Comparison of Use of the Massachusetts Child Psychiatry Access Program and Patient Characteristics Before vs During the COVID-19 Pandemic

This cross-sectional study compares the number of encounters at the Massachusetts Child Psychiatry Access Program, patient characteristics, and mental health diagnoses before vs during the COVID-19 pandemic.

Accentuate the Positive: Strengths-Based Therapy for Adolescents

Purpose

The field of psychiatry has conventionally employed a medical model in which mental health disorders are diagnosed and treated. However, the evidence is amassing that using a strengths-based approach that promotes wellness by engaging the patient's assets and interests may work in synergy with the medical model to promote recovery. This harmonizes with the patient-centered care model that has been promoted by the Institute of Medicine.

Methods

The article uses a clinical case to highlight the attributes of a strength-based model in the psychiatric treatment of adolescents.

Results

Outcome metrics from a number of studies have demonstrated enhanced youth and parent satisfaction and decreased use of hospital level of care with the implementation of strengths-based therapeutic modalities.

Implications

Incorporating strengths-based interventions into conventional psychiatric practice provides a multi-faceted treatment approach that promotes recovery in children and adolescents with psychiatric disorders.

Measurement-Based Care in the Pediatric Primary Care Setting

Challenges associated with the integration of pediatric mental health care in the primary care setting include limitations of training and time, high volume of patients, need for coordination with external specialists, limited infrastructure, and limited funding. All of these issues can negatively influence the quality of mental health service delivery. Measurement-based care (MBC) processes have the potential to mitigate many of these challenges and generate data, allowing practices to evaluate and improve the performance of integrated mental health processes. Implementing MBC requires initial investment of staff resources for planning and training and information technology resources.

Impact of Child Psychiatry Access Programs on Mental Health Care in Pediatric Primary Care: Measuring the Parent Experience

OBJECTIVE

This study aimed to assess parents' satisfaction with the primary care provider (PCP) in the treatment of their child's mental health problems after the PCP consulted with the Massachusetts Child Psychiatry Access Program (MCPAP). It studied how parental satisfaction may vary across factors, including service utilization, parental perception of the child's illness, and parental perception of certain PCP attributes.

METHODS

The study analyzed 374 telephone consultations made from PCPs to MCPAP between March 2010 and June 2012. Questions in a structured telephone survey administered to parents identified the types of services participants were referred to and assessed satisfaction rates on the basis of measures reflective of the patient-doctor relationship and of illness factors.

RESULTS

Eighty-six percent of participants expressed satisfaction with their PCP's handling of their child's mental health problems after MCPAP consultation. Participants who agreed with statements reflective of a positive patient-doctor relationship (in terms of the PCP's empathy and knowledge) exhibited higher rates of satisfaction with the PCP's role in the treatment of their child's mental health problems than those who did not agree. The most common recommendations made to families after consultation were to follow up with the child's PCP (94%) and to obtain further MCPAP consultation (78%).

CONCLUSIONS

The survey results indicated high rates of parents' satisfaction with the PCP's handling of their child's mental health issues. Recommendations made to PCPs by MCPAP consultants aimed to strengthen the PCP's role as a mental health provider.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience.

RESULTS

Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting.

METHODS

By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience.

RESULTS

These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized.

CONCLUSIONS

The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.

Implementing Integrated Care in Pediatric Mental Health: Principles, Current Models, and Future Directions

Traditional models of health care delivery are inadequate for addressing all the needs of the child and adolescent population that has mental illness. The integrated care model seeks to partner pediatric mental health specialists with primary providers to better meet these needs. The authors outline the core principles guiding integrated care for youths and describe key characteristics of the team members involved. Three models of integrated care have emerged and have proven effective. Several representative programs are described, and the advantages and disadvantages of each are reviewed. The review concludes by identifying the challenges that have prevented wider dissemination of the integrated care model and by exploring potential future directions for the field.

The Use of Health Information Technology Within Collaborative and Integrated Models of Child Psychiatry Practice

There is a consistent need for more child and adolescent psychiatrists. Despite increased recruitment of child and adolescent psychiatry trainees, traditional models of care will likely not be able to meet the need of youth with mental illness. Integrated care models focusing on population-based, team-based, measurement-based, and evidenced-based care have been effective in addressing accessibility and quality of care. These integrated models have specific needs regarding health information technology (HIT). HIT has been used in a variety of different ways in several integrated care models. HIT can aid in implementation of these models but is not without its challenges.

Integrating Mental and Physical Health Services Using a Socio-Emotional Trauma Lens

This article provides a synthesis of the lessons learned from the Pediatric Integrated Care Collaborative (PICC), a SAMHSA-funded project that is part of the National Child Traumatic Stress Network. The high prevalence of trauma exposure in childhood and shortage of mental health services has informed efforts to integrate mental and behavioral health services in pediatric primary care. This article outlines strategies to integrate care following the six goals of the PICC change framework: create a trauma/mental health informed office; involve families in program development; collaborate and coordinate with mental health services; promote resilience and prevent mental health problems through a particular focus on trauma-related risks; assess trauma-related somatic and mental health issues; and address trauma-related somatic and mental heath issues. We conclude with a summary of key strategies that any practice or practitioner could employ to begin or continue the process of integration.

Behavioral health care for children: the massachusetts child psychiatry access project

Access to behavioral health care for children is essential to achieving good health care outcomes. Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet children's need for behavioral health care. The Massachusetts Child Psychiatry Access Project has addressed this problem by delivering telephone child psychiatry consultations and specialized care coordination support to over 95 percent of the pediatric primary care providers in Massachusetts. Established in 2004, the project consists of six regional hubs, each of which has one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the 1.5 million children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children. Pediatric primary care providers enrolled in the project reported a dramatic improvement in their ability to meet the psychiatric needs of their patients. Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States.

Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms

OBJECTIVE

Perinatal depression is common and associated with poor birth, infant and child outcomes. Screening for perinatal depression alone does not improve treatment rates or patient outcomes. This paper describes the development, implementation and outcomes of a new and low-cost population-based program to help providers address perinatal depression, the Massachusetts Child Psychiatry Access Project (MCPAP) for Moms.

METHOD

MCPAP for Moms builds providers' capacity to address perinatal depression through (1) trainings and toolkits on depression screening, assessment and treatment; (2) telephonic access to perinatal psychiatric consultation for providers serving pregnant and postpartum women; and (3) care coordination to link women with individual psychotherapy and support groups.

RESULTS

In the first 18months, MCPAP for Moms enrolled 87 Ob/Gyn practices, conducted 100 trainings and served 1123 women. Of telephone consultations provided, 64% were with obstetric providers/midwives and 16% were with psychiatrists. MCPAP for Moms costs $8.38 per perinatal woman per year ($0.70 per month) or $600,000 for 71,618 deliveries annually in Massachusetts.

CONCLUSION

The volume of encounters, number of women served and low cost suggest that MCPAP for Moms is a feasible, acceptable and sustainable approach that can help frontline providers effectively identify and manage perinatal depression.

Public-academic partnerships: Public-academic partnerships to address the need for child and adolescent psychiatric services

There is a severe shortage and a maldistribution of child and adolescent psychiatrists in the United States. Public-academic collaborations play a major role in attempting to address these conditions. This column describes examples of two types of collaborations: newer programs that emphasize consultation, education, and support to primary care providers and more traditional efforts that provide consultation to general psychiatrists and psychiatric nurse practitioners. In both cases videoconferencing plays a role in reaching difficult-to-serve populations. Residency programs for both child and adolescent psychiatrists and primary care providers should include training in collaborative treatment approaches.

Bridging the divide between child psychiatry and primary care: the use of telephone consultation within a population-based collaborative system

The Massachusetts Child Psychiatry Access Project is a public system for improving access to care for children with mental health problems in which the provision of telephone consultation by child psychiatry teams to pediatric primary care providers (PCPs) plays a central role. In this article, the practice of telephone consultation within this system is explored through the examination of case studies, demonstrating its use in common clinical scenarios. The telephone consultations provide immediate case-based clinical education, and also serve as a gateway for the provision of as-needed direct child psychiatry evaluation and care coordination services. Most importantly, the telephone consultations build sustaining collaborative relationships, enhancing the ability of PCPs to meet the needs of children with mental health problems.

Improving access to mental health care for children: the Massachusetts Child Psychiatry Access Project

BACKGROUND

Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance.

METHODS

Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35,335 encounters. PCC surveys assessed satisfaction and impact on access to care.

RESULTS

The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10,114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0-245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs.

CONCLUSIONS

PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.