Opinion
VIEWPOINT
John V. Campo, MD Wexner Medical Center, The Ohio State University, Columbus; and College of Medicine, The Ohio State University, Columbus. Jeffrey A. Bridge, PhD College of Medicine, The Ohio State University, Columbus; and The Research Institute, Nationwide Children’s Hospital, Columbus, Ohio. Cynthia A. Fontanella, PhD Wexner Medical Center, The Ohio State University, Columbus; and College of Medicine, The Ohio State University, Columbus.
Corresponding Author: John V. Campo, MD, Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, OSU Harding Hospital, 1670 Upham Dr, Columbus, OH 43210 (john.campo @osumc.edu). jamapediatrics.com
Access to Mental Health Services Implementing an Integrated Solution Pediatric mental disorders affect 1 in 5 children, and most serious mental disorders begin early in life, approximately 50% by age 14 years and 75% by age 24 years.1 The Surgeon General’s report2 on mental health called national attention to the public health relevance of pediatric mental disorders, citing encouraging news of an increasing number of evidence-based treatments, as well as the discouraging news that most youth struggling with mental disorders receive no mental health services and that even when services are accessed, they are often inadequate in quality and/or quantity. More than a decade later, still less than half of young people with a mental disorder obtain treatment.3 Given that mental health and substance use disorders are risk factors for several leading and potentially remediable causes of death, such as accidents, violence, and suicide, this disturbing reality likely has serious consequences for morbidity and mortality in the pediatric- and transitional-aged population. For example, a growing body of evidence indicates that improving access to effective mental health care can reduce suicide risk in young people.4 Few will argue against efforts to improve access to competent mental health and addiction services for the young; however, the practical challenges are real and difficulties accessing care are likely multidetermined. Barriers to care have been conceptualized as structural and attitudinal, and stigma for mental and substancerelated disorders in all probability contributes to both. Structural barriers include fiscal challenges such as the inability to pay, insurance restrictions, operational inefficiencies, a system that segregates physical and mental health care delivery, geography and transportation problems, and shortages and misdistribution of appropriately trained and experienced health care professionals. Hopes have been high that health care reform might prove a necessary solution. Unfortunately, although efforts to address structural barriers will be necessary to improve access to mental health services, they are unlikely to prove sufficient given that attitudinal barriers to care appear to be most important in influencing treatment initiation and continuation amongindividualswithcommonmentaldisorders.5 Young people with a mental disorder and their families may fail to perceive a need for treatment, wish to address the problem on their own, be pessimistic about the effectiveness of available treatments, or lack trust in health care professionals. Attitudinal barriers may also exert differential effects in specific demographic, ethnic, and cultural groups and settings. Health care professional beliefs and attitudes are also relevant, as professionals may be uninformed or inordinately pessimistic about the availability and effectiveness of existing treatments.2
Finally, there is the problem of inertia. Most children with recognized mental disorders in primary care are not referred for mental health treatment, and only a minority of those referred receives any services. Although low rates of referral completion are commonly attributed to structural and attitudinal barriers alone, studies of collaborative care interventions for pediatric mental disorders in primary care report disappointing rates of referral completion for patients randomized to the usual care condition despite sometimes extraordinary efforts to facilitate referral. For example, approximately half of patients randomized to usual care enhanced by a comprehensive evaluation and facilitated specialty referral did not access any mental health treatment.6 Another collaborative care study focused on adolescent depression found that only 1 in 4 depressed adolescents in the usual care condition obtained psychotherapeutic or antidepressant treatment meeting minimal quality standards, despite the study taking place within a well-regarded and prepaid health delivery organization that emphasizes ready access to mental health services for members.7 While addressing fiscal challenges, such as inadequate insurance coverage and poor health care professional reimbursement for mental health services, will be necessary to improving access to care, elimination of fiscal barriers alone will not be sufficient given the multiple and diverse challenges presented by efforts to connect children and youth with mental disorders to the competent care they deserve. Improvement efforts will almost certainly require a multifaceted approach that considers stigma, structural and attitudinal barriers, and patient and health care professional inertia. One important strategy with potential to address each of these issues is the integration of mental health services in general medical settings, particularly in primary care. Primary care has been defined as first-contact personal health care that is comprehensive and delivered longitudinally within a community-based medical setting. Closely related is the concept of the medical home, which offers accessible, continuous, comprehensive, family-centered, and coordinated care provided by a personal physician. The medical home provides or arranges care with other qualified professionals to meet all of the patient’s health care needs including preventive care and both acute and chronic illness management. How might the integration of mental health services into primary care and the medical home help address the multifaceted problem described here? Integration challenges stigma by communicating that health is a unitary construct that cannot be parsed into physical health and mental health, and it has potential to (Reprinted) JAMA Pediatrics April 2015 Volume 169, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 06/02/2015
299
Opinion Viewpoint
change patient, family, and health care professional attitudes and beliefs, as well as address structural barriers to care. Families typically look to primary care professionals (PCPs) as trusted resources and are more likely to allow on-site, collaborating mental health professionals to earn their trust. Integration also forces PCPs to confront their own unease and avoidance in dealing with mental health problems. Specialty mental health professionals embedded in the general medical setting are well positioned to educate patients, families, and PCPs, creating opportunities to better challenge stigma and beliefs. Finally, delivering mental health services in primary care has the potential to address inertia by simplifying and eliminating an inefficient step in the care delivery process. Primary care offices are more likely to be geographically accessible, particularly in rural areas where mental health services are especially limited, and may be a more appealing setting than specialty mental health for patients and families, especially for groups likely to struggle to access mental health services such as lowincome, minority, and disabled children. By leveraging the infrastructure of general medicine, integrated services may mitigate shortages of specialty mental health professionals by using PCPs as the foundation of care delivery, just as in the care of other chronic ARTICLE INFORMATION Published Online: February 9, 2015. doi:10.1001/jamapediatrics.2014.3558. Conflict of Interest Disclosures: None reported. REFERENCES 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication [published correction appears in Arch Gen Psychiatry. 2005;62(7):768]. Arch Gen Psychiatry. 2005;62(6):593-602. 2. US Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Dept of Health and Human Services,
300
illnesses such as asthma. Collaborative care interventions based on the chronic care model and applied to pediatric mental disorders in primary care have been demonstrated to be feasible and effective in improving access to mental health services, treatment outcomes, and consumer satisfaction for both disruptive behavioral problems and depression.6,7 Applying technologies, such as the telephone, telemedicine, and computer-based psychotherapeutic interventions, can facilitate the delivery of mental health services in general medical settings. Efforts to integrate mental health services in primary care call attention to inequities and unnecessary complexities of health care financing such as mental health carve outs, which imply that mental health and physical health are distinct. Despite the success of integrated models in research settings, real-world examples of successful integration of pediatric mental health services in primary care settings are less common than desirable. Successful implementation will require modifications to existing models of reimbursement, as well as changes in the culture of care, to prove broadly sustainable. There is also little doubt that additional research to develop and refine practical, effective, and patient- and family-centered interventions that can be easily disseminated is needed.
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. 3. Costello EJ, He JP, Sampson NA, Kessler RC, Merikangas KR. Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatr Serv. 2014;65(3):359-366. 4. Campo JV. Youth suicide prevention: does access to care matter? Curr Opin Pediatr. 2009;21 (5):628-634.
the WHO World Mental Health surveys. Psychol Med. 2014;44(6):1303-1317. 6. Kolko DA, Campo JV, Kilbourne AM, Hart J, Sakolsky D, Wisniewski S. Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial. Pediatrics. 2014;133(4): e981-e992. 7. Richardson LP, Ludman E, McCauley E, et al. Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA. 2014;312(8):809-816.
5. Andrade LH, Alonso J, Mneimneh Z, et al. Barriers to mental health treatment: results from
JAMA Pediatrics April 2015 Volume 169, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 06/02/2015
jamapediatrics.com
VIEWPOINT
John V. Campo, MD Wexner Medical Center, The Ohio State University, Columbus; and College of Medicine, The Ohio State University, Columbus. Jeffrey A. Bridge, PhD College of Medicine, The Ohio State University, Columbus; and The Research Institute, Nationwide Children’s Hospital, Columbus, Ohio. Cynthia A. Fontanella, PhD Wexner Medical Center, The Ohio State University, Columbus; and College of Medicine, The Ohio State University, Columbus.
Corresponding Author: John V. Campo, MD, Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, OSU Harding Hospital, 1670 Upham Dr, Columbus, OH 43210 (john.campo @osumc.edu). jamapediatrics.com
Access to Mental Health Services Implementing an Integrated Solution Pediatric mental disorders affect 1 in 5 children, and most serious mental disorders begin early in life, approximately 50% by age 14 years and 75% by age 24 years.1 The Surgeon General’s report2 on mental health called national attention to the public health relevance of pediatric mental disorders, citing encouraging news of an increasing number of evidence-based treatments, as well as the discouraging news that most youth struggling with mental disorders receive no mental health services and that even when services are accessed, they are often inadequate in quality and/or quantity. More than a decade later, still less than half of young people with a mental disorder obtain treatment.3 Given that mental health and substance use disorders are risk factors for several leading and potentially remediable causes of death, such as accidents, violence, and suicide, this disturbing reality likely has serious consequences for morbidity and mortality in the pediatric- and transitional-aged population. For example, a growing body of evidence indicates that improving access to effective mental health care can reduce suicide risk in young people.4 Few will argue against efforts to improve access to competent mental health and addiction services for the young; however, the practical challenges are real and difficulties accessing care are likely multidetermined. Barriers to care have been conceptualized as structural and attitudinal, and stigma for mental and substancerelated disorders in all probability contributes to both. Structural barriers include fiscal challenges such as the inability to pay, insurance restrictions, operational inefficiencies, a system that segregates physical and mental health care delivery, geography and transportation problems, and shortages and misdistribution of appropriately trained and experienced health care professionals. Hopes have been high that health care reform might prove a necessary solution. Unfortunately, although efforts to address structural barriers will be necessary to improve access to mental health services, they are unlikely to prove sufficient given that attitudinal barriers to care appear to be most important in influencing treatment initiation and continuation amongindividualswithcommonmentaldisorders.5 Young people with a mental disorder and their families may fail to perceive a need for treatment, wish to address the problem on their own, be pessimistic about the effectiveness of available treatments, or lack trust in health care professionals. Attitudinal barriers may also exert differential effects in specific demographic, ethnic, and cultural groups and settings. Health care professional beliefs and attitudes are also relevant, as professionals may be uninformed or inordinately pessimistic about the availability and effectiveness of existing treatments.2
Finally, there is the problem of inertia. Most children with recognized mental disorders in primary care are not referred for mental health treatment, and only a minority of those referred receives any services. Although low rates of referral completion are commonly attributed to structural and attitudinal barriers alone, studies of collaborative care interventions for pediatric mental disorders in primary care report disappointing rates of referral completion for patients randomized to the usual care condition despite sometimes extraordinary efforts to facilitate referral. For example, approximately half of patients randomized to usual care enhanced by a comprehensive evaluation and facilitated specialty referral did not access any mental health treatment.6 Another collaborative care study focused on adolescent depression found that only 1 in 4 depressed adolescents in the usual care condition obtained psychotherapeutic or antidepressant treatment meeting minimal quality standards, despite the study taking place within a well-regarded and prepaid health delivery organization that emphasizes ready access to mental health services for members.7 While addressing fiscal challenges, such as inadequate insurance coverage and poor health care professional reimbursement for mental health services, will be necessary to improving access to care, elimination of fiscal barriers alone will not be sufficient given the multiple and diverse challenges presented by efforts to connect children and youth with mental disorders to the competent care they deserve. Improvement efforts will almost certainly require a multifaceted approach that considers stigma, structural and attitudinal barriers, and patient and health care professional inertia. One important strategy with potential to address each of these issues is the integration of mental health services in general medical settings, particularly in primary care. Primary care has been defined as first-contact personal health care that is comprehensive and delivered longitudinally within a community-based medical setting. Closely related is the concept of the medical home, which offers accessible, continuous, comprehensive, family-centered, and coordinated care provided by a personal physician. The medical home provides or arranges care with other qualified professionals to meet all of the patient’s health care needs including preventive care and both acute and chronic illness management. How might the integration of mental health services into primary care and the medical home help address the multifaceted problem described here? Integration challenges stigma by communicating that health is a unitary construct that cannot be parsed into physical health and mental health, and it has potential to (Reprinted) JAMA Pediatrics April 2015 Volume 169, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 06/02/2015
299
Opinion Viewpoint
change patient, family, and health care professional attitudes and beliefs, as well as address structural barriers to care. Families typically look to primary care professionals (PCPs) as trusted resources and are more likely to allow on-site, collaborating mental health professionals to earn their trust. Integration also forces PCPs to confront their own unease and avoidance in dealing with mental health problems. Specialty mental health professionals embedded in the general medical setting are well positioned to educate patients, families, and PCPs, creating opportunities to better challenge stigma and beliefs. Finally, delivering mental health services in primary care has the potential to address inertia by simplifying and eliminating an inefficient step in the care delivery process. Primary care offices are more likely to be geographically accessible, particularly in rural areas where mental health services are especially limited, and may be a more appealing setting than specialty mental health for patients and families, especially for groups likely to struggle to access mental health services such as lowincome, minority, and disabled children. By leveraging the infrastructure of general medicine, integrated services may mitigate shortages of specialty mental health professionals by using PCPs as the foundation of care delivery, just as in the care of other chronic ARTICLE INFORMATION Published Online: February 9, 2015. doi:10.1001/jamapediatrics.2014.3558. Conflict of Interest Disclosures: None reported. REFERENCES 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication [published correction appears in Arch Gen Psychiatry. 2005;62(7):768]. Arch Gen Psychiatry. 2005;62(6):593-602. 2. US Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Dept of Health and Human Services,
300
illnesses such as asthma. Collaborative care interventions based on the chronic care model and applied to pediatric mental disorders in primary care have been demonstrated to be feasible and effective in improving access to mental health services, treatment outcomes, and consumer satisfaction for both disruptive behavioral problems and depression.6,7 Applying technologies, such as the telephone, telemedicine, and computer-based psychotherapeutic interventions, can facilitate the delivery of mental health services in general medical settings. Efforts to integrate mental health services in primary care call attention to inequities and unnecessary complexities of health care financing such as mental health carve outs, which imply that mental health and physical health are distinct. Despite the success of integrated models in research settings, real-world examples of successful integration of pediatric mental health services in primary care settings are less common than desirable. Successful implementation will require modifications to existing models of reimbursement, as well as changes in the culture of care, to prove broadly sustainable. There is also little doubt that additional research to develop and refine practical, effective, and patient- and family-centered interventions that can be easily disseminated is needed.
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. 3. Costello EJ, He JP, Sampson NA, Kessler RC, Merikangas KR. Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatr Serv. 2014;65(3):359-366. 4. Campo JV. Youth suicide prevention: does access to care matter? Curr Opin Pediatr. 2009;21 (5):628-634.
the WHO World Mental Health surveys. Psychol Med. 2014;44(6):1303-1317. 6. Kolko DA, Campo JV, Kilbourne AM, Hart J, Sakolsky D, Wisniewski S. Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial. Pediatrics. 2014;133(4): e981-e992. 7. Richardson LP, Ludman E, McCauley E, et al. Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA. 2014;312(8):809-816.
5. Andrade LH, Alonso J, Mneimneh Z, et al. Barriers to mental health treatment: results from
JAMA Pediatrics April 2015 Volume 169, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 06/02/2015
jamapediatrics.com
