Abstract
There is an urgent need for new clinical models to improve access to child mental health care. Pediatricians are tasked to care for youth with mild to moderate mental health problems, but require additional training. This article describes an outpatient child psychiatry consultation clinic (CPC) designed to empower pediatricians to care for youth with depression, anxiety, and attention deficit/hyperactivity disorder. Over a 2-year period, 40 primary care physicians (PCPs) referred 159 patients to the CPC. The most common primary diagnoses of patients seen for consultation were generalized anxiety disorder (35%), major depressive disorder (24%), and attention deficit/hyperactivity disorder (20%). Most patients (89%) had at least 2 psychiatric diagnoses. Nearly four fifths (79%) of these patients successfully returned to their PCP for ongoing care. PCPs reported that the CPC enhanced their skills and improved access to mental health care. Similar models are needed to facilitate early intervention for the millions of youth with mental health problems.
Keywords
Approximately 7.7 million US children and adolescents (16.5%) suffer from mental health disorders. 1 Research has consistently shown that these disorders are associated with significant morbidity and increase risk for future disability, addiction, psychiatric problems, serious legal problems, academic failure, early parenthood, and suicidality during adulthood. 2 Despite these negative consequences, only half of US youth with mental health disorders receive needed treatment from a mental health professional. 1 Furthermore, there are certain subpopulations who are particularly at risk for not receiving treatment such as youth who are uninsured, racial, or ethnic minorities, or those who live in rural communities. 3 In some cases, the stigma associated with mental illness and its treatment precludes families from seeking help. Even those families who seek treatment are often unable to access care due to limited mental health insurance coverage as well as the national shortage of child and adolescent mental health providers. 4 With fewer than 18 child and adolescent psychiatrists (CAPs) per 100 000 US youth under the age of 18 years, the current psychiatric workforce is unable to care for the needs of this at-risk population. 5
Early intervention is the key to mitigate some of the consequences of untreated mental health problems for our youth. Furthermore, stratification of this large population by mental health severity will allow for adequate treatment given the limited number of specialists available. For instance, those with severe mental health problems will require treatment by specially trained mental health professionals such as CAPs. Whereas children with mild to moderate mental health problems can receive care by their pediatricians as recommended by the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP).6-8 Specifically, the AAP has tasked pediatric providers to develop skills in the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD), anxiety, and depression, which are common among youth,6,7 and has provided tool kits and best practice guidelines to support them.9-11 In spite of this recommendation, only 57% of pediatric providers surveyed by the AAP reported that they provide mental health treatment to children in their practice. 12 The majority of pediatricians surveyed reported that 2 of the major barriers to providing treatment were their lack of both confidence and training in using psychotropic medications. 12 According to a separate study, only around half (54% to 55%) of pediatricians reported that they were comfortable treating depression and anxiety with medication. 13 To address these barriers, the current pediatric workforce needs immediate clinical training and support to care for youth with mild to moderate mental health problems, especially anxiety and depression.
There are a number of existing large-scale models that offer clinical education in child mental health care along with access to telephone psychiatric consultation for pediatricians.14-18 These programs have been shown to be highly valued by pediatricians as they help them improve their skills in treating mental health problems and facilitate access to child psychiatry services.14,15,17,18 One potential drawback of all of these models is that they rely on significant external funding to support the operational expenses and salaries for consulting CAPs, psychotherapists, social workers, and care coordinators.
For states and regions without such external funding, alternative models are needed. One strategy is to work within existing reimbursement paradigms (ie, fee-for-service) by providing outpatient psychiatric consultation to pediatric providers. In this model, participating pediatricians are trained by child psychiatrists to screen, evaluate, and treat youth with mild to moderate severity mental health problems. When trained pediatricians require additional assistance, they are able to refer patients to a psychiatrist for an extended outpatient psychiatric consultation, which would be covered using standard outpatient billing codes. This extended consultation consists of an initial evaluation plus a limited number of follow-up visits. Following the extended consultation, the patient returns to the care of the referring pediatrician. The ultimate goal of the consultation is to help the pediatrician manage mild to moderate mental health problems within their practice. Through case-by-case consultation, primary care physicians (PCPs) have the opportunity to learn specific clinical skills that they can use to care for patients with mental health needs. If this outpatient consultation model is successful, it would be an efficient way to appropriate the limited child psychiatrist availability and to reduce barriers to mental health treatment for a large population of youth all while requiring minimal subsidization.
However, there are little empirical data available on an exclusively outpatient consultation model. In the only study to examine a child psychiatric consultation clinic, 49 children with ADHD, depression, and/or anxiety were referred by their PCP and evaluated by a CAP. 19 This pilot study comprised CAPs at a pediatric subspecialty clinic and pediatric providers (PCPs) from 3 urban practices. The model was well received by the pediatricians, all of whom agreed that the consultation provided by the CAPs improved their skills in mental health care and helped them meet the needs of their patients with psychiatric problems. More than half of the patients seen for outpatient consultation did return to their pediatrician for ongoing management of mental health problems. 19 Although the results of the pilot study were promising, there were several limitations. First, there were a relatively small number of referring pediatric providers (n = 25) and consulting CAPs (n = 4). Second, while short-term data were available, there were limited long-term outcome data regarding the final disposition for over a third of patients. Finally, although pediatricians were surveyed there was no evaluation of the CAP satisfaction with the model.
The present study aimed to build on the results of the pilot study and add to the dearth of empirical data on outpatient psychiatric consultation models for child mental health problems designed to help PCPs personally treat youth with mild to moderate mental health problems in the primary care setting. Specifically, the study aimed to develop, implement, and describe the feasibility, utilization, and satisfaction with a Child Psychiatric Consultation clinic (CPC) for pediatric providers at a different institution. This study further differs from the pilot study in that it includes a larger sample of both CAPs and PCPs as well as a larger patient sample size obtained over a 2-year period with an extended follow-up period of up to 4 years. The specific aims were to describe clinical and demographic characteristics of patients referred and/or seen for consultation by the CAP, to determine the proportion of patients seen for outpatient consultation who ultimately returned back to their pediatrician for ongoing management, and to ascertain both PCP and CAP satisfaction with this clinical model. A secondary aim was to examine if demographic or clinical characteristics predicted whether or not a patient was able to return to their pediatrician for ongoing mental health care.
Methods
Setting
The CPC was implemented at an existing academic child and adolescent psychiatry clinic where youth (ages 2-21 years) with a wide range of clinical psychopathology received comprehensive mental health care. At the time of the study, the clinic accepted both private and public insurance. The teaching clinic consisted of 3 attending CAPs who supervised CAP fellows, general psychiatry residents, and a psychiatric nurse practitioner (ARNP). Each CAP worked in clinic an average of 2 to 3 days per week. In addition, the clinic employed a clinical psychologist and 2 child and adolescent mental health therapists.
Consulting Psychiatrists
All psychiatric providers from the academic clinic were invited to participate and conduct consultations. Two faculty CAPs, 2 CAP fellows, 5 general psychiatry residents, and the ARNP participated as consultants. Consulting providers were trained to document and code for outpatient consultations using the appropriate common procedural technology codes (ie, 9924x). Consultants were instructed to document as they typically would for an outpatient new evaluation or follow-up visit. In addition, they were encouraged to include specific recommendations to the PCP about anticipated next steps in their plan. For example, instead of simply writing, “Start Fluoxetine 10 mg daily,” consultants were taught to write, “Start Fluoxetine 10 mg daily in the morning. Every 4 to 6 weeks, will re-evaluate symptoms and consider whether to increase the dose in increments of 10 mg with a target dose range 20 to 40 mg.” For the final outpatient visit, consultants were instructed to include anticipatory guidance to the referring PCP. For example, in addition to writing, “Continue biweekly cognitive behavioral therapy and Fluoxetine 20 mg,” consultants were trained to write, “If symptoms of anxiety re-emerge based on clinical evaluation and elevated scores on anxiety rating scales, first ensure that the patient is participating in biweekly cognitive behavioral therapy. If not, encourage her to return to therapy. If symptoms persist in spite of regular therapy, consider increasing the Fluoxetine dose from 20 mg to 30 mg. Wait 4 to 6 weeks to re-evaluate symptoms. If symptoms persist and she tolerates the medication, consider increasing the dose in increments of 10 mg every 4 to 6 weeks to a maximum dose of 60 mg.” Copies of the consultants’ notes were sent to referring PCPs after each visit. Participation was voluntary, and consultants received no compensation.
CPC Design
The CPC was set up to help pediatric providers manage youth with mild to moderately severe mental health problems by providing outpatient consultation by a psychiatrist. Results from the pilot study of a similar CPC showed that patients with mild to moderate severity mental health problems such as ADHD, depression, and/or anxiety were best suited for this type of consultation model. 19 An algorithm was developed to aid pediatricians and consulting psychiatrists in determining who was appropriate for consultation (see Figure 1). Those who were currently using drugs or alcohol multiple times a week; those with a past history of trauma, abuse, aggression, bipolar disorder, psychosis, suicide attempts, or psychiatric hospitalizations were not suitable for this clinic, nor were those who required emergent care.
Algorithm for determining which patients are appropriate for the Child Psychiatry Consultation clinic.
Patients accepted into the CPC were scheduled for an initial psychiatric evaluation with a limited number of follow-up visits. Once stabilized, the patient was transitioned back to their referring provider for ongoing management. Although the goal was that patients would return to the care of their referring pediatric provider for ongoing treatment, it was acknowledged that there would be cases where this would not be clinically appropriate. Ultimately, the consulting psychiatrists would use their clinical judgment to determine if and when patients could transfer their care back to the referring provider.
Scheduling Consultations
It was imperative that the CPC fit into the existing workflow of the larger child psychiatry clinic. One of the challenges of implementing this model was that the participating psychiatrists had limited time available for new patient consultations given existing, large case loads. To prioritize access for patients referred for consultation, each clinician was given the flexibility to determine the number of appointment slots that would be reserved each week for the CPC. Some clinicians chose to reserve the same day/time each week, while others reserved a half-day a week for the CPC patients, depending on their caseload. The referral coordinators/schedulers were aware of which slots were designated for new CPC referrals. If these slots were not filled by CPC patients, they could be opened and used for other patients.
Selection of Pediatric Practices
As it was not possible to estimate the volume of potential referrals, the CPC team made the decision to limit the number of pediatric providers and practices who could refer patients to the CPC. Furthermore, in order to ensure that referring pediatricians would be able to provide ongoing medication management for patients following the consultation, the CPC team chose to recruit pediatric clinicians who had some experience or interest in prescribing the psychotropic medications commonly used to treat ADHD, depression, and anxiety (ie, stimulants, α-agonists, and selective serotonin reuptake inhibitors [SSRIs]). Consequently, the CPC team chose to engage pediatric practices that had previously committed to building their skills and knowledge in child and adolescent mental health care by attending a local training workshop. The 2.5-hour workshop focused on the identification, screening, and treatment of adolescent depression including when to safely initiate psychotropic medication and how to monitor treatment response. 20 As participants demonstrated significant post-workshop increases in knowledge and comfort with prescribing SSRI medication for depression, 20 we postulated that this could be applied to managing youth with anxiety, for whom SSRIs are first-line of medication treatment.
Twelve community pediatric practices were identified, and subsequently approached by the lead researcher who is a child and adolescent psychiatrist and medical director of the CPC. She met with each practice to explain the CPC model, its goals, structure, and to discuss any questions or concerns. All 12 pediatric practices agreed to participate, consisting of 40 providers (including physicians, advanced practice nurses, and physician assistants) and pediatric subspecialists. There were 5 medium-large sized private practices that saw predominantly privately insured patients, 3 academic-affiliated practices that saw a mix of privately insured and publicly insured patients, 2 practices that were federally qualified health centers, and there were 2 pediatric subspecialty practices.
The algorithm for determining which patients were appropriate for consultation was reviewed with clinic staff, with additional clarification of those patients who would require traditional psychiatric care (see Figure 1). Given that pediatric providers would have varying degrees of comfort with managing ADHD, depression, and anxiety, it was emphasized that each provider should refer patients that they would ultimately feel comfortable co-managing following consultation, regardless of the severity of symptoms. Referring pediatric providers were reassured that they would receive detailed written reports regarding ongoing treatment recommendations by the psychiatrist, as well as guidance regarding how to troubleshoot anticipated issues or worsening of symptoms.
Determination of Suitability for the CPC
The CPC protocol was modeled on the existing referral workflow to ensure consistency and minimal disruption for clinic staff. The pediatric providers were asked to fax or e-mail a copy of the patient’s face sheet, the most recent clinical note, and a consultation request form (see Supplemental Figure, available online) to the CPC for review. This differs from traditional referrals in which the clinic required copies of the referring pediatric provider’s recent note as well as the consultation request form which specifies the reason for consultation. This additional clinical information helped the consulting CAP to determine whether the referred patient was appropriate for the CPC or would require a higher level of care. The clinic referral coordinator would verify that a referred patient’s insurance was accepted by the consultation clinic. If so, the patient’s referral packet would be sent to the director of the CPC, a CAP, who would determine whether the patient was appropriate for outpatient consultation or whether they required a higher level of care. Finally, the referral coordinator would schedule an outpatient appointment in the CAP clinic and inform the referring PCP. Those patients who required a higher level of care were referred to the appropriate resources (ie, emergency room evaluation, partial hospitalization program). Patients who were not appropriate for consultation, but who would benefit from traditional outpatient psychiatric care were offered an appointment in the non-CPC clinic.
Outcome Measures
The sample consisted of patients who were initially referred to the CPC from September 1, 2016, to August 31, 2018; the data endpoint was January 31, 2020. All patient data were collected by clinical providers. After data extraction, all patients were assigned a unique study identification number to enable data to be de-identified. Data regarding demographics and clinical characteristics of patients referred for consultation were abstracted from the clinic’s secure electronic database. Data regarding patients seen for outpatient consultation were abstracted from the electronic medical records. All referring PCPs were contacted to determine whether or not patients seen for outpatient consultation returned to their PCP for ongoing care. A waiver of the requirement for informed consent was granted by the institutional review board for data collected from the database and electronic medical record.
Both PCPs and CAPs were asked to complete a short survey assessing their experience of the CPC model. The PCP survey had been used previously 19 and comprised 6 statements. Respondents were asked to indicate their level of agreement to each statement using a 5-point Likert-type scale (ranging from 1 = strongly disagree to 5 = strongly agree). An 11-item survey was specifically developed for CAPs to complete and was reviewed by outside CAPs for face validity. Again, respondents were asked to indicate their level of agreement with each item on a 5-point Likert-type scale. At the end of both surveys, there were 2 free-text options; one was for any additional comments and the other asked respondents to identify the best and worst aspects of the model.
Data Analysis
Descriptive statistics including frequencies and percentages are reported. Differences between groups (ie, patients who were accepted vs not accepted for the consultation clinic) were tested using t-tests for continuous data and associations between categorical variables were tested using χ2 analysis. Logistic regression analysis was used to predict the dichotomous outcome of the patient returning to their PCP for care (yes/no) from clinical and demographic variables. All analyses were conducted using SPSS version 24.0. The written comments were analyzed using inductive thematic content analysis, a method for identifying, analyzing, and reporting themes in qualitative data. 21 The analysis is conducted in 6 phases: establish familiarity with the data, generate initial codes, search for themes, review themes, name themes, and provide the report.
Results
Clinical and Demographic Characteristics of Patients Referred for Consultation
Demographic and clinical characteristics of the sample are shown in Table 1. A total of 159 patients were referred for CPC consultation over the 2-year period and their cases were reviewed by a child and adolescent psychiatrist. All 12 pediatric practices referred at least one patient for consultation. Consultation requests by practices ranged from 1 to 51 (mean = 4.6 patients, SD = 2.1). The mean number of referrals per individual provider was 4.0 (SD = 4.6, range = 1-21). The majority of referrals (84%) came from the 4 largest practices. The majority of patients were referred for consultation regarding at least 2 different psychiatric concerns (76%) per the pediatric provider.
Sociodemographic and Clinical Characteristics of Patients Referred to the Child Psychiatry Consultation Clinic by Outcome Group.
Abbreviations: ADHD, attention deficit/hyperactivity disorder; ns, nonsignificant; OCD, obsessive compulsive disorder.
Unpaired t-test.
Chi-square test.
As shown in Figure 2, of the 159 referrals, 77% (n = 123) were determined to be appropriate for outpatient consultation. Of the 36 patients who were not felt to be clinically appropriate for consultation, the majority (n = 30, 88%) required a higher level of care, 5 patients had insurance that was not accepted by the clinic, and 1 patient did not require care by a psychiatrist.
Process from referral to Child Psychiatry Consultation clinic to final disposition.
Differences Between Those Patients Who Were Appropriate Versus Not Appropriate for Outpatient Consultation
Inferential analyses, shown in Table 1, found that those patients who were determined to be appropriate for outpatient consultation were significantly older and significantly more likely to be female, White, and have private insurance compared with those who were not accepted. Patients referred for concerns about anxiety, depression, or a behavioral issue were significantly more likely to be accepted for outpatient consultation.
Outcome of Patients Appropriate for Outpatient Consultation
Of the 123 patients determined to be appropriate for outpatient consultation, 72% (n = 89) scheduled and attended their initial evaluation (see Figure 2). The remaining patients either chose to not schedule an appointment (n = 25, 20%), scheduled but then cancelled their appointment (n = 6, 5%), did not attend (ie, “no showed”) their appointment (n = 2, 2%), or left without being seen (n = 1, 1%).
The mean number of days until the initial appointment was scheduled was 17.9 (SD = 10.2, range = 1-55) with 50% of appointments scheduled within 15 days.
The most common primary psychiatric diagnoses given by the consulting CAP after initial consultation were generalized anxiety disorder (n = 31, 35%), major depressive disorder (n = 21, 24%), and ADHD (n = 18, 20%). A full list of primary psychiatric diagnoses is shown in Table 2. Most patients were given at least 2 psychiatric diagnoses after consultation (n = 72, 89%; see Table 3).
Primary Psychiatric Diagnoses Given by the Consulting Psychiatrist After Initial Outpatient Consultation in the Child Psychiatry Consultation Clinic.
Abbreviations: GAD, generalized anxiety disorder; MDD, major depressive disorder; ADHD, attention deficit/hyperactivity disorder; OCD, obsessive compulsive disorder, PTSD, posttraumatic stress disorder.
Total Number of Psychiatric Diagnoses Given by Psychiatrist Following Consultation.
The treatment plan for the majority of patients involved a combination of treatment with psychotropic medication and referral for psychotherapy (n = 76, 92%). Only a minority of patients (n = 33, 37%) were in psychotherapy at the time of consultation.
Patient Disposition Following Consultation
As the CPC was intended to deliver short-term outpatient consultation for referring pediatricians, we examined whether the referred patients were able to return their PCP following the consultation. The disposition of the patients who underwent consultation is shown in Figure 2. Briefly, 78% (n = 69) of the patients seen for consultation ultimately returned back to the care of their PCP and did not require long-term, ongoing care by a psychiatrist. Patients were seen for an average of 3.3 (SD = 2.6) follow-up visits before returning to the care of their referring PCP.
Clinical Predictors of Returning to PCP
Logistic regression analysis was used to predict the dichotomous outcome of the patient returning to their PCP for care (yes/no). Gender, age at referral, insurance type, race (White vs non-White), total number of diagnoses, and presence of depression (yes/no) or anxiety (yes/no) were used as predictor variables using the Enter method. Statistical significance was set at P < .05. This model correctly predicted 78.7% of cases. This model found that only total number of diagnoses significantly predicted the outcome (β = −.56, standard error [SE] = .25, df [degrees of freedom] = 1, P = .025; Exp(β) = .57, 95% confidence interval [CI] = 0.35-0.93). That is, those patients who were diagnosed with a higher number of psychiatric conditions at the initial consultation were significantly less likely to return to their PCP for care.
PCP Satisfaction With the CPC
Of the 40 PCPs who participated, 26 completed the survey giving a response rate of 65%. The majority were MDs (92%, n = 24) and female (73%, n = 19).
Figure 3 shows the PCPs experience and perceived usefulness of the CPC. The overwhelming majority of respondents (96%) agreed or strongly agreed that they found the consultations useful, that the model met the needs of their patients with mental illness; the model improved their skills in providing mental health care to patients, and that it improved access to Child and Adolescent psychiatry services. Variation was seen among the other statements; 40% of PCPs agreed or strongly agreed that they spent a great deal of time caring for the consult model patients during their follow-up visits, with 28% neutral and 28% disagreeing with the statement.
Primary care physicians’ (PCPs) experience with the Child Psychiatry Consultation clinic: percentage of PCPs (N = 26) endorsing “strongly agree” or “agree.”
More than half of the respondents (56%) agreed or strongly agreed that they were able to be reimbursed for the time spent caring for CPC patients during follow-up visits, with 32% stating that they did not know.
CAP Experience With the CPC
Of the 10 CAP providers who participated, only one did not complete the survey, for a response rate of 90% (n = 9). The majority were female (78%, n = 7) and all were MDs (56% residents, 22% attendings, and 22% were fellows).
Figure 4 shows the CAP experience with the CPC. The overwhelming majority of CAPs (≥89%) agreed or strongly agreed that they felt confident co-managing patients with pediatricians, were comfortable deciding when a patient could be transferred back to the care of the PCP, and felt that it improved their collaboration skills with pediatricians. Similarly, 89% agreed or strongly agreed that they enjoyed practicing within the CPC and that it improved access to CAPs.
Child and adolescent psychiatrists’ (CAPs) experience with the Child Psychiatry Consultation clinic: percentage of CAPs (N = 10) endorsing “strongly agree” or “agree.”
Most agreed that the CPC patients were less complex than traditional patients (66%) and disagreed or strongly disagreed that these types of consults required more time (78%) with most indicating that they took the same time as a traditional consult (66%). Similarly, the majority disagreed or strongly disagreed that follow-up visits required more time (78%) with most agreeing the follow-up visits took around the same amount of time (66%). All of the CAP providers planned to continue using an outpatient consultation model in their practices.
Qualitative Analysis of Comments From PCPs and CAPs
Inductive thematic analysis of the written comments provided by 26 of the PCPs showed that they all found the CPC to be a valuable community resource. Specifically, PCPs reported that the CPC improved access to care (100%, n = 26), increased their knowledge and clinical skills regarding psychiatric management (100%, n = 26), and forged new collaborative relationships with psychiatrists (81%, n = 21). Many expressed sentiments of feeling overwhelmed trying to care for multiple patients in their practice with complex mental health needs (58%, n = 15). The CPC allowed the patient to be stabilized which enabled PCPs to feel that they could realistically manage them (58%, n = 15). The psychiatrists were seen as a valuable resource in cases where the patient was not progressing or if the PCP was questioning the diagnosis (65%, n = 17). Having multiple psychiatrists available for consultation was seen as a major benefit (69%, n = 18), as previously, some PCPs only knew one child psychiatrist to whom they could refer (42%, n = 11). Consequently, the majority of PCPs felt that consultations happened more quickly and there was greater availability of appointments as there were more psychiatrists available (69%, n = 18).
More than half of the PCPs reported that their main frustration with the CPC was that it was not suitable for highly complex patients in their practices, particularly acutely suicidal patients (54%, n = 14). Although the PCPs were aware that the CPC was targeted to mild to moderate cases of depression, anxiety, and ADHD they were still concerned with how best to obtain care for emergent, serious situations. They did acknowledge, however, that the consulting psychiatrists provided advice or referrals on these cases even though the patient was not suitable for the CPC (54%, n = 14). There was also frustration with patients being limited by their insurance coverage and that the CPC was not designed to improve access to psychologists or counseling services, which most felt that their patients may benefit from (88%, n = 23).
The CAPs were divided as to whether the CPC patients were more or less complex than traditional referrals (56%, n = 9). However, it was evident that all of the CAPs enjoyed collaborating with the pediatricians and expressed a sense of immediate gratification from helping patients (100%, n = 9). All expressed a sense of fulfillment and appreciation from the PCPs which they may not always receive in typical practice (100%, n = 9). Tight loop communication was seen as a major contributing factor to the success of the referrals, specifically timely exchange of information and having history and screening information prior to the initial appointment (78%, n = 7). CAPs also felt that the parents were more invested and ensured follow-up, again promoting a positive outcome (89%, n = 8). One resident expressed some discomfort regarding the sense of responsibility that he felt; he discussed medicolegal concerns if there was a negative outcome based on a recommendation or evaluation that he gave to the PCP.
Both PCPs and CAPs were mutually positive about the collaborative nature of the relationship which extended their professional network (100%, n = 35). The PCPs were appreciative of the thoroughness and timeliness of the evaluations and grateful for the providers’ availability (100%, n = 26). Both sets of providers also expressed concern and frustration with navigating insurance issues, with concern that the most vulnerable patients may not receive the help that they need quickly and may experience more barriers to care (71%, n = 25).
Discussion
The high prevalence of untreated child mental health disorders coupled with the national shortage of child psychiatrists necessitates the development of new clinical models to increase and improve access to child mental health care.1,5 Pediatricians have been called upon to treat mild to moderate mental health problems,6-8 yet require additional clinical training with support from CAPs in order to do so. Our study is one of the first that examines an exclusively outpatient psychiatric consultation model designed to empower pediatricians to care for youth with a combination of depression, anxiety, and/or ADHD. The results suggest that this model was feasible, utilized by pediatricians, and highly valued by both pediatricians and CAPs. These findings contribute to the growing literature that shows how clinical consultation programs can help PCPs gain proficiency in managing children with mental health problems, and, in turn, improve access to child mental health care.14-18
There are several major advantages of the CPC, notably that it provides expedited access to outpatient psychiatric consultation (ie within 2 weeks of referral) and that it does not require external funding to implement. Such a model may be a feasible option for other communities that lack state-wide funding and external resources to support the salaries of on-call psychiatry consultants, therapists, and case workers for on-demand consultation hotlines for pediatricians. Furthermore, this type of model can be successfully integrated into an outpatient clinic with minimal changes to the existing schedule and workflow. Since around four fifths of patients returned to their PCP for ongoing care, the CAPs maintained ongoing availability to see new patients for consultation. This, in turn, is an efficient way to increase capacity for new patient evaluations within a limited amount of CAP time.
Another positive finding is that all of the participating CAPs stated that they intended to continue practicing the CPC model after the completion of the study. The high degree of satisfaction could be related to their perception that CPC patients were less complex than traditional psychiatric patients and, as such, improvements were seen more quickly. The fact that the CAPs differed in terms of their level of training and experience but all found it rewarding and intended to adopt the model, suggests that it could be generalizable to other CAPs and sites.
Pediatricians have cited a lack of confidence and a lack of training in using psychotropic medications12,13 as barriers to treating mental health issues. Therefore, increasing both knowledge and confidence in clinical skills are central to successful consultation models. To support pediatric providers in developing these skills, the AAP has made toolkits and best practice guidelines readily available9-11 in addition to online and in-person training opportunities. Within this sample, the majority of PCPs had previously participated in a workshop on depression as a means to increase these skills. Thus, formal clinical training (obtained online or in-person) on assessment and indications for management with psychotropic medication is critically important. In addition, access to case-by-case clinical consultation with a CAP likely catalyzed PCPs in this study to care for youth with depression, anxiety, and ADHD. PCPs commented that they appreciated the support of consulting CAPs who could evaluate and stabilize patients who had previously not responded to treatment, so that PCPs could safely and efficiently manage these patients in a primary care setting. Being able to consult with the CAP whenever needed during that time may have contributed to a sustained confidence in managing these youth. The fact that PCPs were able to provide ongoing treatment for the cohort of patients who returned to their care over a 4-year period, is very promising. Future studies should examine if the PCPs who participate in this model over a duration of time will build their skills and confidence to treat mild to moderate mental health issues within their practice while minimizing referral to specialists.
It should be noted that there a number of limitations to both the CPC model and study design. The CPC model is designed for children with mild to moderate cases of ADHD, depression, and/or anxiety who could be managed by their PCP. It is not designed for those with more severe, complex mental health problems. Indeed, this study found that patients with a greater number of psychiatric comorbidities, which is often a marker for severity, were significantly more likely to require ongoing care by a psychiatrist. Additional models that provide expedited access to emergency mental health care are needed to help manage youth with more severe, chronic, and unstable mental health problems. Given the high lifetime prevalence rates of ADHD, depression, and anxiety among youth (prevalence rates of 8%, 11%, and 32%, respectively),10,22,23 a CPC could potentially assist a large population of youth. As the vast majority of youth with these illnesses present with mild to moderate symptoms,23,24 this type of model could help a large proportion of these cases. In addition, early intervention models which deliver expedited and safe, evidence-based care by PCPs may help to mitigate the emotional and social morbidities associated with these disorders. Additional limitations of the study are that data from the PCP’s medical or billing records could not be obtained to determine details regarding the PCP’s ongoing care for mental health problems (ie, PCP prescribing practices for psychotropic medication including duration of treatment with medication, whether or not PCPs required additional CAP consultation, changes in patient symptoms, and persistence or resolution of mental health problems). These outcomes would be important to assess in future studies. Finally, only self-pay patients or those whose insurance was accepted by the clinic could be included in the study. Although limited insurance coverage for mental health problems is a national issue and not specific to this study, it does raise concerns about barriers to care.
Study limitations include an observational cohort design resulting in a lack of a control group, 65% response rate on the PCP survey, and the fact that the patient population consisted of mainly White, non-Latino, and privately insured patients, which may not generalize to other populations. Although this is reflective of the geographical population that the clinic serves, future studies need to focus on and specifically recruit populations at risk of health care disparities, such as those who are uninsured, are racial or ethnic minorities, or who live in rural communities.
Conclusion
A 4-year study of a collaborative psychiatric consultation clinic for mild to moderate cases of ADHD, depression, and anxiety showed feasibility, utilization, and high satisfaction for both pediatric providers and CAPs. Almost 80% of patients returned to their PCP for ongoing mental health treatment, and PCPs reported increased confidence in their clinical skills and managing these cases, including with psychotropic medications. Limited access to child mental health care is a major national crisis. Models such as the CPC help address this problem by empowering pediatricians to manage psychiatric conditions in youth through increased knowledge and clinical skills, in collaboration with CAPs. An important strength of this model is that it was able to be sustained in the absence of supplemental external funding and resources, and was incorporated into an existing clinic workflow. Further studies are needed to replicate these findings and also focus on populations at risk of health care disparities. Continued research on, and development of, consultation models are urgently required to address the needs of the millions of youth with untreated mental health problems.
Author Contributions
EMF: Contributed to conception and design; contributed to acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.
REL: Contributed to data interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.
KL: Contributed to conception and design; contributed to data interpretation; critically revised the manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.
ERB: Contributed to design; conducted data analysis; contributed to data interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.
Supplemental Material
sj-pdf-1-cpj-10.1177_00099228211015844 – Supplemental material for Child Psychiatry Consultation Clinic for Pediatricians: Long-Term Outcomes
Supplemental material, sj-pdf-1-cpj-10.1177_00099228211015844 for Child Psychiatry Consultation Clinic for Pediatricians: Long-Term Outcomes by Elise M. Fallucco, Robin E. Landy, Kitty Leung and Emma Robertson Blackmore in Clinical Pediatrics
Footnotes
Acknowledgements
The authors would like to thank all of the pediatric providers (especially those at Carithers Pediatrics and Baptist Pediatrics) and child and adolescent psychiatrists who participated in this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Substance Abuse and Mental Health Services Administration (Grant 6H79SM082201-01M002 to the Parternship of Child Health); and the Hall-Halliburton Foundation.
Supplemental Material
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References
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