Training in Psychotropic Prescribing Helps Pediatricians Improve Care

A New York state initiative to provide psychiatric consultation to pediatric primary care providers (PCPs) about prescribing psychotropic medication shows promise for enhancing providers’ comfort with prescribing, according to a report published online December 15, 2014, in Psychiatric Services in Advance.

Researchers in the Department of Child and Adolescent Psychiatry at New York University School of Medicine and colleagues at other institutions evaluated Project TEACH (PT), a statewide training and consultation program for pediatric PCPs on identification and treatment of mental health conditions.

They compared an intervention group of 176 PCPs who volunteered for PT training with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York state Medicaid files for youth seen by the trained and untrained PCPs.

They found that the percentage of children prescribed psychotropic medication increased after PT training (from 9 percent to 12 percent), a larger increase than in the untrained group (from 4 percent to 5 percent). Outpatient mental health service use increased among children who saw the PT-trained providers (85 percent to 94 percent), whereas no significant change in outpatient mental health service use was observed for the comparison group.

The findings are preliminary and offer little or nothing about patient outcomes. But they do suggest the potential usefulness of training of—and psychiatric consultation with—PCPs as a way to meet a vast unmet need. “Provider training and consultation may be a meaningful way to help reduce the number of children who do not receive treatment for mental health conditions, but further research is necessary to determine whether this type of model will be useful as the responsibility for mental health care and outcomes shifts under health care reform,” the researchers stated.

PT grew out of a dialogue among the Office of Mental Health, the American Academy of Pediatrics, the New York State Chapter of the American Academy of Family Physicians, and the Conference of Local Mental Hygiene Directors. Two separate programs are funded under PT to cover the state of New York: the Child and Adolescent Psychiatry Education and Support Program for Primary Care Physicians and the Child and Adolescent Psychiatry for Primary Care (CAP-PC) program.

The latter, which is the larger of the two, is a collaboration among the child and adolescent psychiatry divisions at the University at Buffalo, Columbia University Medical Center/New York State Psychiatric Institute, Hofstra–North Shore LIJ School of Medicine, University of Rochester, and SUNY Upstate Medical University (Syracuse) to provide education and phone, face-to-face, and telepsychiatric consultation to pediatricians and family physicians caring for children in more than 90 percent of the state.

CAP-PC has partnered with the REACH Institute (Resource for Advancing Children’s Health) to provide a training curriculum for pediatric PCPs that consists of 15 hours of in-person training, a tool kit, and Web-based learning tools along with a six-month distance learning program that includes 12 one-hour consultation calls with child psychiatrists (Psychiatric News, September 5, 2014).

Photo courtesy David Kaye, M.D.

David Kaye, M.D., CAP-PC project director at the University at Buffalo, says that while there is high satisfaction with the project among primary care providers, what is really necessary are data on patient satisfaction and outcomes. He noted that there are an estimated 24 statewide child collaborative care programs around the country and that almost all of them are funded by a state or region or insurer as clinical projects and have not been set up for research.

“Everyone is trying to come up with something in the way of patient-level data that supports the usefulness of these child collaborative care programs,” he said.

A qualitative review of PT appearing online in General Hospital Psychiatry (November-December 2014) found that PCP participation was facilitated by perceived patient needs, lack of financial and logistic barriers, and continuity of PCP-program relationships from training to ongoing consultation. “Trained PCPs reported more confidence interacting with families about mental health, assessing severity, prescribing medication, and developing treatment plans,” the General Hospital Psychiatry review found. “They were encouraged by satisfying interactions with [mental health] specialists and positive feedback from families.”

And an accompanying editorial by Danielle Laraque, M.D., chair of the Department of Pediatrics at Maimonides Medical Center, stated that the evaluation of PT pointed up the “serious gaps in our system of care and argue for aggressive efforts to reach a much more integrated and family-centered approach to the rendering of mental health services to children in the settings that they are most likely to find welcoming and nonstigmatizing.”

Anecdotally, Kaye said, CAP-PC has seen steadily increasing use by pediatric PCPs. “We have now provided the REACH training to over 500 physicians in New York state,” he said. “Pediatricians and family medicine docs get very little in the way of child mental health training, and what the family medicine physicians do get is mainly on the adult side,” he said. “Pretty clearly, they are not getting the training that they need. When we look at our numbers we think we are doing a good job and making progress.”

Kaye added that PCP evaluations of the program have rated the consultation and REACH training programs highly—with scores of 4.7 to 4.9 on a five-point scale.

And he said that there is an awareness among pediatricians about the urgency of finding ways to address the overwhelming mental health needs of children and adolescents in primary care. In a July 11, 2014, blog post by David Nichols, M.D., executive director of the American Board of Pediatrics, Nichols wrote that many pediatricians “report seeing a swelling tide of children with developmental, behavioral and mental health problems.”

He added, “I use the swelling-tide metaphor not just because of the numbers of patients but also in the sense of feeling overwhelmed by a subject area for which there was inadequate preparation during residency.”

Nichols said, “Pediatricians must identify the child with mental health needs and then coordinate care with early intervention services, mental health professionals, schools, and various agencies.” And, he concluded, “Since the days of typhoid fever, pediatricians have always stepped forward to answer urgent child health needs when no one else could or would. Today’s pediatricians carry forward that tradition in extending themselves to tackle the mental health crisis among the young.” ■