Primary Care and Identification of Mental Health Needs

The following article has been republished from the "Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda" completed in 2000. 

By:  Kelly J. Kelleher, M.D., M.P.H.,
University of Pittsburgh

Dr. Kelleher reviewed practice in primary care, discussed efforts to improve identification, and considered policy options to improve the recognition and referral of children in primary care with mental health needs. Each year, there are more than 150 million pediatric visits to primary care providers in the United States (NAMCS, 1998). Primary care practitioners prescribe the majority of psychotropic drugs, and they often counsel families about behavior and emotional problems and disorders. Still, some surveys suggest that families do not view this counseling from family doctors as mental health services, even though the physicians do. Most children with mental health problems see their primary care providers rather than mental health specialists. For many preschool children, such visits are their only contact with any major delivery system. Parents trust these primary care providers more than others. Yet, many barriers impede the delivery of effective mental healthcare. For example, the average visit is only between 11 and 15 minutes (NAMCS, 1988; CBS, 1997).

One major challenge is the disparity between what parents report versus what physicians report as psychiatric problems in children. In at least one large study, primary care physicians identified about 19% of all children they see with behavioral and emotional problems. Yet that overlapped by only 7% with what parents identified as problems. Girls and young children are less likely to be identified than boys. African American and Hispanic American children are identified and referred at the same rates as other children, but they are much less likely to actually receive specialty mental health services or psychotropic medications. This follow-through, or lack thereof, is very often linked to trust in the doctor, the history of that relationship, as well as demographics and insurance status.

Most referrals from primary care physicians for behavior problems are for child psychologists. Significant barriers to referral include lack of available specialists, insurance restrictions, and appointment delays. More than two thirds of primary care clinicians report appointment delays, with average time to appointment with a specialist being three to four months. Of those patients who were referred, 59% had zero visits to the specialist; only 13% averaged one or more visits a month in the follow-up period of six months. In short, an increasing number of problems (15-30%) are being identified by primary care providers, but rates of recognition (48-57%) are still low and connections to mental health specialists are difficult.

Dr. Kelleher suggested more efforts in the following areas: (1) Train primary care practitioners; this seems to have no impact on management practices except for those who complete at least a two-year fellowship training. Nonetheless, the training of primary care physicians also needs to be expanded to include more mental health issues. (2) Screen for disorders in primary care; however, the effectiveness of screening depends on the availability of assistance for scoring screening protocols and the availability of treatment services. (3) Link specialty services through consultation-liaison services, co-location with mental health services, and use of behavioral specialists.

Public policy options include: (1) Payment coordination to ensure reimbursement for behavioral services by primary care providers, care coordination, parallel incentives for Managed Behavioral Health Organizations, Managed Care Organizations, and Primary Care Practitioners; (2) Data coordination through the Substance Abuse and Mental Health Administration (SAMHSA), Maternal and Child Health (MCH) Block grant requirements, Medicaid waiver requirements for sharing data, and state contract mandates, so that systems can track families and use reasonable case management across populations; (3) Accountability standards for screens, referrals, and treatment; and (4) Expansion of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

Source

U.S. Public Health Service, Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington, DC: Department of Health and Human Services, 2000.

Dated: December 12, 2008