Across the country, there is a large treatment gap for children and adolescents facing mental health challenges; up to 70 % of adolescents don’t receive care (SAMHSA). One of the ways to solve this crisis is to increase the capacity of primary care offices to provide mental health services.
The integration of mental health care into the primary care setting has been well-studied and is strongly supported within the evidence. Yet there are numerous models for integrated care, and often when we discuss integrated models with our peers, we are not talking apples to apples. For example, there are a number of different integrated interventions within our SmartCare program, each drawing from a different set of data and different standard practices. Our SmartCare BHCS telephone consultation draws from the Massachusetts Child Psychiatry Access Project (MCPAP), while our tele-video capabilities draw from various co-located care models.
Collaborative Care, one of the most well studied models, has shown great efficacy in treating depression, anxiety and substance abuse in adult primary care settings. This model has been less broadly implemented in the pediatric setting, but it is exciting to know that the evidence is very promising. Collaborative care has been shown to be effective at treating adolescents with Depression (Richardson et al. 2014), Disruptive Behaviors and ADHD (Kolko et al., 2014). We would like to see more studies in anxiety. Given the strong data for adults, and preliminary positive data for kids, this model has an important place in the future landscape.
Here is a brief overview of the elements of collaborative care (Katon et al., 2002):
- Screening within the primary care setting helps to identify at-risk youth (phq 9 is an example)
- The multi-disciplinary team includes
- PCP: Sees patient regularly, provides referral to social worker, prescribes medications with guidance from psychiatrist
- Social worker: (can be LMFT, RN other allied professionals) provides case management, family support, brief therapeutic interventions including CBT and behavioral activation, and referral to more specialized psychiatric services.
- Psychiatrist: provides supervision to the social worker, in-person consultation of complex cases, guidance for psycho-pharm management for patients who meet criteria for MDD, ADHD, or anxiety disorders, reviews cases on a weekly basis.
- Caseload Review: A database of all patients in the program, including their PHQ 9 scores is used to track response to intervention, and guide treatment. This is reviewed on a weekly basis.
- Collaboration: Plans are discussed with patient, PCP and the social worker to develop a mutually agreed upon set of goals. These goals are measured in the caseload review
- Algorithmic care: There is some variation in the this, but most collaborative care models use a specific algorithm for medication management, shaped by diagnosis.
Holt, W.(2010). The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment in Primary Care. Case Study Health Treatment in Primary Care. Health (San Francisco), 41(March).
Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., … Langston, C. (2002). Collaborative Care Management of Late-Life Depression in the Primary Care Setting. JAMA, 288(22).
Kolko, A. D. J., & Campo, J. (2014). Collaborative Care Outcomes for Pediatric Behavioral Health Problems : A Cluster Randomized Trial, Pediatrics 2014, 133(4).
Richardson LP, Ludman E, McCauley E, Lindenbaum J, Larison C, Zhou C, Clarke G, Brent D, Katon W.(2014) Collaborative care for adolescents with depression in primary care: a randomized clinical trial.JAMA. 2014 Aug 27;312(8):809-16. doi: 10.1001/jama.2014.9259. PMID: 25157724
SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013