During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.
In my life as an early-career child and adult psychiatrist in the very “of-the-moment” role of consulting to primary care, I am now in a “pod” – a shared space with nurses, clinicians, and nursing assistants – in a practice where patient panels run into the 10,000s. The frenetic pace of visits includes the imperative to expertly address diverse medical needs such as flu symptoms, mental health problems, preventative care, and everything else across the spectrum of human needs – all to be met within 15-minute appointments. The role of the primary care physician (PCP) can leave one breathless in the expectations and demands to address broad health care needs.
The impetus to create an integrated mental health care approach has been well elucidated by the American Academy of Child and Adolescent Psychiatry (AACAP) in its report, Collaborative mental health care in pediatric primary care. It is based on some telling statistics: Fifty percent of all cases of mental illness begin before age 14 years and 75% begin by age 24. Half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. The American Academy of Pediatrics’ Task Force on Mental Health similarly has stated that primary care clinicians can and should be able to provide mental health services to children and adolescents in a primary care setting.
Integrative psychiatry and primary care treatment comes in three forms: classic consultation, in which a specialist sees a patient and refers back to the PCP with recommendations; colocation, in which mental health specialists practice in the same office but essentially are “ships crossing in the night” with PCPs; and the most-lauded form, collaborative/integrative care, in which back-and-forth consultation and discussions of a case occur between mental health specialists and PCPs, with in-person follow-up as needed.
Several institutions offer programs to address the AACAP and AAP imperatives, most prominently the University of Washington, Seattle, and the University of Massachusetts, Worcester. Both offer resources on how to create an integrated care model ( University of Washington AIMS Resource Center ; The University of Massachusetts Center for Integrated Care ).
What can one do in a busy pediatric primary care practice to address mental health imperatives on the individual provider level? Often PCPs can, as I do, offer families some resources by having a set of mental health handouts and resources. I have gathered useful handouts for families throughout my residency to use as shortcuts and visual aids to promote mental health. I use the AACAP Facts for Families for handouts on mental health diagnoses and topics. I use the National Sleep Foundation for its sleep hygiene tips. I also offer some low-cost mindfulness resources to help kids and parents with their anxiety, such as the Calm app and Headspace app . If parents have difficulty with access to parent management training (the first-line treatment to manage aggression in children), I often recommend “ The Defiant Child: A Parent’s Guide to Oppositional Defiant Disorder ” (Lanham, Md.: Taylor Trade Publishing, 1997), which shows how to create a rewards system in the home to promote positive behavior. “ How to Talk So Kids Will Listen & Listen So Kids Will Talk ” (New York: Scribner, 2012 ) is a beloved book for parents (and there is a teenager version) that I recommend when parents launch into questions about how to talk to kids and teens about difficult topics so that, ultimately, they can improve their relationship.
With the pace of primary care, it can be helpful to have some of these things ready to use without having to wait to refer patients to an office counselor, social worker, or psychiatrist or to wait for an integrated collaborative care model to come to fruition in one’s practice. Then, by the time patients may see someone like me, they may already be more knowledgeable about their mental health and may have made some strides in how to help themselves.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at firstname.lastname@example.org .
The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”
The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. ( 2009;123;1248-51).