Referrals For Mental Health Services Research Articles

Impact of Long-COVID in children: a large cohort study

BackgroundThe impact of long-term Coronavirus disease 2019 (COVID-19) on the pediatric population is still not well understood. This study was designed to estimate the magnitude of COVID-19 long-term morbidity 3–6 months after the date of diagnosis.MethodsA retrospective study of all Clalit Health Services members in Israel aged 1–16 years who tested positive for SARS-CoV-2 between April 1, 2020 and March 31, 2021. Controls, who had no previous diagnosis of COVID-19, were one-to-one matched to 65,548 COVID-19-positive children and teens, and were assigned the infection dates of their matches as their index date. Matching included age, sex, socio-economic score, and societal sector. Individuals were excluded from the study if they had severe medical conditions before the diagnosis such as cancer, diabetes, chronic respiratory diseases, and/or abnormal physiological development. Generalized Estimating Equations were used to estimate the associations between COVID-19 and the use of medical services. The analysis focused on the 3–6 months after the infection date. Adjustments were made for demographics and for the use of medical services 6–12 and 3–6 months before the infection date. The latter was necessary because of observed disparities in medical service utilization between the groups before the COVID-19 diagnosis, despite the matching process.ResultsStatistically significant differences were only found for referrals for mental health services [adjusted relative-risk (RR) 1·51, 95%CI 1·15 − 1·96; adjusted risk-difference (RD) 0·001, 95%CI 0·0006 − 0·002], and medication prescriptions of any kind (RR 1·03, 95%CI 1·01–1·06; RD 0·01 95%CI 0·004 − 0·02).ConclusionsThe significant increase in medication prescriptions and mental health service referrals support the hypothesis that COVID-19 is associated with long-lasting morbidities in children and adolescents aged 1–16 years. However, the risk difference in both instances was small, suggesting a minor impact on medical services.

Psychological Health Among Older Adults During and After Quarantine: A Multi-Method Study.

Depression among older adults is a growing problem. With aging being a risk factor for COVID-19 infection, depression in this population may have been exacerbated. This study aimed to describe experiences and changes in depressive symptoms and well-being of older adults during and after the COVID-19 first wave in Spain. The study used a multi-method design. Participants self-reported depressive symptoms (Geriatric Depression Scale) and well-being (Cantril Ladder of Life). Participants were asked about changes in depressive symptoms or well-being during quarantine. If a change was perceived, they were asked to describe the change. In addition, the Patient Global Impression of Change scale was used. Both quantitative and qualitative analyses were performed on the data. 111 participants (mean age: 71±5 years; 76% women) completed the study. Sixty-three percent reported mild and 2% reported major depressive symptoms. Nearly half (47.7%) reported changes in depressive symptoms during the lockdown. While 37% reported feeling better during the lockdown, about 11% reported depressive symptoms were worse now compared with during the lockdown. 60% reported worsening well-being during the quarantining period. The qualitative analysis revealed 2 main themes: (1) psychological discomfort (mood deflection, fear/worries, and boredom/inactivity) and (2) social issues (inability to go out, missing family members and others). Worsening depressive symptoms and lowering of well-being were noticed in this sample of older adults during and post-COVID lockdowns. Evaluation of mental health in the primary care setting and providing referrals for mental health services is essential for older adults who experienced COVID-19-related lockdowns.

Improving Postpartum Depression Screening in the NICU: Partnering with Students to Improve Outreach.

The Institute For Healthcare Improvement Model for Improvement was the framework for this project. Our initial intervention bundle included provider education, standardized identification of parents to be screened, and bedside screening performed by the nurse with social work follow-up. This intervention transitioned to weekly screening by phone by health professional students and the use of the electronic medical record for notification of team members of screening results. Under the current process, 53% of qualifying parents are screened appropriately. Of the parents screened, 23% had a positive Patient Health Questionnaire-9 requiring referral for mental health services. Implementing a PPD screening program that complies with the AAP standard is feasible within a Level 4 NICU. Partnering with health professional students greatly improved our ability to screen parents consistently. Given the high percentage of parents with PPD uncovered with appropriate screening, this type of program has a clear need within the NICU.

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

Mapping the effectiveness of integrating mental health in HIV programs: a scoping review

IntroductionMental health and substance abuse issues are increasing among HIV-positive people, and it negatively impacts health outcomes like engagement, retention in HIV care, and adherence to ART. Thus, national ART programs must include mental health management. The scoping review sought to map evidence on the efficacy of combining HIV and mental health care.MethodsThe Arksey and O’Malley methodological framework was used to map the existing research on integrating HIV and mental health services to identify knowledge gaps. Two independent reviewers screened articles for inclusion. Studies on HIV-mental health integration were considered. We searched numerous sources, extracted data, and summarized publications by integration model and patient outcomes.ResultsTwenty-nine articles met the criteria for this scoping review. Twenty-three studies were from high-income countries, with only six from low and middle-income countries in Africa (Zimbabwe 1, Uganda 3, South Africa 1, and Tanzania 1). Most of the literature discussed single-facility integration although multi-facility and integrated care through a case manager was researched as well. There was a reduction in depression, alcohol use, increased social function, decreased self-reported stigma, decreased psychiatric symptoms, and improved mood in PLHIV who received cognitive behavioral therapy in settings implementing integrated care. When providing integrated mental health services to PLHIV, healthcare workers reported feeling more comfortable discussing mental illness. Personnel in the mental health field reported less stigma and increased PLHIV referrals for mental health services due to integrated HIV and mental health care.ConclusionAccording to the research, integrating mental health services into HIV care improves the diagnosis and treatment of depression and other mental disorders related to substance abuse in PLHIV.

Disparities in Mental Health Service Referrals in Child Sexual Abuse Cases

ABSTRACT Child sexual abuse increases risk for future negative mental health outcomes. However, the factors influencing the likelihood of receiving referrals for mental health services for victims of child sexual abuse are not well understood. The current study sought to determine such factors and disparities via a secondary analysis of the National Survey of Child and Adolescent Well-being (NSCAW), a national probability study of children and caregivers investigated by US child welfare agencies. The sample consisted of the subset of children from NSCAW residing in-home with confirmed sexual abuse cases (n = 225, weighted N = 58,635). Weighted multivariable logistic regression analyses were conducted to estimate the odds of receiving a mental health service referral while controlling for important demographic and clinical characteristics. Black children and children residing in non-urban counties were significantly less likely to receive mental health referrals, while child health insurance coverage type and symptoms of mental health concerns were non-significant predictors. These results highlight an urgent need for efforts to overcome systemic biases and increase access to mental health services for victims of child sexual abuse.

Pediatric residents’ parenting guidance after exposure to Incredible Years

Background: The Incredible Years® (IY) is an evidence-based group parenting program that provides parenting guidance to parents of children with disruptive behavior. Pediatric residents are expected to provide parenting guidance to families, but often express discomfort with doing so. Little is known whether exposure to the IY curriculum may impact pediatric resident parenting guidance. Methods: A pilot study was developed to determine whether pediatric residents exposed to the IY Program demonstrate better knowledge of positive parenting practices, higher comfort levels with providing parenting guidance and increased confidence in demonstrating parenting skills. Residents were exposed to an on-going IY Preschool Parenting Program during their Developmental-Behavioral Pediatrics rotation in 2017 - 2018. They completed pre and post surveys with questions about demographics, resident knowledge, comfort, and confidence with parenting guidance, as well as satisfaction with the program. Results: Eleven interns participated in the intervention, and 8 completed post-intervention surveys (64% response). All residents reported higher comfort in discussing parenting strategies with families (W = 0, p < .05) and providing referrals for mental health services (W = 0, p < .05). Residents reported more confidence with demonstrating specific parenting skills in the office (W = 0, p < .05). All interns reported that exposure to IY was “useful” or “somewhat useful” to their training, and all recommended that others be exposed to the program. Conclusions: Results support the value of exposure to IY for pediatric residents. Exposure to IY may be an effective way to educate residents about parenting guidance.

Implementing a Peer Advocate Mental Health Digital Intervention Program for Ohio Youth: Descriptive Pilot Study.

BackgroundIn the United States, millions of adolescents report poor mental health, where 1 in 5 teenagers considers suicide. Reducing stigma and fostering peer support remains critical for positive mental health interventions and programs. Increasingly, digital mental health tools have emerged with great promise, leveraging social networks. Despite the potential, limited understanding of such comprehensive programs and their implementation exist.ObjectiveThe objective of this study investigates a piloted digital mental health training program (Be Present) for youth, specifically describing the impact on youth behavioral outcomes and user engagement and identifying high-risk youth in the early phases of prevention.MethodsEligibility included Ohio residents (aged 14 to 22 years) to be enrolled as either a Friend or a Peer Advocate. From May 1 to June 1, 2019, participants completed the Advocate training course, taking pretest and posttest surveys. Single-arm descriptive analyses measured youth outcomes (self-efficacy, intentions, behaviors, social support, knowledge, and sources of strength) and engagement and assessed risk based on survey responses.ResultsA total of 65 adolescents participated, with 54 completing both pretest and posttest surveys. The majority of participants included non-Hispanic White females. Findings illustrated a significant increase in self-report of referrals for mental health services as well as in perceptions that youth had of experiencing social support; however, no significant differences were found for measures of self-efficacy, knowledge, and sources of strength between pretest and posttest surveys. Roughly two-thirds of the participants completed all of the Advocate training modules, and we observed a gradual decline in engagement. Most respondents who received escalated high-risk response messages identified as female.ConclusionsThe pilot presented promise for implementing a digital mental health program focused on peer support, specifically observing reported youth behavioral outcomes and user engagement and identifying high-risk youth. Various limitations exist given the small nonrepresentative sample and lack of control group. All findings should be considered preliminary to a larger trial and underscore the feasibility of delivering online training programs to bolster adolescent mental health. Such formative evaluation proved critical for future implementation and research, offering opportunity for substantial improvements for real-world digital mental health programs.

Health and social outcomes of HIV-vulnerable and HIV-positive pregnant and post-partum adolescents and infants enrolled in a home visiting team programme in Kenya.

ObjectivesHIV‐positive and HIV‐vulnerable pregnant adolescent girls and adolescent mothers face significant barriers and vulnerabilities. Infants born to adolescent mothers are also more likely to die and be exposed to life‐threatening conditions. This paper presents findings from an evaluation of a programme that used a home visitation model and offered a case‐management, team‐focused approach to increase family and community supportiveness to enhance health and social service uptake among pregnant adolescent girls and adolescent mothers in Kenya.MethodsThe study used a quasi‐experimental design with before and after comparisons among a non‐randomised population to examine the effectiveness of bi‐monthly household visits to 384 enrolled pregnant adolescent girls, adolescent mothers (ages 10–19) and their infants (0–24 months) between March 2018 and February 2019 in three counties in Kenya.ResultsDuring the programme, household support increased from 57% to 85%, while 100% of eligible participants were on ART and virally suppressed (total of 20 adolescents). Nearly all pregnant adolescent girls (94%) delivered under skilled care vs. 78% of those who were post‐partum at the time of enrolment (P < 0.001); 100% of infants (total of 17 infants) had an up‐to‐date PCR test with no seroconversions. Uptake of modern family planning increased from 39% at baseline to 64% at end line (P < 0.001). The referral rate declined from 84% to 78% from baseline to end line with low uptake of referrals for mental health services (17.3%).ConclusionsA team‐focused approach of home visits to HIV‐vulnerable and HIV‐positive pregnant and post‐partum adolescent girls and their infants combined with efforts to reduce stigma and increase supportiveness of households and the community can help address critical socio‐cultural and behavioural barriers to accessing and using health and social services.

787-P: Mental Health Discussions during Routine Diabetes Care Visits with Adolescents and Young Adults

Background: Adolescents and young adults (AYAs) with T1D are at risk for elevated depressive symptoms. Health care providers (HCPs) are in a unique position to discuss mental health (MH) and T1D self-care during routine diabetes medical visits. Objective: Evaluate the frequency and content of MH discussions during medical visits. Methods: Data were drawn from a longitudinal study of AYA-HCP communication and T1D care. Secondary analyses include evaluation of 108 medical visits (M duration=22.5 min; n=8 HCPs) with 33 AYAs with T1D (48.5% male; 45.5% non-Hispanic White; M age=17.5±1.1 yrs; M clinic visits=3.27). 22 AYAs self-reported elevated depressive symptoms using the Center for Epidemiologic Studies-Depression scale (M CES-D score=22.6±8.3); a matched sample of 11 AYAs without elevated depressive symptoms was selected for comparison (M CES-D score=5.7±3.9). Medical visits were audio-recorded, transcribed, and coded by trained coders to identify and characterize MH discussions. Results: Coding of transcripts identified 43/108 medical visits (39.8%) with ≥ 1 MH discussion. AYAs with elevated depressive symptoms were as likely to have a MH discussion (42.6%) as AYAs without elevated depressive symptoms (35.0%; p=.43); the elevated group had 2.48 distinct MH conversations/visit compared to 1.64 distinct MH conversations/visit for the non-elevated group (p=.10). MH discussions were initiated most often by HCPs (67.4%), followed by AYAs (23.3%) and parents (9.3%). MH resources were provided in 60.5% of all visits with MH discussion, including: referral for MH services (76.9%), general MH education (30.8%), and recommendation to continue current MH services (26.9%). Discussion: MH content is commonly discussed in routine T1D care. Results suggest a need to increase HCP-delivered resources for AYAs with MH concerns. Evaluation of MH discussions can improve the quality of AYA-HCP communication around MH symptoms and, ultimately, improve diabetes care. Disclosure M. Monaghan: Research Support; Self; American Diabetes Association. C. Wong: None. D.L. Polyakov: None. M. Rose: None. Funding American Diabetes Association/Pathway to Stop Diabetes (1-18-ACE-27 to M.M.); National Institutes of Health (R03DK110259)

Psychosocial Correlates of Body Image and Lipodystrophy in Women Aging With HIV.

Body image disturbance is increasingly relevant as women living with HIV (WLWH) live longer. We explored body image disturbance and changes in fat distribution (lipodystrophy) in 63 WLWH (mean age = 51 years) and evaluated associations among lipodystrophy, body image, and psychosocial variables. Eighty-one percent of participants reported one or more body parts (of six assessed) demonstrating lipodystrophy, and more than one third reported three or more affected body parts. Increased belt/waist (58%) and increased chest/breast (39%) sizes were most common. More diffuse lipodystrophy was significantly associated with poorer body image (F[2,54] = 11.86, p < .001, partial η = .313) and anxiety (F[2,52] = 3.82, p = .029, partial η = .133) after controlling for age and duration of infection. Lipodystrophy was prevalent in our sample; more diffuse lipodystrophy was associated with anxiety and poor body image. Providers should assess lipodystrophy in older WLWH and provide referrals for mental health services.

Traumatic Experiences and Mental Health Risk for Refugees.

Refugees who settle in Western countries exhibit a high rate of mental health issues, which are often related to experiences throughout the pre-displacement, displacement, and post-displacement processes. Early detection of mental health symptoms could increase positive outcomes in this vulnerable population. The rates and predictors of positive screenings for mental health symptoms were examined among a large sample of refugees, individuals with special immigrant visas, and parolees/entrants (N = 8149) from diverse nationalities. Logistic regression analyses were used to determine if demographic factors and witnessing/experiencing violence predicted positive screenings. On a smaller subset of the sample, we calculated referral acceptance rate by country of origin. Refugees from Syria, Iraq, and Afghanistan were most likely to exhibit a positive screening for mental health symptoms. Refugees from Sudan, Iraq, and Syria reported the highest rate of experiencing violence, whereas those from Iraq, Sudan, and the Democratic Republic of Congo reported the highest rate of witnessing violence. Both witnessing and experiencing violence predicted positive Refugee Health Screener-15 (RHS-15) scores. Further, higher age and female gender predicted positive RHS-15 scores, though neither demographic variable was correlated with accepting a referral for mental health services. The findings from this study can help to identify characteristics that may be associated with risk for mental health symptoms among a refugee population.

Age Differences in Suicide Risk Screening and Management Prior to Suicide Attempts

This study examined differences by age in suicide risk screening and clinical actions to reduce suicide risk among patients with visits to Veterans Health Administration (VHA) medical facilities in the year prior to an attempt. Ninety-three VHA patient records were reviewed specific to the last visit before an attempt. Information was extracted regarding documentation of individual suicide risk factors and provider actions to reduce risk. The authors examined differences by patient age (≥50 versus 18-49). Older patients' medical records were less likely to have evidence of 1) screening for impulsivity and firearms access and 2) engagement in safety planning, referrals for mental health services, and consideration of psychiatric hospitalization. General medical providers were less likely to document these risk factors and action steps in comparison with mental health clinicians. Lethal means education and collaborative care are universal strategies that may improve identification of and lower suicide risk in older veterans.

The Relationship Between Depressive Symptoms and Health Services Utilization in U.S. Chinese Older Adults.

Depressive symptomatology is a significant predictor of increased health services utilization and health care cost in the general older adult population. However, there is scant information on the relationship between depressive symptoms and health service utilization among U.S. Chinese older adults. The objective of this study was to examine the relationship between depressive symptoms and physician visits, emergency department (ED) visits, and hospitalization. Cross-sectional data were derived from the Population Study of Chinese Elderly in Chicago (PINE) collected between July 2011 and June 2013 (N = 3,159). Depressive symptoms were measured by the nine-item Patient Health Questionnaire (PHQ-9). Bivariate and multivariate logistic regression analyses were conducted to examine the relationship between depressive symptoms and physician visits, ED visits, and hospitalization. U.S. Chinese older adults with depressive symptoms were more likely to have at least one ED visit (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.44-2.28) and hospitalization (OR = 1.9, 95% CI = 1.47-2.33) in the past 2 years than those without depressive symptoms, while adjusting for sociodemographic and health-related covariates. Other significant factors associated with health services utilization in this population included number of people in household, health insurance coverage, and acculturation. Depressive symptoms are positively associated with hospitalization and ED visits among U.S. Chinese older adults. Routine screenings of depressive symptoms should be part of the clinical encounter in these care settings so that appropriate treatment or timely mental health service referrals could be provided to this population to ultimately optimize their utilization of health services.

Examining the association between suicidal behaviors and referral for mental health services among children involved in the child welfare system in Ontario, Canada

Although various studies have investigated factors associated with mental health service utilization, few studies have examined factors associated with referral for mental health services among maltreated children. The objective of this study was to examine the association between suicidal thoughts and self-harming behavior and referral for mental health services among children involved in the Child Welfare System in Ontario, Canada. Data for this study were obtained from the Ontario Incidence Study of Reported Child Abuse and Neglect 2013. An estimate 57,798 child maltreatment investigations was analyzed using binary logistic regression with referral for mental health service as the outcome variable. Of the 57,798 cases, 4709 (8.1%), were referred for mental health services. More than seven out of ten maltreated children who engaged in self-harming behavior and two out of three maltreated children who expressed suicidal thoughts were not referred for mental health services. In the multivariate logistic regression model, children who expressed suicidal thoughts had 2.39 times higher odds of being referred for mental health services compared to children with no suicidal thoughts (AOR = 2.39, 99% C.I. 2.05–2.77) and children who engaged in self-harming behavior had 1.44 times higher odds of being referred for mental health services compared to children who did not engage in self-harming behavior (AOR = 1.44, 99% C.I. 1.24–1.67), both after controlling for child demographic characteristics, maltreatment characteristics, and child functioning concerns. Given that referral is the initial step towards mental health service utilization, it is important that child welfare workers receive the necessary training so as to carefully assess and refer children in care who expressed suicidal thoughts or engaged in self-harming behavior for appropriate mental health services. The paper discusses the results and their implications for child welfare policy and practice.

Colorado Healthy Schools Smart Source: Testing the Association Between Collaboration with Community Mental Health Centers and Tier 2 Implementation

Implementing targeted (Tier 2) interventions for youth at risk of developing behavioral health concerns is critical for a comprehensive approach to school mental health. Given challenges in school-based implementation of targeted interventions, identifying factors associated with their implementation may contribute to a better understanding of contexts favorable to their delivery. Collaboration with community mental health centers (CMHCs), due to their capacity to share knowledge and resources with schools and facilitate alignment of Tier 2 interventions with other school-based prevention efforts, may be one factor that facilitates targeted intervention implementation. The current study tested the association between collaboration with CMHCs and the implementation of Tier 2 programs in 451 schools that completed Colorado Healthy Schools Smart Source, a comprehensive assessment of school health best practices. Items assessed whether schools collaborate with CMHCs and whether schools provide in-school curricular programs (Tier 2). A logistic regression model tested the association between collaboration with CMHCs and implementation of Tier 2 programs while controlling for the following covariates: having a wellness committee, a school-wide approach to social and emotional learning, in-school therapeutic services, as well as referrals for mental health services outside of school, and school counselor availability. Results demonstrated that schools collaborating with CMHCs were more than twice as likely to implement Tier 2 programs as those that did not.

Psychologist and Physician Interest in Telehealth Training and Referral for Mental Health Services: An Exploratory Study

The current study explored psychological and medical professionals’ interest in videoconferencing telehealth training and mental health telehealth referral. An online survey assessed 782 participants comprised of 669 psychological (45% male, Mean Age = 47.01, SD = 16.82) and 113 medical professionals (58% male, Mean Age = 46.19, SD = 12.40). Z-test analyses indicated that although psychological professionals were statistically more interested in receiving telehealth training, both groups reported some interest. Ranked responses indicated efficacy data, ethical issues, and legal concerns as the most endorsed areas of training interest. Referral concerns were also found. Findings were discussed related to both statistical and clinical significance. Application of findings is discussed related to future work, practice, and program creation. The development of telehealth training programs will provide interested professionals with tools required for practice and may serve as an impetus to increase utilization and/or referral.

Caregiver Depression Screening in a Specialty Mental Health Clinic

Many children receiving mental health services have parents who suffer from depression. Prevalence of depressive disorders among parents of children brought for evaluation in child specialty mental health clinics is two to three times higher than national averages, and yet rates of treatment seeking are very low. Parental depression constitutes an important risk factor for childhood psychiatric illness, poor child treatment outcomes, and higher child-related mental health service expenditures. Despite the public health importance of this problem, routine screening for parental depression is rarely conducted in child mental health settings. This report describes implementation of caregiver depression screening and treatment referral in a child mental health clinic that serves youths ages four to 18. All procedures were approved by the University of Pittsburgh Medical Center Quality Improvement Review Board. Caregivers (parents, foster parents, grandparents, and non-related legal guardians) were screened with the nine-item Patient Health Questionnaire (PHQ-9), a self-report measure of depressive symptoms. Total scores range from 0 to 27 (higher scores indicate more depressive symptoms). Children’s demographic data were extracted from clinical records. Clerical staff placed copies of the PHQ-9 in intake paperwork packets. Letters invited caregivers to complete the form but specified that participation was voluntary. Completed forms were returned to intake clinicians, who scored them and provided feedback. If scores were ≥8, clinicians offered referrals for mental health services using an adult referral list that sorted treatment options by location, insurance accepted, and type of treatment provided. Clinicians recorded whether or not referrals were accepted. Safety procedures were developed to address concerns about detection of occult suicidality. If caregivers endorsed a 1, 2, or 3 on the suicidal ideation item of the PHQ-9 (corresponding to “several days,” “more than half the days,” and “nearly every day”), clinicians probed further. If threat appeared imminent, clinicians sought emergency services for the caregiver. If clinicians did not detect imminent threat, caregivers were either referred to their own treatment team (if already in care) or “fast tracked” to a scheduled appointment at a local adult mental health clinic. Although this was a large concern prior to implementation of screening, these procedures were never implemented because of absence of high levels of suicidality among caregivers. Between June 1, 2010, and May 31, 2012, a total of 1,274 youths were seen for an initial psychiatric evaluation. The mean±SD age of children was 11.7±3.7 years. Approximately half (55%; 701 of 1,270) were boys, and 60% were white (767 of 1,274). The most common primary clinical diagnoses were attention-deficit hyperactivity disorder (30%; 381 of 1,274) and adjustment disorders (24%; 299 of 1,274). Payer mix was evenly divided between commercial insurance and medical assistance. Forty-six percent (581 of 1,274) of caregivers completed the PHQ-9. Most were female (89%; 438 of 492) and white (68%; 329 of 483). Caregiver age was 40.0±8.59 years. The mean PHQ-9 score was 7.00±5.95 (range 0–25). Twelve percent (67 of 581) of caregivers endorsed the suicide item of the PHQ-9 at the level of 1 (“several days”) or higher. Of 581 caregivers screened, 233 (40%) scored ≥8 on the PHQ-9. Of those, 45% (106 of 233) accepted referrals for mental health services; 12% (28 of 233) declined referrals, indicating that they were already receiving psychiatric treatment; 16% (38 of 233) were deemed by the child clinician not to require referrals; <1% (1 of 233) requested more information, and 25% (58 of 233) declined referrals. There was no difference in mean PHQ-9 score between those deemed by the clinician not to require a referral and those who accepted a referral. Those who accepted a referral had significantly higher PHQ-9 scores than those who declined a referral (14.5±4.0 versus 10.9±2.9, respectively; p<.001). There were no significant differences in age, gender, or race-ethnicity between those who accepted and those who declined a referral. With a more conventional threshold of PHQ-9 score ≥10 (corresponding to moderate depression), 31% (182 of 581) would have been identified as having elevated depression scores. Most caregivers experienced the depression screening process as supportive. Anecdotally, many families expressed appreciation for the clinic’s willingness to address caregiver needs in addition to those of their offspring. Although caregivers who accepted mental health referrals represent only 8% (106 of 1,274) of total intakes during the performance period, this translates to approximately one caregiver per week referred for mental health services who likely otherwise would not have been identified. Although depressed caregivers of psychiatrically ill children are unlikely to access mental health services for themselves, many will seek care for their children. Thus settings in which children receive mental health services may constitute important locations in which to identify—and potentially treat—depressed caregivers. Future studies should examine the impact of such initiatives on child outcomes.

Mental Health Care Treatment Initiation When Mental Health Services Are Incorporated Into Primary Care Practice

Most primary care patients with mental health issues are identified or treated in primary care rather than the specialty mental health system. Primary care physicians report that their patients do not have access to needed mental health care. When referrals are made to the specialty behavioral or mental health care system, rates of patients who initiate treatment are low. Collaborative care models, with mental health clinicians as part of the primary care medical staff, have been suggested as an alternative. The aim of this study is to examine rates of treatment startup in 2 collaborative care settings: a rural family medicine office and a suburban internal medicine office. In both practices referrals for mental health services are made within the practice. Referral data were drawn from 2 convenience samples of patients referred by primary care physicians for collaborative mental health treatment at Fletcher Allen Health Care in Vermont. The first sample consisted of 93 consecutively scheduled referrals in a family medicine office (sample A) between January 2006 and December 2007. The second sample consisted of 215 consecutive scheduled referrals at an internal medicine office (sample B) between January 2009 and December 2009. Referral data identified age, sex, and presenting mental health/medical problem. In sample A, 95.5% of those patients scheduling appointments began behavioral health treatment; in sample B this percentage was 82%. In sample B, 69% of all patients initially referred for mental health care both scheduled and initiated treatment. When referred to a mental health clinician who provides on-site access as part of a primary care mental health collaborative care model, a high percentage of patients referred scheduled care. Furthermore, of those who scheduled care, a high percentage of patients attend the scheduled appointment. Findings persist despite differences in practice type, populations, locations, and time frames of data collection. That the findings persist across the different offices suggests that this model of care may contain elements that improve the longstanding problem of poor treatment initiation rates when primary care physicians refer patients for outpatient behavioral health services.

Overview of Intellectual/Developmental Disabilities

Patients with intellectual/developmental disabilities (IDD) present many challenges to mental health professionals. The capacity to work with such patients requires a working knowledge of IDD as well as an awareness and understanding of the factors that affect the clinical presentation of mental health disorders across the spectrum of IDD.