Why isn't mental health viewed like every other screening test?
I recently attended a meeting of primary care pediatricians and child psychiatrists. We were discussing what might now be possible within the medical home through the use of electronic medical records (EMRs).
In an increasing number of states and nationally under the Federal Medicaid program’s Early and Periodic Screening, Diagnostic and Treatment component, there is a requirement to screen all children for psychosocial issues such as autism, functioning in major areas of life, adolescent depression, and substance use.
In Massachusetts, and I believe in several other states, these screening tests are reimbursed a small amount to encourage their use and to reimburse the time used to administer the screening, as well as the time a pediatrician or nurse spends with the family discussing the results. The screen Michael Murphy and I have worked on for many years is the Pediatric Symptom Checklist (PSC) which focuses on psychosocial functioning from age 4 to 16 years and takes about 3 minutes to complete and 1 minute to score. It is available for free downloads in multiple languages from the web: http://www.massgeneral.org/psychiatry/services/psc_home.aspx.
Many practices are putting the PSC on a tablet, and Epic (Epic Systems Corporation, Verona, Wisconsin) as well as other EMRs have it built into their core system. So, it is now possible in many settings to screen children with the PSC during the annual visit; have the results appear instantly in the electronic record; and, if positive have the pediatrician spend a few extra minutes in that visit confirming that there are areas of daily functioning that are of concern and deciding whether a mental health referral is indicated. Many pediatric medical homes are now integrating a social worker or setting up better connections to mental health services.
Facilitated by the EMR, the mental health clinician could do the necessary evaluation and send back information to the pediatrician. This information might note a diagnosis, but, just as importantly, offer an evaluation of functioning and treatment recommendations. When scores on the PSC are logged into the medical record, it is possible to assess whether there is an improvement in symptoms and functioning through repeat PSCs. Hopefully, with treatment, PSC scores would go down and key symptoms would go from “often” to “sometimes.”
We would then have a loop:
PSC screen at annual visit - PSC positive - Pediatrician assessment of severity - Referral to Mental Health as need - Treatment as needed - repeat PSC to Pediatrician at regular intervals, direct verbal feedback as needed.
This loop rarely exists for a child with psychosocial problems and studies have shown that without routine psychosocial screening the referral rate from pediatric practice to mental health evaluation is well below half of what it should be based on need.
Of course, there are many barriers to implementation of the loop. Reimbursement for mental health services, using screening tools, access to mental health services, etc.
However, it is increasingly possible for health systems to implement this loop. And it is STUNNING in some ways that this loop exists without question for a positive urine screen for glucose and diabetes or a low hematocrit and hematology consultation. Yet, for mental health, building this loop and applying quality assurance standards to tracking its use and effectiveness is far less developed and rare.
Is it stigma? Stigma against the most common problems pediatricians now face in primary care practice?
I believe we have an opportunity to improve the care of our children by overcoming the stigma and other barriers, and by applying professional standards in the pediatric medical home for the provision of mental health services to children.