Extending Our Virtual Reach: Pediatricians and Mental Health Providers Bridging the Chasm to Mental Health Care for Adolescents and Transition-Age Youth During COVID-19

As a consequence of the pandemic and global circumstances, mental health concerns among adolescents are exacerbated. ¹ Limited face-to-face peer socialization, increased exposure to social media stressors, adaptation to online learning, and familial and economic strain, to name just a few, ² are contributing to a surge in rate and severity of adolescents’ mental health needs. ³

Such difficulties are frequently identified in pediatric primary care and subsequently referred to specialty care when clinically indicated. Not surprisingly, mental health care providers to whom pediatricians commonly refer—in short supply even pre-pandemic—are now inundated, ⁴ resulting in months-long waitlists in the face of increasing urgency for services. ⁵ Pediatricians are left to manage high-acuity mental health presentations for extended periods until specialty care can be accessed. Meanwhile, mental health care providers, full to capacity, struggle with the knowledge that youth and families continue to suffer while awaiting much-needed care.

As a pediatrician and a clinical psychologist with a shared deep commitment to adolescent and transition-age youth mental health, we are advocating for a collective effort to bridge the chasm between identification and referral in pediatrics, and subsequent engagement in specialty mental health care. This approach requires extending our respective professional reach from both sides of the chasm in unique ways.

Beyond initial identification and referral, pediatricians are well-positioned to lean in virtually to support mental health during these challenging times. Pediatricians’ often long-standing relationships with youth and families enable adolescents to feel more comfortable and less stigmatized discussing mental health concerns. While many pediatricians may avoid telemedicine for sore throats and ear infections, the platform can be a critical means to bridge to mental health care. In line with recommendations by the American Academy of Pediatrics to engage in frequent follow-ups with youth with mental health symptoms, ¹ such interim virtual appointments serve multiple functions, including to improve continuity of care, enhance likelihood of follow through with referrals, enable ongoing assessment of treatment needs, and allow for prompt and responsive medication adjustment and/or short-term problem-solving and intervention. We find this approach especially valuable for transition-age youth, many of whom left for college with prescribed psychotropic medications and poorly controlled or undiagnosed mental health concerns. They have subsequently encountered unprecedented stressors, coupled with limited access to appropriate mental health resources. ⁶ The ability to remain linked to such patients via telemedicine during these vulnerable periods allows us to remain aware of and respond to concerns before irreversible damage is done. While we acknowledge limits to pediatricians’ capacity to intervene as non–mental health specialists, we argue that collaboration with mental health specialists can help equip pediatricians with helpful resources for adolescents in need.

Across the chasm, mental health care providers are unable to meet the increasing demand for services. Just 1 year ago, a mental health specialist full to capacity would provide a list of referrals to a family seeking services, confident that they would be seen by another provider in a timely way. Yet, in the current climate, families recontact weeks and months after initial referral, unsuccessful at finding a provider with availability. In the interim, stressors persist, the schoolyear marches on, and the impact of untreated/undertreated mental health symptoms continues to pervade the adolescent’s functioning. The ability to connect with referring colleagues in primary care offers potential to ease this transition period. Through provision of consultation, resources, and guidelines for interim clinical management, specialists can help pediatrician colleagues to support adolescents during these extended transitions to mental health care. A wealth of resources exist, including the COVID-19 (coronavirus disease-2019) mental health care toolkit created by psychiatrists for use in general care by nonspecialists, ⁷ and can be supplemented by evidence-based electronic resources like disorder-specific online interventions ⁸ and apps. ⁹ Brief consultation calls between referring pediatricians and mental health care providers enable collaboration on interim management/treatment plans that are implementable via telemedicine by pediatricians to minimize clinical deterioration in the period from referral to mental health care initiation.

We have come to appreciate unanticipated perks of telemedicine in our work with adolescents and young adults with mental health concerns that make it a helpful platform to ease this handoff. Foremost, we are observing enhanced autonomy and self-efficacy in mental health care in this population. Our patients, no longer dependent on parents for transportation or bus fare to the clinic, and with expanded scheduling flexibility, are increasingly making and attending appointments on their own. This is particularly promising since mental health self-efficacy is associated with mental health outcomes and functioning among young adults. ¹⁰ Additionally, telemedicine affords unexpected insight into patients’ lives, along with opportunity for connection. We saw beautiful art on a bedroom wall created by a patient we did not know was an artist; we were introduced to the most beloved of stuffed animals gracing the bed of a teen who had previously been reluctant to engage; and we witnessed an adolescent benefit from stroking the family pet while disclosing suicidal thoughts.

We also acknowledge the substantial barriers to telehealth. Disparities in access to care permeate telemedicine, as access to devices, reliable Internet service, and protected space and time may be limited for underserved youth. Poor quality of Internet connection on either end can contribute to frustration. Additionally, limited privacy restricts the capacity to share critical information relevant to care. Meanwhile, some adolescents are uncomfortable being on a screen, and/or do not trust the security of the Internet to share personal information. At the systems level, such vital services may be unbillable, highlighting the desperate need to revisit payment models of care delivery.

The current youth mental health crisis has spawned an unprecedented need for providers to extend our reach. Through pediatricians and mental health care providers both leaning in, together we enhance our collective capacity to successfully bridge the chasm between primary care and mental health care for adolescents and young adults.