A teenage boy has had a fight with his sibling that included choking and threats. The teen tells his parent that he felt bad about the fight, but everything lately has been building up. He feels like he wants to kill himself and shares some disturbingly conceivable ways to do it.
There’s something at the bottom of all this; it may be a tragedy like abuse, a relationship, or underlying depression. The parent calls our clinic nurse for help; our office is the familiar and trusted place where that teen has been coming for years, for sickness and health, the safe harbor, the medical home.
It’s almost 4 p.m. on a Thursday and I still have three other patients to see: a newborn with feeding problems who has lost weight, a disabled child with new seizures, and a healthy tweenager ready for shots and sports physical. Do I send the family in crisis to the emergency room, or work them in? I work them in to assess the patient’s needs and provide the family support. Sending this teen to the ER is not an ideal option. I text my spouse that I won’t be making it to dinner, or my own teen’s concert that night.
After our clinic, the next steps available to a child and family in need of mental health services are severely limited.
I make some calls and hope the family will be able to be seen within a week by an over-burdened crisis service for intervention and mental health evaluation. I plan to check with the parent the next day to get an update on the situation and see if they’ve been able to find someone to see them in a reasonable time frame — before things escalate.
This scenario is not uncommon. One in five children in the United States suffers from a mental disorder such as anxiety, depression or a behavior disorder, but only 20 percent of these children receive needed services. Half of adult mental disorders have their onset during childhood.
According to “Parity or Disparity: The State of Mental Health in America 2015,” prepared by Mental Health America, our state ranked 47th in the country regarding youth behavioral health service needs and access to care.
The front line for identifying and coordinating treatment for these disorders is primary pediatric care — the medical home. I am doing my best to provide a medical home for my patients and their families, but practices like mine throughout the state lack the necessary resources to provide timely behavioral health care. The American Academy of Pediatrics recommends annual screening for depression and substance use starting at age 11. Screening would allow us to address many problems early, before they reach a crisis state. Unfortunately, Washington’s Medicaid program does not reimburse physicians for performing these screens or coordinating services when a child is in need of help.
Our current mental health system is inadequate to handle the volume of patients who need care. To address this, the state’s Managed Care Organizations should be held accountable for providing timely access to mental health care, and we need to invest in increased hospital capacity for inpatient and outpatient care. Creative use of telemedicine, like Seattle Children’s Hospital’s Physician Access Line, can help bridge gaps where there are too few providers in a region to care for all the kids who need services.
What would make the biggest difference in my practice is somebody who is available every day to help our families in times of crisis, and do it with calm and competence. They might be a social worker, a mental health nurse, or another mental health specialist trained to help our families develop a sound course of action in real time, with diligent follow up.
We need behavioral health integration in primary care. This is not a luxury, it is an absolute necessity that has been adopted by some large practices but has thus far remained untenable for small private practices like mine. But, towards the goal of providing comprehensive, value-based care, I am optimistic that this will become a reality for small and large practices alike throughout our state. Remarkable strides have been made in behavioral health integration in primary care utilizing evidenced-based approaches to screening, diagnosis and intervention. The results are clear: There is much to gain from implementing such programs, and there are numerous models to choose from throughout the country.
We know timely access to quality mental health care is important, especially for children. Now, we just need the political will to make it happen.
Dr. Matt Thompson is a primary care pediatrician in Spokane and a trustee for the Washington Chapter of the American Academy of Pediatrics.
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