Child Psychiatry Access Programs Research Articles

Psychiatry Consultation in Primary Care: Examining Treatment Access for Adolescent Depression

PurposeYouth in the United States are experiencing mental health concerns at an unprecedented level. Child Psychiatry Access Programs offer an innovative approach to close the gap between the need for care and insufficient mental health workforce. This study examined whether primary care provider consultation with a Child Psychiatry Access Program, Michigan Clinical Consultation & Care (MC3), was associated with greater access to treatment for adolescents with moderate to severe depression symptoms. MethodsA retrospective chart review was conducted of primary care visits between 2017 and 2021 for adolescent patients with first-time positive scores on the Patient Health Questionnaire-9. Descriptive statistics and logistic regression were used to examine if patients whose primary care provider used MC3 psychiatric consultations had improved access to depression treatment compared to those who did not. ResultsFour hundred seventy nine patients reported Patient Health Questionnaire-9 scores indicating moderate to severe depression symptoms. Compared to non-MC3 consult patients (n = 409), MC3 consult patients (n = 70) had higher odds of being prescribed antidepressant medications (odds ratio [OR], 2.16; 95% confidence interval [CI] [1.11–4.22], p = .05), 4 times higher odds of having a primary care follow-up visit to monitor depression symptoms (OR, 4.56, 95% CI [2.56–8.14], p < .001), and higher odds of accessing mental health therapy (OR, 2.14; 95% CI [1.13–4.05], p = .05). DiscussionUse of MC3 consultations was associated with increased utilization of evidence-based depression treatments including medication, therapy, and follow-up care. Greater adoption of models such as MC3 may increase the capacity for addressing mental health needs in children.

A Pilot Study in Adapting the Chronic Care Model to Address Shortage of Child and Adolescent Psychiatry.

There is a nationwide shortage of child and adolescent psychiatrists. This, combined with the mental health crisis caused by the coronavirus 2019 pandemic has lead to low access to care for many individuals. Child Psychiatry Access Programs have been developed to address this need, but we believe they are not sufficient to care for complex cases. We propose that the Chronic Care Model can address these issues by providing, more longitudinal and and faster access to mental health care for patients. Our pilot study had 50 children and adolescent participants in our clinic model, which included the use of trainees supervised by an attending. We found that the mean wait time to appointment with a child and adolescent psychiatrist was 13.54 ± 14.8days, which is significantly shorter by that reported by other studies. We believe our model clinic may be helpful in a variety of settings and want to share it with other psychiatrists.

Children in Mental Health Crisis: Pediatric Primary Care Providers' Role in Bridging Treatment Following Higher Levels of Care.

The current study examines the role of pediatric PCPs in bridging treatment for youth who have experienced mental health crises and the characteristics of these patients for whom PCPs sought psychiatric consultation and referral support from a child psychiatry access program, Maryland Behavioral Health Integration in Pediatric Primary Care. Psychiatric consultation and referral calls between 2012 and 2021 were included if a) the patient was recently seen in a higher level of care and b) the PCP was bridging treatment following the patient's discharge; 208 calls met criteria. The most common mental health concerns included depressed mood, suicidal thoughts/gestures, and anxiety. Acute concerns of aggression, suicide attempts, and hallucinations were also reported. Over half of the patients had two or more mental health diagnoses. At the time of the call, only one quarter of these patients had outpatient therapy services while about half were receiving medication treatment. Most of these patients were discharged from the higher level of care without a care plan. Pediatric PCPs are managing their patients' complex mental health concerns following receipt of higher levels of care. Improvements in collaboration and care coordination between pediatric PCPs and emergency department providers are needed.

Comparing the effect of two systems-level interventions on perinatal generalized anxiety disorder and posttraumatic stress disorder symptoms

BackgroundThe Massachusetts Child Psychiatry Access Program (MCPAP for Moms) and PRogram In Support of Moms (PRISM) are designed to help obstetric practices address perinatal depression. PRISM includes the statewide MCPAP for Moms program plus proactive implementation support. ObjectiveThe goal of this study was to understand the impact of these programs on perinatal Generalized Anxiety Disorder (GAD) and Post-traumatic Stress Disorder (PTSD) symptoms among individuals screening positive for depression. Study DesignWe conducted a secondary analysis of 2017–2022 data from a cluster randomized controlled trial of MCPAP for Moms vs. PRISM. We included participants completing a GAD or PTSD screen at baseline (n=254) with antenatal Edinburgh Postnatal Depression Scale (EPDS) scores ≥ 10. We assessed change in GAD and PTSD symptoms at from pregnancy (4 to <25 weeks Gestational Age (GA) or 32–40 weeks GA), to 4–12 weeks postpartum and 11–13 months postpartum. We conducted a difference-in-difference analysis to compare symptom change from pregnancy to postpartum. We used adjusted linear mixed models with repeated measures to examine the impact of MCPAP for Moms and PRISM on changes in the Generalized Anxiety Disorder 7 (GAD-7) and the PTSD CheckList (PCL-C). Results: Mean GAD-7 scores decreased by 3.6 (MCPAP for Moms) and 6.3 (PRISM) points at from pregnancy to 4-12 weeks postpartum. Mean PCL-C scores decreased by 6.2 and 10.0 points, respectively, at 4–12 weeks postpartum among individuals screening positive on the GAD-7 (n=83) or PCL-C (n=58) in pregnancy. GAD-7 and PCL-C scores decreased among both groups at 11–13 months postpartum. These changes were clinically meaningful. PRISM conferred a statistically significant greater decrease (2.7 points) on the GAD-7 than MCPAP for Moms at 4–12 weeks postpartum. No differences were found between MCPAP for Moms and PRISM in PCL-C or GAD-7 change at 11–13 months, although both were associated with a reduction in GAD and PTSD symptoms at 4–12 weeks and 11-13 months postpartum. ConclusionBoth MCPAP for Moms and PRISM could help to improve symptoms for individuals experiencing co-occurring symptoms of depression, GAD, or PTSD. PRISM may confer additional benefit in the early postpartum period, although this difference was not clinically significant.

A Statewide Consultation Helpline for Rapid Linkage to Services for Youths With Opioid Use Disorder and Other Substance Use.

The authors examined the initial implementation of the Indiana Adolescent Addiction Access (AAA) program, modeled on the widely disseminated Child Psychiatry Access Program framework. The AAA program developed a statewide consultation helpline to connect health care providers with adolescent addiction specialists. The AAA line was staffed by a coordinator, who fielded initial questions, and on-call clinical specialists (social workers, nurse practitioners, psychiatrists, and psychologists), who were paged to complete telephone consultations and provide care recommendations. When necessary, AAA providers offered urgent clinical assessments and initiated treatment. Descriptive analyses were performed for key variables over the first 21 months of AAA operations. From July 2021 to March 2023, a total of 125 consultations were completed. Most callers were health care providers (71%) or parents (27%). Calls pertained to youths ages 10-18 years (mean±SD age=16.4±1.3; 62% of callers were male, 84% White, and 11% Black), with concerns around cannabis (63%), opioids (38%), and other substances. About 26% of calls related to an overdose, and 41% of cases were rated as severe. Recommendations included starting new medications (17%) or outpatient therapy (86%), and 17% of consultations resulted in urgent evaluations. The Indiana AAA program helps overcome key barriers to adolescent substance use treatment. Increasing the capacity to initiate medication for opioid use disorder and other treatment rapidly through consultation and direct care is a promising, scalable approach for preventing overdose deaths among youths.

Linking Primary Care to Community-Based Mental Health Resources via Family Navigation and Phone-Based Care Coordination.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children's mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

Effectiveness of two systems-level interventions to address perinatal depression in obstetric settings (PRISM): an active-controlled cluster-randomised trial

Perinatal depression is a common and undertreated condition, with potential deleterious effects on maternal, obstetric, infant, and child outcomes. We aimed to compare the effectiveness of two systems-level interventions in the obstetric setting-the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms and the PRogram In Support of Moms (PRISM)-in improving depression symptoms and participation in mental health treatment among women with perinatal depression. In this cluster-randomised, active-controlled trial, obstetric practices across Massachusetts (USA) were allocated (1:1) via covariate adaptive randomisation to either continue participating in the MCPAP for Moms intervention, a state-wide, population-based programme, or to participate in the PRISM intervention, which involved MCPAP for Moms plus a proactive, multifaceted, obstetric practice-level intervention with intensive implementation support. English-speaking women (aged ≥18 years) who screened positive for depression (Edinburgh Postnatal Depression Scale [EPDS] score ≥10) were recruited from the practices. Patients were followed up at 4-25 weeks of gestation, 32-40 weeks of gestation, 0-3 months postpartum, 5-7 months postpartum, and 11-13 months postpartum via telephone interview. Participants were masked to the intervention; investigators were not masked. The primary outcome was change in depression symptoms (EPDS score) between baseline assessment and 11-13 months postpartum. Analysis was done by intention to treat, fitting generalised linear mixed models adjusting for age, insurance status, education, and race, and accounting for clustering of patients within practices. This trial is registered with ClinicalTrials.gov, NCT02760004. Between July 29, 2015, and Sept 20, 2021, ten obstetric practices were recruited and retained; five (50%) practices were randomly allocated to MCPAP for Moms and five (50%) to PRISM. 1265 participants were assessed for eligibility and 312 (24·7%) were recruited, of whom 162 (51·9%) were enrolled in MCPAP for Moms practices and 150 (48·1%) in PRISM practices. Comparing baseline to 11-13 months postpartum, EPDS scores decreased by 4·2 (SD 5·2; p<0·0001) among participants in MCPAP for Moms practices and by 4·3 (SD 4.5; p<0·0001) among those in PRISM practices (estimated difference between groups 0·1 [95% CI -1·2 to 1·4]; p=0·87). Both the MCPAP for Moms and PRISM interventions were equally effective in improving depression symptoms. This finding is important because the 4-point decrease in EPDS score is clinically significant, and MCPAP for Moms has a lower intensity and greater population-based reach than does PRISM. US Centers for Disease Control and Prevention.

5.75 Consults With a Child Psychiatry Access Program: Comparison of Physician and Mid-Level Primary Care Clinicians

5.75 Consults With a Child Psychiatry Access Program: Comparison of Physician and Mid-Level Primary Care Clinicians

3.25 Examining Practice Change Among Pediatric Primary Care Providers Participating in Maryland’s Child Psychiatry Access Program

3.25 Examining Practice Change Among Pediatric Primary Care Providers Participating in Maryland’s Child Psychiatry Access Program

Clinicians' Experience with a Graduate Medical Education Implemented Child Psychiatry Access Program.

The authors aim to measure differences in primary care clinicians' (PCC's) perceptions of managing pediatric mental health before and after launch of a child psychiatry access program (the access program) and identify the impact of engaging trainees from child psychiatry, pediatrics, and family medicine in administration and use of this program. Child psychiatry fellows provide coverage of a grant-funded state-wide access program and engage trainee-peers in learning how to use the program. A survey measuring PCC's experience managing children's mental health conditions was administered before and after the child psychiatry access program launched. Rotation evaluations collect trainee's feedback. Statistically significant differences are identified before and after the program's launch in PCC's perception of access to child psychiatry (U = 294.5, p < 0.001) and between PCC's perceptions of the impact of behavioral health problems in their patients in those with less than 4years post-residency training compared with those with 4 or more years post-residency (U = 524.5, p < .01). Trainee evaluation of the rotation is consistently positive (average 5:6 rating). The authors conclude that (1) the presence of a state-wide access program positively impacts PCC's reported access to child psychiatry; (2) child psychiatry fellows rate the clinical rotation experience favorably; and (3) there appears to be an association between less time out of primary care residency training and perception of improved access to child psychiatry and less clinical burden from behavioral health issues. Further research is required to understand the impact of a training in this model.

Remodeling Broken Systems: Addressing the National Emergency in Child and Adolescent Mental Health.

A national emergency in child and adolescent mental health was declared in the United States in 2021 in the wake of the COVID-19 pandemic. This Open Forum discusses potential solutions to better support child and adolescent mental health by improving or expanding school-based mental health services, child psychiatry access programs, virtual mental health services, and new models of care (e.g., integrated youth services hubs and crisis stabilization units). The success of such programs is dependent on stable funding, strong leadership and accountability, robust and well-trained workforces, systems integration, and attention to health equity.

Key attributes of child psychiatry access programs

The gap between the need for and the availability of pediatric mental health providers is well documented. One solution is regional/state Child Psychiatry Access Programs (CPAPs), which aid in the assessment and management of youth with behavioral health (BH) concerns by providing consultation to Pediatric Primary Care Clinicians. Our authorship team and the National Network of Child Psychiatry Access Programs (NNCPAP) board worked to describe operational definitions for CPAPs elements and related outcome monitoring processes and data systems. CPAP elements include regional child psychiatry availability by phone; real time phone availability; referral and resource assistance; and, expedited face-to-face psychiatric evaluation. Defining a child psychiatry consultation program as a CPAP and describing key attributes for CPAPs is an important step in facilitating implementation of the model and advancing research into its effectiveness.

Improving front-line clinician capacity to address depression and bipolar disorder among perinatal individuals: a longitudinal analysis of the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms.

Perinatal mood disorders (PMDs) are common, yet many patients are undertreated. The Massachusetts Child Psychiatry Access Program (MCPAP) for Moms is designed to increase clinicians' willingness to address PMDs. We examined utilization of MCPAP for Moms and associations with PMDs treatment, including the more complex bipolar disorder (BD). Analyses of MCPAP for Moms data examined utilization from 7/2014 to 6/2020 and associated treatment outcomes. Participants were clinicians (n = 1006) in obstetrics/gynecology, family medicine, and pediatrics. Encounters included (1) resource and referrals and (2) psychiatric consultations (program psychiatrist consultation with clinicians or patients). Utilization sub-groups were identified using group-based trajectory modeling. Higher utilization of MCPAP for Moms was associated with increased rates of treating PMDs (incidence rate ratio [IRR] = 1.07, 95% CI: 1.06-1.07). Examining by encounter type, psychiatric consultations resulted in more frequent rates of clinicians treating PMDs than resource and referral encounters. Utilization of direct patient consultation was associated with the greatest increase in rates of clinicians treating BD (IRR = 2.12, 95% CI: 1.82-2.41). Clinicians with highest utilization rates of psychiatric consultations longitudinally had strongest predictive associations with providing direct mental healthcare to patients with BD (IRR = 13.5, 95% CI: 4.2-43.2). Utilization of MCPAP for Moms facilitates clinicians' ability to provide mental health treatment to patients.

Psychiatrists Call for Action After CDC Data Reveal Worsening of Youth Mental Health Crisis

Psychiatrists Call for Action After CDC Data Reveal Worsening of Youth Mental Health Crisis

When Adverse Childhood Experiences Present to a Statewide Child Psychiatry Access Program

Many children experience adversity, yet few receive needed psychiatric services. Pediatric primary care providers (PCPs) are uniquely positioned to intervene but often lack training and resources to provide patients with adverse childhood experiences (ACEs) the psychiatric support they need. The current study examines characteristics of youth with and without ACEs who were the focus of PCP contacts with a statewide child psychiatry access program (CPAP). Compared to those without ACEs, patients with ACEs were more often receiving medication treatment at time of CPAP contact, prescribed two or more psychotropic medications, and diagnosed with two or more mental health disorders. Study findings indicate that patients with ACEs for whom PCPs sought CPAP support were experiencing more clinically severe and complex mental health concerns. These findings underscore the important role of CPAPs in supporting PCPs with pediatric patients who have ACEs and will inform training provided by CPAPs to PCPs.

DC Mental Health Access in Pediatrics: Evaluating a Child Psychiatry Access Program in Washington, DC

Child psychiatry access programs (CPAPs) provide primary care providers (PCPs) with assistance in mental health diagnosis, management, and resource navigation. Data collected from DC Mental Health Access in Pediatrics (MAP) included PCPs and patient demographics, clinical encounter information, and provider satisfaction. DC MAP consult volume increased 349.3% over the first 5 years. Services requested included care coordination (85.8%), psychiatric consultation (21.4%), and psychology/social work consultation (9.9%). Of psychiatry-involved consultations, PCPs managed patient medication care with DC MAP support 50.5% of the time. Most (94.1%) PCPs said they would recommend colleagues use DC MAP, and 29.6% reported diverting patients from the emergency departments using DC MAP. DC MAP grew quickly, highlighting program impact and need. Demand for care coordination required flexible staffing and highlighted the need for coordination in pediatrics. Child psychiatry access programs offer an innovative way to enhance PCP management of their patients' mental health needs.

Characteristics of Patients Served by a Statewide Child Psychiatry Access Program.

Maryland's Behavioral Health Integration in Pediatric Primary Care (BHIPP) is a child psychiatry access program offering child-adolescent psychiatry consultation, resource and referral networking, and direct-to-patient mental health intervention. This study investigated characteristics of patients for whom primary care providers sought BHIPP services. Data from 6,939 unique patient contacts between October 2012 and March 2020 were collected on service type, demographic characteristics, presenting concerns, clinical severity, clinicians' diagnostic impressions, current treatments, and BHIPP recommendations. Descriptive statistics and latent class analysis were used. Of the 6,939 patient contacts, 38.6% were for direct-to-patient mental health intervention, 27.3% for child-adolescent psychiatry consultation, and 34.2% for resource and referral networking. In total, 50.3% of patients were female, 58.7% were White, and 32.7% were already receiving mental health services. Latent class analysis identified four classes of presenting concerns: anxiety only (44.2%); behavior problems only (30.7%); mood and anxiety (17.1%); and attention, behavior, and learning problems (8.0%). Compared with patients in the anxiety-only class, those in the attention, behavior, and learning problems class were more likely to receive direct-to-patient mental health intervention (OR=3.59), and BHIPP clinicians were more likely to recommend in-office behavioral interventions for those in the mood and anxiety class (OR=1.62) and behavior problems-only class (OR=1.55). Patients supported through BHIPP varied in presenting concerns, condition severity and complexity, current receipt of services, and BHIPP utilization. Latent class analysis yielded more clinically useful information about the nature and complexity of patients' concerns than did consideration of individual presenting concerns.

Utilization and Outcomes of Direct Consultation in a Child Psychiatry Access Program.

The high prevalence of child and adolescent psychiatric disorders in the United States, coupled with the severe and pervasive shortage of child and adolescent psychiatrists, has led 46 states and territories to launch programs providing child psychiatry consultation to pediatricians. Although these programs aim to increase access to psychiatric expertise, evidence of favorable program outcomes beyond user satisfaction has been limited. Findings from the authors' child psychiatry consultation program suggest that such programs may enable pediatricians to manage most cases referred for consultation, thereby extending the behavioral health workforce to the primary care setting.

1.122 Consults With a Child and Adolescent Psychiatry Access Program: Comparison of Rural and Nonrural Primary Care Providers

Child psychiatry access programs (CPAPs) provide primary care providers (PCPs) with timely consults from child and adolescent psychiatrists and referral assistance for patients with mental health conditions by telephone or by an electronic, asynchronous platform. Resources for mental health are scarcer in rural areas, and rural PCPs may have different needs from a CPAP than nonrural PCPs. We aimed to compare consults from rural and nonrural PCPs with Colorado’s CPAP.

58.4 Perinatal and Child Psychiatry Access Programs in North Carolina: Opportunities for Synergy to Augment Family Services

The goal of this presentation is to describe the cooperation between the perinatal and pediatric psychiatric access programs in North Carolina in support of pregnant individuals and families with young children. Since 2019, the Health Resources and Services Administration (HRSA) has funded NC Maternal Mental Health MATTERS (NC MATTERS) and the North Carolina Psychiatry Access Line (NC-PAL) to support perinatal and pediatric providers through direct telephone consultation and statewide training efforts.