Mental health services in primary care
Integrating behavior health services into the primary care setting can be beneficial for the patient as well as profitable for the pediatrician.
Many people in the United States live with a mental illness, and far too many suffer needlessly despite proven treatments to ease such suffering. Children are no exception. A report of the Surgeon General in 1999 estimated that 1 in 5 children have a diagnosable mental disorder but that only 20% to 25% receive treatment.1,2
Current estimates are similar, with about 1 in 5 adolescents aged 13 to 18 years expected to experience a severe mental disorder at some point in their life. In addition, most chronic mental illness begins by age 24 years with half of all cases beginning by age 14 years. Treatment for many of these children is delayed for years.3
One reason given for this dismal response is the challenge to children and their families in gaining access to services as well as continual follow-up once on treatment. What the 1999 report recommended as a solution to this access and continuity of care problem is the solution that stands today: making mental health a part of the medical home.
Despite this need, recognized over 16 years ago, the quality of care provided for mental health disorders in the primary care setting remains inadequate.4
A call for change
The need to change is highlighted by the long recognition that treatment of mental illness is highly successful and, for children in particular, imperative to catch early to halt the cascade of emotional and behavioral difficulties that often get worse over time if left unaddressed.
The burden on patients, families, and society is great, and in cost terms alone, unsustainable. Mental disorders are among the top chronic medical diseases driving healthcare costs, with a 2009 report by the Agency for Healthcare Research and Quality (AHRQ) listing mental health disorders in children aged younger than 18 years as incurring the highest expense for children. In 2006, cost to treating children with mental disorders totaled $8.9 billion.5
The incentives to make mental health services more accessible and better used are there, but pediatricians, like many physicians on the front lines of care, grapple with how to do this.
One approach singled out in the above mentioned 1999 report is to integrate mental health services into the primary care setting. Jay Rabinowitz, MD, FAAP, a clinical professor in the Department of Pediatrics at the University of Colorado in Denver, recently spoke to pediatricians at the 2016 American Academy of Pediatrics (AAP) annual conference on the need for better access and use of mental health services for pediatric patients as well as ways to address this need by integrating these services in the primary care setting.
In his talk “Integrating mental health services in the primary care office,” Rabinowitz, who practices at Parker Pediatrics and Adolescents, a comprehensive pediatric practice in Parker, Colorado, highlighted things he and his colleagues have learned over the 8 years in which they have succeeded in integrating mental health services in their clinic.
Why integrate services?
The reasons to integrate mental health services into the primary care setting are many, affecting both patients and providers. Along with the statistics cited above on the prevalence of mental disorders, Rabinowitz emphasizes that pediatricians are seeing more and more mental health issues in their patients and in most cases don’t have the easy means to manage them. “Mental health has always been carved out of the insurance contract,” he says. “We can see a child for pretty much anything medically, but if they have a mental health issue they need to go to a mental health organization.”
Unlike referral for other medical conditions, say to an otolaryngologist for an ear problem, in which pediatricians are kept in the loop and can track the follow-up care of these children, when children are referred out for mental health services, no such follow-up is done. This lack of continuity of care disempowers pediatricians from providing the best care to their patients, making it difficult to know which patients actually see an outside mental health specialist and receive and adhere to treatment.