Call-In Consults the Answer to Severe Child Psychiatrist Shortage?

Michael Vlessides

July 30, 2019

Children who live in areas that offer statewide child psychiatric telephone consultation programs are significantly more likely to receive mental health services than their counterparts who live in states without such programs, new research suggests.

In the first national study of its kind, investigators examined the growth of such services from 2003 to 2016. They found that compared to 2003, children in 2016 were 37% more likely to receive mental health services.

"The bottom line is that in states where these programs have been implemented on a statewide basis, more children receive mental health services than in states without any such programs," study author Bradley D. Stein, MD, PhD, a senior physician scientist at the RAND Corporation, told Medscape Medical News.

He noted that previous research has examined what happens with such programs in a single state.

"But all kinds of states have these programs, and each one is run a little bit differently," Stein said. "To our knowledge, this is the first study using national data looking over a decade to see whether these programs are making a difference."

The findings were published online June 27 in the Journal of the American Academy of Child and Adolescent Psychiatry.

50% of Children Lack Treatment

According to previous research, as many as half of all American children with mental health problems do not receive needed treatment. Many times, such shortcomings occur simply because there are too few child mental health specialists to provide needed services.

To help address the problem, many states have established child psychiatric telephone consultation programs. The theory is that easy access to psychiatric specialists will encourage more primary care physicians to provide mental health services to their patients.

"Far too many children who need mental health treatment aren't evaluated and don't get treatment," Stein said. "And while that's been getting a little better over the last couple of decades, it's far from perfect."

He noted that a recent study of American children showed that the average time between the onset of mental health symptoms and the initiation of treatment was a decade.

"That's a public health crisis; those numbers are obscene," Stein said.

"So we've been interested in thoughtful and creative approaches that increase access to and quality of care for children with mental health problems," he added.

Most state programs are modeled after the Massachusetts Child Psychiatry Access Program, which first introduced the telephone child psychiatry concept in 2004. Now a majority of states boast similar programs, although some states' programs serve only select counties.

"These programs are designed around the idea that if we make child psychiatrists available to pediatricians and other primary care providers who treat children, they can call in while the child and family are in their office and get advice about what they're seeing and how better to treat the children," Stein said.

"This may be a beneficial way of getting more children the treatment they need, and hopefully over time it will make pediatricians more comfortable in treating these problems," he said.

Programs Grow, Access Increases

To assess the efficacy of such programs over time, Stein and his colleagues accessed multiple waves of data from the National Survey of Children's Health. The investigators then supplemented these data with information about the establishment of telephone consultation programs.

They used weighted information on 245,512 children and adolescents (aged 5 to 17 years) from 2003, 2007, 2011, and 2016 to identify those who received mental health services.

These findings were then merged, by year and state, with information about state child psychiatric telephone access programs from the National Network of Child Psychiatry Access Programs.

Because the states adopted child psychiatric telephone-access programs in different years, the researchers examined treatment trends over time. This allowed them to account for the influence of other efforts to improve access to child mental health services.

The analysis documented the growth in child psychiatric telephone-access programs over time. By 2016, 28.1% of children lived in states with complete statewide programs; 48.6% of children resided in states with partial-access programs; and 23.3% of children lived in states with no such programs.

The percentage of children who received mental health treatment increased from a baseline of 8.4% in 2003 (before any state programs were created) to 9.5% in 2007, 11.1% in 2011, and 11.4% in 2016.

More tellingly, the study showed that 12.3% of children who lived in areas with statewide child psychiatric telephone-access programs received mental health services, compared with 10.9% of those who lived in states with partial child psychiatric telephone access programs and 9.5% of those who lived in states with no such programs (P < .0001).

Multivariate regression models showed that, compared to 2003, in 2007, children were 16% more likely to receive mental health services (adjusted odds ratio [OR], 1.16; 95% confidence interval [CI], 1.08 – 1.26); in 2011, children were 34% more likely (OR, 1.34; 95% CI, 1.24 – 1.46); and in 2016, children were 37% more likely (OR, 1.37; 95% CI, 1.25 – 1.49).

Important Step

After controlling for such factors as family income and secular trends, children from states with statewide child psychiatry telephone-access programs were significantly more likely to receive mental health services than those in states without such programs.

These results show that telephone-based programs are already changing the treatment landscape for children who need mental health services, the researchers note.

The findings also reflect a general willingness among government institutions to lower barriers to the receipt of mental health care, as exemplified by such legislation as the Mental Health Parity and Addiction Equity Act of 2008 and the 2010 Affordable Care Act with Medicaid Expansion.

The investigators point out that recent federal investments to expand child psychiatric telephone consultation programs could significantly increase the number of children who receive mental health services.

"As we try, as a nation, to figure out ways to address the crisis of unmet mental health needs for our children, this is an important step," Stein said.

"Our study suggests that these programs are an important step in trying to address this problem," he added.

Severe Shortage

Commenting on the findings for Medscape Medical News, Katherine Hobbs Knutson, MD, MPH, child and adolescent psychiatrist and adjunct assistant professor of psychiatry and behavioral sciences, Duke University School of Medicine, Durham, North Carolina, said telephone consultation programs address the severe shortage of child and adolescent mental health specialists in the country.

Hobbs Knutson, who was not involved with the current research, has played an integral role in the development of similar programs in Washington, DC, and North Carolina.

"What I love about these programs is that they're not dependent on expanding the number of providers," she said. "Instead, they look at how we can use the resources we have, organize them more efficiently, and then extend these limited resources to reach more kids."

Building such programs from the ground up is not without challenges, particularly when it comes to incorporating them into pediatricians' everyday workflow, Hobbs Knutson noted.

"There's a lot of outreach to primary care to get them on board," she explained. "We ask pediatricians to cover so many things in a 10- or 20-minute visit. And while we may believe in the importance of these programs, incorporating them into the pediatricians' workflows takes time."

It is also critical that telephone consultation programs work in real time and that a mental health care professional is available when needed, Hobbs Knutson added.

"Some programs are built so that the psychiatrist is only available on Friday at lunch time. Well, that doesn't work on Tuesday when that pediatrician is actually seeing the patient; they won't call back 3 days later. You have to have those people available," she said.

Stein noted that as encouraging as the study's results may be, child psychiatry telephone consultation programs are by no means a silver bullet. "This is going to be one piece of the puzzle. And we're going to need other pieces as well," he said.

"I think these types of programs will be most useful for pediatricians treating children with relatively straightforward mental health problems. But we're still going to need mental health specialists to treat children who have more complicated situations," he added.

Still, "in an area where we have been struggling for years to try to have kids get some of the help they need, this appears to be an important piece of the puzzle," Stein concluded.

The study was funded by the National Institute of Mental Health. Stein has received funding from the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the Pew Foundation, and the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services.

J Am Acad Child Adolesc Psychiatry. Published online June 27, 2019. Abstract

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