For the past decade, cutting-edge health care providers and researchers have increasingly pushed to integrate care for mental health and substance use problems within primary medical care for children and adolescents. Their hope is that children and teens who suffer from mental and behavioral disorders would fare better if their pediatricians or family doctors took an active role in linking them with mental health care, particularly when these doctors team up with mental health clinicians to help meet the needs of their young patients.
Now, a team of UCLA researchers has studied a wide range of published research on the approach and found that children and adolescents who receive integrated mental health and medical treatment are 66 percent more likely to have a good outcome than those who receive more traditional primary care.
Previous studies have demonstrated the value of integrating mental health and primary care, but only analyzed the approach for one or two mental health disorders -- not the full array that routinely affect young people, including depression, anxiety, attention deficit disorders, substance abuse and behavioral problems. And in earlier research, the extent of the physician's involvement varied widely.
The UCLA study, published in the current issue of JAMA Pediatrics, is the first meta-analysis of research on the subject. Supported by funding from the National Institute of Mental Health and the American Psychological Association's Society for Clinical Child and Adolescent Psychology, the authors combined the results of 31 studies that compared outcomes in an integrated model with those in a more conventional approach. In all, the data covered outcomes for 13,129 children and adolescents.
"The take-home message is that integrated care works," said lead author Joan Asarnow, a UCLA professor of psychiatry and biobehavioral sciences and director of the UCLA Youth Stress and Mood Program, a depression and suicide prevention program. "Kids and teens do better than they otherwise would. That's promising because we have a huge mental health problem in this country."
In the U.S., an estimated 40 percent of adolescents suffer from mental health or substance use disorders. Among children between 8 and 15, approximately 1 in 8 suffer from mental health disorders. And suicide is the second leading cause of death among adolescents and young adults.
The likelihood of a positive outcome increased the more directly primary care and mental health providers worked together. When a psychologist or social worker was actually embedded in a pediatrician's or family doctor's office and collaborated with the physician on treatment and follow-up, the youth was 73 percent more likely to have a good outcome than in conventional primary care.
"The old model has been that if your child has a medical problem, he or she goes to the pediatrician," said Dr. Lonnie Zeltzer, a co-author of the study and a UCLA distinguished professor of pediatrics, anesthesiology, psychiatry and biobehavioral sciences.
"But mental health was often not addressed, or if it was, patients were referred to a mental health specialist, and the child's health insurance determined whether or not the child had access to the mental health specialist as well as the quality of that care," said Zeltzer, who also is director of the Pediatric Pain and Palliative Care Program at UCLA Mattel Children's Hospital. "Children of poorer families lost out."
But times may be changing. New incentives for mental health coverage by insurance providers remove at least some of the hurdles primary care doctors have faced in joining forces with psychologists, psychiatrists and social workers. Under the Affordable Care Act, behavioral health treatment is considered an essential health benefit and the Mental Health Parity and Addiction Equity Act of 2008 mandates increased insurance coverage for behavioral health. In the past, getting insurers to pay for mental health care was much more difficult.
Most children do not have ongoing relationships with mental health care providers. They do, however, see primary care doctors or nurses each year for back-to-school check-ups -- or treatment for illness or injury -- making the family doctor or pediatrician a convenient conduit to a range of care.
"Integrated approaches bring mental health care to a setting where kids already are, reducing barriers to mental health care such as stigma or the practical complications of shifting to a different care setting," said Asarnow, who is the immediate past president of the Society of Clinical Child and Adolescent Psychology. "Efforts to improve access to behavioral health care through primary care are likely to lead to real improvements in the lives of kids and families."
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