There is a recognized shortage of child and adolescent psychiatrists in the United States and a great need for their services. Studies show that approximately one in five youths in the United States has a mental disorder, but only about 20% of these youths receive treatment (1). Further, there is a significant maldistribution of child and adolescent psychiatrists, which is especially severe in rural areas (2). Stubbe and Thomas (3) surveyed early-career child and adolescent psychiatrists and found that although 29% of respondents reported some work in the public sector, only 15% of total workforce hours were spent in public-sector activities.
In the face of this need, numerous public mental health programs have been developed to provide services in the public—and sometimes private—sectors. These programs frequently depend on public-academic collaborations. In some cases, innovative programs provide various forms of consultation to primary care providers (pediatricians and family physicians). In other cases, the consultative programs to general psychiatrists and nurse practitioners that have been in existence for many years have now added new technology to increase their scope. This column describes examples of these two types of public-academic partnerships.
Primary care providers are well positioned to provide mental health services to youths. Nearly all youths are seen at some point in primary care settings. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have advocated for more appropriate funding and reimbursement to facilitate the provision of mental health services in pediatric settings (4). The AAP has urged its members to develop competencies in mental health assessment and treatments (5). The concept of the patient-centered medical home that has been endorsed by several specialty groups is consistent with this emphasis. The patient-centered medical home calls for the primary care practice to be the focus of treatment for the child or adolescent, with primary care providers implementing or coordinating care with specialist providers, such as child and adolescent psychiatrists and other mental health providers.
Several statewide programs of consultation, coordination, and education for primary care providers that are in accord with these recommendations have been developed. Although programs vary, they all emphasize that youths be treated in primary care settings by their own primary care providers whenever possible. Formal training and education for primary care providers in mental health assessment and treatments are provided through Web-based education, face-to-face seminars, group case consultations, and larger conferences. Individual consultations to primary care providers by child and adolescent psychiatrists are provided mainly by telephone, but most programs also provide face-to-face consultations, sometimes using videoconferencing. Case coordination and referral or linkage services are provided. Depending on the program, short-term therapeutic intervention is available. All of the programs highlighted here are associated with one or more academic medical centers or university departments of psychiatry.
An example of this type of program is the Massachusetts Child Psychiatry Access Project (MCPAP), a state-funded program covering all youths in the state regardless of payer source (6). It is the oldest of these large consultative models, having been a statewide program since 2005. Six regional teams of child and adolescent psychiatrists, along with psychotherapists and care coordinators, affiliated with Harvard University, Tufts University, and the University of Massachusetts, provide services to primary care providers. The initial contact for primary care providers is by telephone. If needed, the youth is then evaluated directly by a child and adolescent psychiatrist (or by the psychotherapist if the clinical question pertains to a psychosocial issue). Videoconferencing is not needed because the geographical distribution of sites allows patients to be seen in person. About 50% of youths are followed after consultation in the primary care setting, and others are referred. The MCPAP maintains a strong educational component for primary care providers through conferences, consultations, and Web-based information. Short-term treatment and help with referrals are provided if needed.
Data compiled after three-and-a-half years of operation (2005–2008) indicated that over 90% of primary care providers found the consultations useful. Surveys at baseline (2005) and about three-and-a-half years later found that the percentage of primary care providers who perceived that they had adequate access to a child and adolescent psychiatrist increased from 5% to 33%. During the same period, the percentage who felt that they were able to meet the needs of their patients with emotional or behavioral problems rose from 8% to 63%. The percentage who felt that they were able to obtain a timely consultation with a child and adolescent psychiatrist rose from 8% to 80%.
Another example of this type of program is the Partnership Access Line (PAL) (7), a statewide program in Washington State that was modeled after the MCPAP, although differences exist. One difference is in the extent of services provided to youths. Those in the public sector (with Medicaid as the payer source) are eligible for face-to-face or videoconference consultation if needed after the initial telephone contact. Those with private insurance are eligible only for telephone consultation. The program's base is Children's Hospital in Seattle. Its director and the other child and adolescent psychiatrists are members of the University of Washington's Department of Psychiatry. Most services to meet the mental health needs of the evaluated youths are provided by the primary care provider, often in conjunction with clinicians in the community. The PAL offers educational sessions and has a manual for primary care providers about treatment on its Web site (8).
A third example is Project TEACH (Training and Education for the Advancement of Children's Health), a statewide program in New York (9). It was developed in 2010 after a series of local and regional programs had provided telephone, face-to-face, and Web-based consultations to primary care providers. The program is state funded, administered through the New York State Office of Mental Health (OMH), and open to all residents of the state, regardless of payer source. Two entities provide the consultative and educational services. Child and Adolescent Psychiatry for Primary Care, or CAP PC, is a consortium of five medical school divisions of child and adolescent psychiatry (Columbia University; North Shore-Long Island Jewish Health System, Albert Einstein College of Medicine; the University at Buffalo-State University of New York; State University of New York-Upstate Medical University; and the University of Rochester) that provide coverage for most of the state. Primary care providers receive education through weekend seminars and telephone group consultations every other week for six months conducted by the REACH Institute (REesource for Advancing Children's Health). Primary care providers attending these trainings (about 100 each year) are eligible to attend the group consultations and to have their patients evaluated by child and adolescent psychiatrists from the program face to face or through videoconferencing. All primary care providers in the regions covered by this program are eligible for telephone consultations, regardless of whether the primary care provider has attended the seminars. CAPES (Child and Adolescent Psychiatry Education and Support) is the other entity providing consultation and educational services to primary care providers in New York State. This program was developed at a private psychiatric hospital and continues to operate from it. All primary care providers in the area served have access to telephone and face-to-face evaluations. Direct educational seminars and Web-based seminars are provided.
The Pediatric Psychiatry Network, Decision Support for Ohio Physicians (www.pedpsychiatry.org), is the most recent of the statewide programs described here. It is a federally funded program intended to provide a series of technologically supported services to primary care providers, community mental health programs, and patient-centered medical homes, including consultation, education, and triage. The program currently provides 24-hour consultative services by telephone seven days a week, but it plans to expand to provide consultation and Web-based and videoconferencing services. Several children's hospitals and academic medical centers are involved in the program's governance, including Case Western Reserve University, Northeastern Ohio University College of Medicine, Ohio State University, University of Cincinnati, University of Toledo, and Wright State University.
Child and adolescent psychiatrists are often not available in particular settings and in rural areas of the country. A study in New York State found that approximately 20% of counties did not have any child and adolescent psychiatrists (10). Academic centers sometimes provide consultation by child and adolescent psychiatrists to general psychiatrists and nurse practitioners and sometimes to primary care providers serving youths in these mental health settings.
The New York State OMH has partnered with two academic departments of psychiatry (Columbia University and the State University of New York-Upstate Medical University) to provide videoconference consultations to licensed mental health clinics that have no child and adolescent psychiatrists on staff. It also partners with the Department of Child and Adolescent Psychiatry at New York University and the Department of Psychiatry at the State University of New York-Upstate Medical University to provide videoconferencing to state hospitals in rural areas.
Academic departments of psychiatry often play a role in providing services to youths in public-sector programs, although the types of involvement have varied. Public-sector mental health services have historically focused on providing institutional and custodial care to patients with chronic disabilities for whom private resources are either inadequate or exhausted. Besides moving toward community-based supports for these patients, public mental health authorities appear to be recognizing the importance of addressing severe inadequacies in access to mental health services for all children. An expanded mission of this sort requires leadership, persistence, and a committed and engaged constituency. In Massachusetts, the state chapter of the AAP organized a Children's Mental Health Task Force, which began meeting in 2000. The task force, made up of a diverse group of stakeholders, including pediatricians, child and adolescent psychiatrists, parent advocates, educators, and policy makers, discussed problems in the children's mental health system. Acknowledging the role of the pediatrician as a key “first responder,” this group strongly advocated for public policy promoting the development of resources that would enable pediatricians to respond effectively to mental health concerns in the primary care setting.
These discussions resulted in a legislatively established Mental Health Commission for Children cochaired by Ronald Preston, who was then the Secretary of the Massachusetts Executive Office of Health and Human Services. Parents of children with mental health problems were highly vocal and well organized, and their descriptions of difficulties accessing care for their children were also influential. Under mounting pressure to address inadequacies in the children's mental health system, Secretary Preston directed the Massachusetts Behavioral Health Partnership (MBHP), one of the state's managed behavioral health vendors, to develop a plan to expand a promising University of Massachusetts pilot project conducted by Ronald Steingard, M.D., in Central Massachusetts into a statewide system for providing child psychiatry consultation to pediatricians. The proposed $2.5 million expenditure was approved by the Massachusetts legislature in June 2004, resulting in the creation of MCPAP.
The project is administered by MBHP, which contracts with each of six academic medical centers for the operation of a regional mental health team exclusively devoted to providing collaborative child psychiatry support to the primary care practices of the team's region. As noted above, services provided by the teams consist mainly of telephone consultation, care coordination, and educational activities and are therefore nonreimbursable. However, reimbursements from insurance payers for face-to-face evaluations offset approximately 5% of the cost of this program. Efforts to engage private insurance carriers in directly supporting its operation have been unsuccessful.
As these innovative statewide programs become more established, it will be important to develop methodologies to study patient outcomes. Funding and sustainability also are crucial. Both public and private sources have a role to play. Statewide surveys to determine the availability, deployment, and utilization of child and adolescent psychiatrists in the public sector would be helpful. It is also important to provide more training in new models of integrated care to child and adolescent psychiatrists generally and to residents in child and adolescent psychiatry and primary care programs.
Public-academic partnerships provide crucial collaborations to enhance the mental health care of youths. Given the limited supply of child and adolescent psychiatrists and the demand for services, it is important to find ways to increase the number of such partnerships.