Primary care pediatrician perceptions towards mental health within the primary care setting

Multilevel perspectives on the implementation of the collaborative care model for depression and anxiety in primary care

BACKGROUND

The Collaborative Care Model (CoCM) is an evidence-based mental health treatment in primary care. A greater understanding of the determinants of successful CoCM implementation, particularly the characteristics of multi-level implementers, is needed.

METHODS

This study was a process evaluation of the Collaborative Behavioral Health Program (CBHP) study (NCT04321876) in which CoCM was implemented in 11 primary care practices. CBHP implementation included screening for depression and anxiety, referral to CBHP, and treatment with behavioral care managers (BCMs). Interviews were conducted 4- and 15-months post-implementation with BCMs, practice managers, and practice champions (primary care clinicians). We used framework-guided rapid qualitative analysis with the Consolidated Framework for Implementation Research, Version 2.0, focused on the Individuals domain, to analyze response data. These data represented the roles of Mid-Level Leaders (practice managers), Implementation Team Members (clinicians, support staff), Innovation Deliverers (BCMs), and Innovation Recipients (primary care/CBHP patients) and their characteristics (i.e., Need, Capability, Opportunity, Motivation).

RESULTS

Mid-level leaders (practice managers) were enthusiastic about CBHP (Motivation), appreciated integrating mental health services into primary care (Need), and had time to assist clinicians (Opportunity). Although CBHP lessened the burden for implementation team members (clinicians, staff; Need), some were hesitant to reallocate patient care (Motivation). Innovation deliverers (BCMs) were eager to deliver CBHP (Motivation) and confident in assisting patients (Capability); their opportunity to deliver CBHP could be limited by clinician referrals (Opportunity). Although CBHP alleviated barriers for innovation recipients (patients; Need), it was difficult to secure services for those with severe conditions (Capability) and certain insurance types (Opportunity).

CONCLUSIONS

Overall, respondents favored sustaining CoCM and highlighted the positive impacts on the practice, health care team, and patients. Participants emphasized the benefits of integrating mental health services into primary care and how CBHP lessened the burden on clinicians while providing patients with comprehensive care. Barriers to CBHP implementation included ensuring appropriate patient referrals, providing treatment for patients with higher-level needs, and incentivizing clinician engagement. Future CoCM implementation should include strategies focused on education and training, encouraging clinician buy-in, and preparing referral paths for patients with more severe conditions or diverse needs.

TRIAL REGISTRATION

ClinicalTrials.gov(NCT04321876). Registered: March 25,2020. Retrospectively registered.

Provider Perspectives on an Integrated Behavioral Health Prevention Approach in Pediatric Primary Care

The purpose of this study was to use qualitative interviews to ascertain the perspective of pediatric primary care providers on the implementation of Integrated Behavioral Health (IBH) as provided by psychologists within an expanded HealthySteps™ model, and with a particular focus on prevention of behavioral health symptoms in the first five years. A semi-structured interview guide was used to assess medical providers' perceptions of behavioral health integration into their primary care clinics. A conventional qualitative content analysis approach was utilized to identify patterns of meaning across qualitative interviews. Four themes were identified: (1) practice prior to IBH and initial concerns about integration, (2) psychologist's role and perceived added value, (3) what integration looks like in practice, and (4) perceived families' response to and experiences with IBH. Despite initial concerns about potential disruptions to clinic flow, providers indicated that adoption of IBH was seamless. The distinct roles of the psychologist were clear, and both treatment and prevention services provided by IBH were valued. Multidisciplinary collaboration and real-time response to family needs was seen as especially important and primary care providers reported that families were accepting of and highly valued IBH.

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.

Pediatric GI Health Care Professionals' Perceptions of and Engagement With Psychosocial Providers in Pediatric IBD Care

Multidisciplinary care is recommended for optimal pediatric inflammatory bowel disease (IBD) care, including psychosocial providers (eg, psychologists). However, health care professionals' (HCPs) perceptions of and engagement with psychosocial providers in pediatric IBD is lacking.

Methods

Cross-sectional REDCap surveys were completed by HCPs (eg, gastroenterologists) across American ImproveCareNow (ICN) centers. Demographics and self-reported perceptions of and engagement with psychosocial providers were collected. Data were analyzed at participant and site levels through descriptives, frequencies, an independent t test, and exploratory analyses of variance.

Results

A total of 101 participants from 52% of ICN sites participated. Participants were 88% gastrointestinal physicians, 49% identifying as female, 94% non-Hispanic, and 76% Caucasian. Of ICN sites, 75% and 94% of sites reported outpatient and inpatient psychosocial care, respectively. Participants referred for various clinical reasons to psychosocial providers (eg, illness adjustment). At the participant level, 92% of HCPs reported psychosocial care was very important and 64% reported their clinical thresholds shifted to engage psychosocial providers earlier in care. Barriers to psychosocial care included limited psychosocial providers (92%), psychosocial providers availability (87%), and IBD patients' lack of openness to psychosocial care (85%). One-way analyses of variance by HCP length of experiences were not statistically significant on perceived understanding of psychosocial providers or perceived changes in clinical threshold over time.

Conclusion

HCPs overall reported positive perceptions of and frequent engagement with psychosocial providers in pediatric IBD. Limited psychosocial providers and other notable barriers are discussed. Future work should continue interprofessional education of HCPs and trainees and efforts to improve access to psychosocial care in pediatric IBD.

Anxiety and Depression Treatment in Primary Care Pediatrics

BACKGROUND AND OBJECTIVES

Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review.

METHODS

We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices.

RESULTS

At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects.

CONCLUSIONS

When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.

Clinical Update: Child and Adolescent Behavioral Health Care in Community Systems of Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of community systems of care as they pertain to the delivery of behavioral health care to children and adolescents METHOD: A search of the literature on this topic from 2002 was initially conducted in 2016 and repeated in 2019 and 2021, yielding 1,604 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 1,684 total citations, of which 1,184 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 156 based on relevance to the topic.

RESULTS

The systems of care approach, arising in the 1980s, expanded child and adolescent behavioral health care from the core services of psychotherapy, medication management, inpatient psychiatric services, and residential treatment to include home- and community-based treatment and support services; promotion, prevention, and early intervention programs; and specialized services for very young children and youth and young adults of transition age. These services and supports are delivered by a large multidisciplinary workforce and are governed by key principles, including a biopsychosocial case conceptualization; family-driven, youth-guided, strengths-based, and trauma-informed care. Services in the least restrictive setting; continuity of care across transitions; a public health framework for service delivery; promotion of wellness and resilience; and elimination of health disparities. Challenges to systems of care implementation include funding availability, workforce shortages, deficiencies in cross-systems collaboration, and variability in insurance coverage. Although controlled studies have failed to provide convincing evidence of favorable outcomes from the whole systems of care approach, uncontrolled research has demonstrated increased access to care, positive clinical and functional outcomes, improved family functioning, and reductions in costs, particularly when research is focused on specific behavioral health problems, specific interventions such as Wraparound care, or highly specified groups of youth.

CONCLUSION

Health professionals who are educated in the systems of care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.