Addressing the Interface Between Pediatrics and Psychiatry
Addressing the Interface Between Pediatrics and Psychiatry
Shortly after completing my training in both pediatrics and psychiatry, I spoke with a retired child and adolescent psychiatrist who had invested his career in improving the relationship between pediatrics and psychiatry. As I excitedly told him about plans to focus my own career on the interface between the disciplines, he wistfully stared off into the distance, then respectfully observed, "Hope springs eternal now, doesn't it?" It is no accident that I continue to think of him often. A quick MEDLINE search gives reason for despair--collaboration between pediatrics and psychiatry has been a topic of interest, discussion and annoyance for half a century, not only in the United States, but also in a host of different countries and cultures. Parallel systems of care for pediatric physical and mental health problems persist despite recommendations to better integrate existing research-based knowledge into routine clinical practice (e.g., U.S. Public Health Service, 2000). Yet despite several "botched beginnings" between the disciplines and the imperfect nature of existing knowledge and practice, there truly is reason for hope. Psychiatry and its affiliated disciplines now offer a better product that is increasingly relevant to the pediatricians and family physicians who are being called on to manage youths with mental disorders in traditional medical settings.
Reason for Hope
This is an exciting time to be a mental health care professional. Tremendous progress has been made with the nosology and the clinical epidemiology of pediatric mental disorders, and treatments for attention-deficit/hyperactivity disorder (Jensen et al., 2001), anxiety disorders (Birmaher et al., 2003; Kendall et al., 1997; Walkup et al., 2001) and depressive disorders (Brent et al., 1997; Emslie et al., 1997) have demonstrated efficacy, calling attention to gaps between the evidence base and routine clinical practice (Institute of Medicine Committee on Quality of Health Care in America, 2001) and creating a need to expand the scientific basis of usual practice (Ringeisen et al., 2002). The future of child and adolescent psychiatry will likely depend on collaborative efforts with pediatricians, family physicians and affiliated mental health care professionals such as nurses, psychologists and social workers to fill in the gaps by improving the scope and quality of pediatric mental health services.
A Shared Challenge
Most youths with psychosocial problems do not receive mental health care services (Rushton et al., 2002), despite as many as one in four suffering from a clinically significant mental disorder (Costello et al., 1988a). The primary care setting is increasingly recognized as being relevant to the management of common pediatric mental disorders, but the role of primary care clinicians in service delivery remains poorly defined on a societal level (Costello and Pantino, 1987; Pincus, 2003). Low rates of primary care clinician recognition and referral of youths with mental disorders are the rule rather than the exception (Costello et al., 1988b; Horwitz et al., 1992; Kelleher et al., 1997), and primary care clinicians report inadequate training in the management of pediatric mental health problems (Kelleher et al., 1997; Rushton et al., 2002). Barriers to pediatric mental health care include stigma, insufficient access to specialty services, a shortage of child and adolescent psychiatrists, imbalances in the geographic distribution of available mental health care professionals, prolonged delays in scheduling appointments, administrative practices that restrict access, and reimbursement problems. Even when a credible referral is offered and available, family compliance with referrals is quite low (Rushton et al., 2002). In addition, primary care clinician management of disorders such as ADHD often fails to meet recommended standards for treatment intensity and follow-up (Jensen et al., 2001), and primary care clinicians are especially uneasy caring for mental health disorders other than ADHD, such as depression (Rushton et al., 2000). Finally, while it is almost certainly true that primary care clinicians and mental health care professionals are dedicated to improving services for pediatric mental disorders, guild issues, differences in experience and training, classification and reimbursement problems, the wish for primacy, and stigma all can interfere with mutually respectful collaboration.
A Bridge to Collaboration?
Despite the challenges outlined above, primary care clinicians remain important resources for families addressing pediatric psychosocial problems (Horwitz et al., 1992). Advantages of the primary care setting include familiarity, proximity and relative acceptability for youths and their families, allowing mental health services to be delivered in the context of an established relationship with the primary care clinician. Most youths with recognized mental disorders are managed by primary care physicians (Rushton et al., 2002), who write the majority of their psychoactive medication prescriptions (Kelleher et al., 1989; Ringeisen et al., 2002). Delivering mental health care services in primary care communicates that physical and mental health are inseparable and may aid in efforts to overcome stigma and the sometimes strained relationships between and among mental health service providers and primary care clinicians (Kelleher et al., 1997).
There is a growing appreciation that mental disorders are most often chronic conditions with a broad range of severity, analogous to asthma, and that high-quality mental health care services are multidisciplinary and collaborative (Pincus, 2003). Consequently, it is unreasonable to expect primary care clinicians to consistently deliver quality mental health care without changes in the organization of primary care health services (Rothman and Wagner, 2003). Successful strategies in adult primary care include using mental health care professionals as educators, consultants, supervisors and/or direct service providers, but specialist involvement alone is less potent than changes in care system design (Katon et al., 2001; Von Korff et al., 1997; Wagner, 2000).