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).
Birmaher B, Axelson DA, Monk K et al. (2003), Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 42(4):415-423.
Bower P, Garralda E, Kramer T et al. (2001), The treatment of child and adolescent mental health problems in primary care: a systematic review. Fam Pract 18(4):373-382 [see comment].
Brent DA, Holder D, Kolko D et al. (1997), A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Arch Gen Psychiatry 54(9):877-885.
Campo JV, Shaffer S, Lucas A et al. (2003), Pediatric mental health services in primary care: a nurse centered model. Presented at the 50th Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Miami Beach, Fla.; Oct. 17.
Costello EJ, Burns BJ, Costello AJ et al. (1988a), Service utilization and psychiatric diagnosis in pediatric primary care: the role of the gatekeeper. Pediatrics 82(3 pt 2):435-441.
Costello EJ, Edelbrock C, Costello AJ et al. (1988b), Psychopathology in pediatric primary care: the new hidden morbidity. Pediatrics 82(3 pt 2):415-424.
Costello EJ, Pantino T (1987), The new morbidity: who should treat it? J Dev Behav Pediatr 8(5):288-291.
Emslie GJ, Rush AJ, Weinberg WA et al. (1997), A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry 54(11):1031-1037.
Horwitz SM, Leaf PJ, Leventhal JM et al. (1992), Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices. Pediatrics 89(3):480-485.
Institute of Medicine Committee on Quality of Health Care in America (2001), Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.
Jensen PS, Hinshaw SP, Swanson JM et al. (2001), Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr 22(1):60-73.
Katon W, Von Korff M, Lin E, Simon G (2001), Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry 23(3):138-144.
Katon W, Von Korff M, Lin E et al. (1999), Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 56(12):1109-1115.
Kelleher KJ, Childs GE, Wasserman RC et al. (1997), Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks. Arch Pediatr Adolesc Med 151(11):1109-1115.
Kelleher KJ, Hohmann AA, Larson DB (1989), Prescription of psychotropics to children in office-based practice. Am J Dis Child 143(7):855-859.
Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM et al. (1997), Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 65(3):366-380.
Pincus HA (2003), The future of behavioral health and primary care: drowning in the mainstream or left on the bank? Psychosomatics 44(1):1-11 [see comment].
Ringeisen H, Oliver KA, Menvielle E (2002), Recognition and treatment of mental disorders in children: considerations for pediatric health systems. Pediatr Drugs 4(11):697-703.
Rothman AA, Wagner EH (2003), Chronic illness management: what is the role of primary care? Ann Intern Med 138(3):256-261 [see comment].
Rushton J, Bruckman D, Kelleher K (2002), Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med 156(6):592-598.
Rushton JL, Clark SJ, Freed GL (2000), Primary care role in the management of childhood depression: a comparison of pediatricians and family physicians. Pediatrics 105(4 pt 2):957-962 [see comment].
U.S. Public Health Service (2000), Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington, D.C.: U.S. Department of Health and Human Services.
Von Korff M, Gruman J, Schaefer J et al. (1997), Collaborative management of chronic illness. Ann Intern Med 127(12):1097-1102.
Wagner EH (2000), The role of patient care teams in chronic disease management. BMJ 320(7234):569-572 [see comment].
Walkup JT, Labellarte MJ, Riddle MA et al. (2001), Fluvoxamine for the treatment for anxiety disorders in children and adolescents. N Engl J Med 344(17):1279-1285.