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Note – a version of this post was previously published in Pediatric News from MD Edge.
There’s little doubt that many pediatricians and other primary care clinicians are doing more and more mental health care these days. Many questions, however, remain. Do these doctors actually want these new responsibilities? Should pediatricians be on the front line of mental health care? And what about those remaining clinicians who just won’t do it?
A recent policy statement published by the American Academy of Pediatrics (AAP) entitled “Mental Health Competencies for Pediatric Practice,” makes it abundantly clear that diagnosing and treating many common childhood behavioral disorders (things like ADHD or anxiety) should be part of what pediatricians do, and that includes the prescribing of certain medication.
This shift toward doing more mental health care is likely coming from multiple sources, not the least of them being pure necessity and an acknowledgment that there simply aren’t enough psychiatrists and other mental health specialists to take over the care of every youth with a diagnosable psychiatric disorder. As the supply of mental health professionals stays flat, the need is increasing based upon the rising rates of youth suicide and the number of children and adolescents presenting to emergency departments in crisis — for reasons still to be fully understood. And all of this is coming at a time when the research is showing — more clearly than ever — that good mental health is a cornerstone of all health.
The response from the pediatric community, whether it be due to personal conviction or simply a lack of options, has largely been to step up to the plate and take on these new responsibilities and challenges as best they can, while at the same time trying to get up to speed with the latest information about mental health best practices. Yet, while many pediatricians now fully endorse the idea that mental health problems should be considered as in their “lane,” the sentiment is far from universal. Some cling to the idea that all mental health problems require a referral, even when most orthopedic problems, infections, asthma, rashes, and other medical problems are managed without sending the patient to a specialist.
Others are happy to do their part when it comes to mental health care but worry that they are being pushed into waters that are too deep or too turbulent for their level of training. Diagnosing and treating ADHD is one thing, they might argue, but being asked to take over the care of an adolescent with bipolar disorder, who just got discharged from a psychiatric hospital is not in the best interest of anyone.
Where someone’s comfort level stops, of course, will vary from clinician to clinician based on that pediatrician’s level of interest, experience, and available resources in the community. The AAP doesn’t mandate or even encourage the notion that all pediatricians need to be at the same place when it comes to competence in assessing and treating mental health problems, although it is probably fair to say that there is a push to raise the collective bar at least a notch or two.
In response, the mental health community has moved to support primary care clinicians in their expanded role. These efforts have taken many forms, most notably the model of integrated care in which mental health clinicians of various types see patients in primary care offices rather than making patients come to them. Many states also now have consultation programs that provide easy access to a child psychiatrist or other mental health professionals for case-related questions delivered by phone, email, or for single in-person consultations. Additional training and educational offerings are also now available for pediatricians either in residency and for those already in practice.
These initiatives are bolstered by research showing that not only can good mental health care be delivered in pediatric settings but that there are cost savings that can be realized, particularly for non-psychiatric medical care. Despite these promising leads, however, there will remain some for whom anything less than the increased availability of a psychiatrist to “take over” a patient’s mental health care will be seen as falling short of the clinical need.
To illustrate how things have and continue to change, consider three common clinical scenarios that commonly present to a pediatrician including, 1) new presentation of ADHD symptoms, 2) anxiety or obsessive-compulsive problems and, 3) the return of a patient who has been psychiatrically hospitalized and now is taking multiple medications. In the past, all three cases would often have resulted in a referral to a psychiatrist. Today, however, it is quite likely that only one of these cases would be referred, as ADHD could be well diagnosed and managed within the primary care setting and problems like anxiety and obsessive-compulsive disorder are sent first not to a psychiatrist but to a non-MD psychotherapist.
Moving forward, today’s pediatrician is expected to do more for the mental health care of patients than refer to a psychiatrist. Most already do, despite having had little in the way of formal training. As the evidence grows that the promotion of mental well-being can be a key to future overall health, as well as to the cost of future health care, there are many reasons to be optimistic that support for pediatricians and collaborative care models for clinicians trying to fulfill these new responsibilities will only get stronger.
Foy JM. Mental health competencies for pediatric practice. Pediatrics 2019;144(5): pii: e20192757.