. Children with such conditions often require complex, complicated diagnostic and specialty care, making them susceptible to repeated referrals and ongoing unmet healthcare needs. Patient navigation programs (PNPs) are designed to integrate care from primary care providers to community-based services, using trained navigators to help patients and their families manage referrals and connect with referred services. This study examines factors associated with repeated referrals to an active PNP to inform ongoing referral patterns and adaptations to standard navigation support within a large healthcare system in South Carolina (SC). Data is sourced from the inception of the PNP in 2017 through 2022, including 15,702 referrals. Overall, 71.07% had no repeated referrals. Children who are older, diagnosed with attention deficit disorder(s), behavioral concerns, depression, multiple referral needs, and insured by Medicaid were found to be most susceptible to repeated referrals. Conversely, children who are non-Hispanic Black, were referred at a well-child visit, and are primarily insured by private insurance or Tricare were least likely to have repeated referrals. Children who are insured by Medicaid are more likely to be younger, identify as non-Hispanic Black, Hispanic, or another race/ethnicity, and have multiple needs at time of initial referral, identifying a potentially compounded risk for those who hold multiple risk factors to experiencing repeated referrals. Findings may inform adaptations to this PNP model to adjust navigator protocol for at-risk populations and equitably optimize referral-to-service connection.

Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges

Introduction

Children and adolescents often do not receive mental healthcare when they need it. By 2021, the complex impact of the COVID-19 pandemic, structural racism, inequality in access to healthcare, and a growing shortage of mental health providers led to a national emergency in child and adolescent mental health in the United States. The need for effective, accessible treatment is more pressing than ever. Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective.

Methods

In response to the youth mental health crisis, Rady Children's Hospital-San Diego's Transforming Mental Health Initiative aimed to increase early identification of mental illness and improve access to effective treatment for children and adolescents. A stakeholder engagement process was established with affiliated pediatric clinics, community mental health organizations, and existing pediatric integrated care programs, leading to the development of the Primary Care Mental Health Integration program and drawing from established models of integrated care: Primary Care Behavioral Health and Collaborative Care.

Results

As of 2023, the Primary Care Mental Health Integration program established integrated care teams in 10 primary care clinics across San Diego and Riverside counties in California. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms. The program works toward fiscal sustainability via fee-for-service reimbursement and more comprehensive payor contracts. The impact on patients, primary care provider satisfaction, measurement-based care, funding strategies, as well as challenges faced and changes made will be discussed using the lens of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

Discussion

Preliminary results suggest that the Primary Care Mental Health Integration is a highly collaborative integrated care model that identifies the needs of children and adolescents and delivers brief, evidence informed treatment. The successful integration of this model into 10 primary care clinics over 3 years has laid the groundwork for future program expansion. This model of care can play a role addressing youth mental health and increasing access to care. Challenges, successes, and lessons learned will be reviewed.

Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study

BACKGROUND

To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting.

METHOD

Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed.

RESULTS

Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14).

LIMITATIONS

Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings.

CONCLUSIONS

To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Impact of colocated behavioral health on OB-GYN clinicians' rate of perinatal behavioral health diagnosis and psychotropic prescription

OBJECTIVE

To examine the association of colocated behavioral health(BH) care with rates of OB-GYN clinician coding of BH diagnoses and BH medications.

METHOD

Using 2 years of EMR data from perinatal individuals treated across 24 OB-GYN clinics, we tested the hypothesis that colocated BH care would increase rates of OB-GYN BH diagnoses and psychotropic prescription.

RESULTS

Psychiatrist integration(0.1 FTE) was associated with 45.7% higher odds of OB-GYN coding for BH diagnoses and BH clinician integration was associated with 25% lower odds of OB-GYN BH diagnosis and 37.7% lower odds of BH medication prescription. Non-white patients had 28-74% and 43-76% lower odds of having a BH diagnosis and a BH medication ordered, respectively. The most common diagnoses were anxiety and depressive disorders(60%) and the most prescribed BH medications were SSRIs(86%).

CONCLUSIONS

OB-GYN clinicians made fewer BH diagnoses and prescribed fewer psychotropics after 2.0 FTE BH clinician integration, a possible indication of external referrals for BH treatment. Non-white patients received BH diagnoses and medications less often than white patients. Future research in real world implementation of BH integration in OB-GYN clinics should examine fiscal strategies that support BH care manager-OB-GYN collaboration as well as methods to ensure equitable delivery of BH care.

Evaluation of a depression care model for the hill tribes: a family and community-based participatory research

BACKGROUND

Even though, there is a particularly high prevalence of depression among individuals from the hill tribes in northern Thailand, they are unable to receive appropriate intervention due to cultural, transportation, communication, and legal barriers. Using community-based participatory research (CBPR), a depression care model was developed for the hill tribe population. The effectiveness of this model was examined using questionnaires, observations, focus groups, and in-depth interviews.

METHODS

Participants include people with depression (n = 17) who were chosen based on their mild to moderately severe depression scores on the Patient Health Questionnaire 9-item (PHQ-9 scores of 5-19) and their caregivers (n = 5). The in-depth interview was conducted to distinguish the selected participants into two groups. The first group, the self-help group program, consisted of 12 participants endorsing negative thoughts about themselves and inappropriate problems solving. The second group, the family camp program, had ten participants, including five patients with family-related issues and their family members. Subjects separately participated in either the self-help or the family groups over three weeks. They completed the PHQ-9 at the beginning and end of the intervention. Questionnaires, observations, focus groups, and in-depth interviews were used to evaluate the effectiveness of the model. Content analysis was used to examine the qualitative data. Wilcoxon signed-rank test was used to analyze the changes in the severity of depression before and after participation in the intervention.

RESULTS

The depression scores on the PHQ-9 of 12 participants improved significantly (11.92 ± 1.08 vs. 3.08 ± 0.51; p = 0.002) following participation in the self-help group. Increased self-esteem and improved interpersonal relationships were reported by participants in the self-help group program during interviews. There was no significant difference in the depression scores of 10 participating in the family camp program (6.00 ± 3.83 to 5.30 ± 3.56; p = 0.161).

CONCLUSION

A model for depression care was tested in a hill tribe community, and its effectiveness was clearly observed. The developed model can be applied to other hill tribe communities in northern Thailand to improve depression care.

Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children

Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.

Advances in Child Psychiatry Education and Training

The article provides a comprehensive overview of the current state of child and adolescent psychiatry, including historical background and the impact of the COVID-19 pandemic. It discusses recent advances in theoretical frameworks related to physician burnout, prevention, access to care, diversity, equity, and inclusion, and trauma-informed care. The authors conclude by emphasizing the importance of education and training in improving the lives of youth and families and encourage their colleagues to push the boundaries of education and training for a better today and brighter tomorrow, while honoring and doing justice to those they serve.