There has been much thought and discussion about the relationship between pediatrics and psychiatry, but research on the integration of the two leaves much to the imagination.
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).
The Chronic Care Model
The chronic care model suggests that optimal care is achieved when informed and motivated patients and families interact with a well-prepared and proactive collaborative care team--a multidisciplinary group of clinicians who communicate regularly about the care of a defined group of patients and participate in that care (Rothman and Wagner 2003; Wagner, 2000). The chronic care model has been applied to mental disorders in primary care in order to improve the quality of service delivery by integrating mental health care professionals into primary care as educators, consultants and clinicians for the more severely ill, and taking advantage of multidisciplinary collaborative care teams that include non-physicians, such as highly skilled nurses and other allied health professionals, as care managers (Katon et al., 2001; Von Korff et al., 1997). The chronic care model shifts the focus of care from the acute to the longitudinal perspective. Goals include ensuring that a mutually understood and agreed-upon care plan is in place; patients and families have the skills and confidence necessary to manage the condition; the most appropriate treatments are available for optimal illness control and prevention of complications; and follow-up care is available (Rothman and Wagner, 2003; Von Korff et al., 1997). The six core elements of the chronic care model are listed in the Table.
Child and adolescent psychiatrists are well positioned to participate in the leadership of collaborative efforts guided by the chronic care model and contribute to care system design; education of primary care clinicians and care managers; and development of decision-support systems, management guidelines and self-management materials. Just as primary care clinicians may play multiple roles (e.g., sources of treatment, gatekeepers determining access to specialty mental health services), child and adolescent psychiatrists can similarly improve mental health services in primary care by educating primary care clinicians and their affiliates, supervising and having their input mediated by non-physician care managers, and providing direct assessment and treatment services for selected patients and families.
A stepped-care approach emphasizes different levels of care depending on the type of specific disorder; its severity, complexity and/or persistence in the face of intervention. This approach acknowledges the need for specialty mental health care and/or referral for selected or treatment-refractory patients (Katon et al., 2001, 1999). The chronic care model has demonstrated the effectiveness of primary care-based intervention for adults with depressive disorders, with landmark quality improvement trials that integrate mental health care professionals into primary care settings, producing remission rates comparable to those observed in specialty care efficacy studies (e.g., Katon et al., 1999). There has been little comparable intervention research in pediatric primary care settings (Bower et al., 2001).
A Working Model
We have applied a stepped-care approach to the management of pediatric mental disorders in a large, rural, primary care practice in western Pennsylvania. Our collaborative care team consists of primary care clinicians, a nurse-clinician/care manager, a psychiatric social worker and a pediatric psychiatrist (Campo et al., 2003). The model affirms the primary care clinician as the physician of record, with responsibilities including initial case identification, targeted medical and psychiatric assessment, presumptive diagnosis, treatment initiation (generally for straightforward cases) or specialty referral, and ensuring the overall continuity of care. Central to the model is a full-time nurse-clinician/care manager with considerable mental health training and experience who mediates specialty input and serves as the primary liaison between primary care clinicians and the psychiatrist, who is on site less than once per week. When a youth with a suspected psychiatric disorder is identified, the nurse-clinician works with the primary care clinician to complete an initial assessment and triage the patient. Options include: collaborative management with the primary care clinician in primary care (relatively straightforward, uncomplicated patients or those on a stable treatment regimen), on-site mental health co-management with the specialty mental health team (treatment failures with the primary care clinician or patients of intermediate complexity or severity) and off-site specialty mental health care referral (patients with more complicated and/or severe disorders and psychosocial circumstances judged unlikely to be successfully managed in primary care).
The nurse-clinician provides relevant patient and family education, ongoing case management and coordination, school liaison, and treatment-support services such as psychopharmacology safety and outcome monitoring. The nurse-clinician may also deliver brief psychotherapeutic and supportive interventions, including training in self-management strategies. The psychiatric social worker is charged with delivering on-site specialty psychotherapeutic interventions, particularly focused cognitive-behavioral treatments, for selected patients and families. The pediatric psychiatrist provides leadership for the on-site mental health care team, regular supervison for the nurse-care manager and therapist, regular education for the primary care clinicians on the assessment and management of common pediatric mental disorders, psychiatric consultation for selected cases (e.g., diagnostic dilemmas, treatment failures), and co-management for intermediate cases.
Although challenging from a fiscal perspective, this approach incorporates pediatric mental health care specialists into primary care, appears to be feasible and compatible with the workings of the practice, and has been well received by primary care clinicians, patients and families. In a single year, primary care clinicians requested triage assistance during 789 primary care visits (2.5% of annual visits), approximately one-third being first-time mental health contacts. Of these, approximately two-thirds were triaged to routine services delivered by the primary care clinician with nurse-clinician support, 20% were managed on-site by the primary care clinician and mental health care team, and the remainder was referred to more intensive specialty services off-site. Family compliance with scheduled assessment and triage visits was quite high (91%) in comparison to findings for off-site mental health referral in other studies.
The Need for Research
The relative lack of research addressing pediatric mental disorders in the primary care medical setting is rather striking, with only a handful of studies addressing this broad area. As a beginning, we have established a functional practice-based research network in primary care dedicated to improving the care of common pediatric mental disorders that is supported by the National Institute of Mental Health (MH 66371). Formal research addressing the effectiveness and design of collaborative pediatric mental health care teams; the roles of specific professionals; and the implementation of specific management guidelines, educational efforts and treatment interventions is warranted, but is best conducted as a shared, collaborative venture involving pediatricians and other primary care clinicians as active participants.
The Task Before Us
How can child and adolescent psychiatrists and other mental health care professionals productively collaborate with each other and with other primary care clinicians to improve the quality of care available to youths with mental disorders? The chronic care model provides a template for the task before us. The issue is not simply whether pediatricians and psychiatrists can successfully collaborate, but rather whether an effective system of mental health service delivery can be crafted that fosters collaboration between the disciplines. Improving the process of specialty mental health care referral alone is unlikely to address the scope of the public health problem. Primary care clinicians, psychiatrists and other mental health care professionals must face the challenges outlined above, which will necessitate real and enduring changes in current practices. Child and adolescent psychiatrists must be open to new models of care delivery and collaboration with our medical and mental health colleagues, or face increasing isolation as a rarefied specialty. The various mental health care disciplines must develop some degree of consensus on appropriate roles for particular specialties with regard to service delivery in primary care. There is wisdom in child and adolescent psychiatrists being proactive rather than simply reactive in any such process.
It makes abundant sense that any successful system of care should be built around the primary care clinician, while taking advantage of the expertise and training of child and adolescent psychiatrists and other mental health care professionals. Child and adolescent psychiatric input can be mediated by non-physician care managers with specialized clinical and behavioral skills who communicate regularly with the specialist and the primary care clinicians (Katon et al., 2001, 1999; Rothman and Wagner, 2003; Wagner, 2000). The goal is not to provide a non-physician substitute for the primary care clinician or specialist, but rather to complement and supplement both the primary care clinician's and specialist's roles by delivering services that they do not have the skills or time necessary to provide (Von Korff et al., 1997; Wagner, 2000). The care manager can thus complement the primary care clinician's mental health care skills while mediating and expanding the impact of psychiatrists within traditional medical settings. Such a model can successfully incorporate the expertise of highly trained, doctoral-level pediatric psychologists who can serve as educators, consultants, supervisors and interventionists focused on the delivery of specialized psychotherapeutic interventions. Master's-level clinicians in disciplines such as nursing, psychology and social work find roles in direct service delivery and in care management.
Relevant professional organizations must come together to develop a credible and committed leadership team that will likely need to include representation from relevant third party payers. Efforts can then follow to develop consensus on delivery system design, decision-support and self-management materials, and information systems relevant to common pediatric mental disorders that can ultimately be tested in a collaborative research process.
Hope does spring eternal.
Dr. Campo was supported by National Institute of Mental Health grant MH 01780, and this work was facilitated by NIMH grant MH 66371 and the ACISR for Early-Onset Mood and Anxiety Disorders.
Dr. Campo is medical director of an on-site mental health program in pediatric primary care, director of the Research Network Development Core of the Advanced Center for Interventions and Services Research (ACISR) for Early-Onset Mood and Anxiety Disorders, and associate professor of psychiatry and pediatrics at Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center.
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.