Collaborative Efforts Improve Adolescent Mental and Behavioral Health Care

Adolescent mental health care can be improved by integration of mental and behavioral health care into primary care settings, according to 2 examinations from the Journal of Adolescent Health.

The first, done by Laura P. Richardson, MP, MPH, with Seattle Children's Research Institute and the University of Washington's Department of Pediatrics, and co-authors from the University of Pittsburgh, and University of California Berkeley, was a systematic review of to identify barriers to integrating mental and behavioral health into primary care.

The second was a review of clinical and preventative services for adolescents, including those affecting mental and behavioral health, reviewing system-level and clinical visit-level strategies to enhance access to preventative care, done by Sion Harris, PhD, of Boston Children's Hospital and Harvard Medical School, and colleagues in the US and Chile.

Richardson and colleagues pointed out that although an estimated 20% of adolescents and young adults face mental and behavioral health disorders, mental and behavioral health concerns for adolescents often go untreated.

Both studies agreed that more can be done in primary care settings to screen and treat mental and behavioral health for adolescents and young adults, and to identify similar barriers inhibiting optimal preventative health.

“Mental and behavioral health concerns are actually the most salient and frequent health issues that adolescents tend to face,” Harris told MD Magazine. “In order to have a general health care delivery system that is responsive to adolescents' primary health needs, we need providers and systems that have the knowledge, skills, and structures/processes to offer adolescents accessible, appropriate, and respectful mental and behavioral health services.”

Richardson’s study assessed a series of 17 studies focusing on collaborative care in three primary forms: coordinated care, between primary care providers (PCPs) and advisory community-based behavioral specialists; integrated care, involving shared treatment plans between PCPs and behavioral specialists; and co-located care, comprising of medical and behavioral services in the same setting to ease communication efforts and referrals.

The analysis of studies using collaborative care found that all of the studies illustrated the successes of collaborative care for mental and physical health in adolescent patients.

However, Richardson and colleagues noted that there remains a gap in research on and use of these treatment models in adolescent health care as opposed to adult health care, and the majority of the studies examined were focused on substance use among older young adults in college settings.

Harris agreed. General intervention approaches, which include not only physical health but behavioral and mental health screenings could drastically improve care, according to Harris, but there remains a lack of consistent studies, publications and reporting on intervention outcomes which provide evidence-based data on interventions and integrated systems.

“There are additional barriers that relate to concerns about mental health confidentiality which limits communication between mental health and medical providers and medical provider lack of training or comfort in managing behavioral health issues,” Richardson told MD Magazine. “Additionally, mental health professionals are less likely to be present in medical clinics than other types of providers that primary care providers might collaborate with such as nurses or social workers to provide collaborative treatment for medical conditions."

Richardson also noted that another barrier "is the historical reimbursement structure that focuses on the fee for service and values medical testing and treatment over behavioral and preventive health."

“If we are able to shift the focus of payment from a per service reimbursement to a system that reimburses for specific outcomes, I think that will also help to allow systems to prioritize behavioral health factors that they know are preventing their patients from improving and thriving,” she added.

A final barrier, according to Richardson, has to do with exposure to effective collaborative models. She commented that “many providers have not had exposure to collaborative care, and so it is a bit of a black box to them. They don’t know what it can or should look like.”

Harris, similarly, pointed out some barriers to effective care for adolescents centered on PCP delivery of preventative services, including a “lack of knowledge or confusion about guidelines or available tools, lack of time, low self-efficacy (i.e., belief by the clinician that he/she can deliver the recommended services), low outcome expectancy (i.e., belief that the delivery of services will lead to the desired outcome), and/or lack of motivation to change practice.”

The researchers noted that integrated screening tools that work with extant electronic medical record (EMR) systems, collaborative support, and “appropriate clinician training” show “particular promise in addressing these barriers.”

"We have found in our research at Boston Children's Hospital that if we give PCPs practical and feasible tools that help them provide these recommended services while overcoming the barriers they face, they really do change their practice, and adolescents actually give higher satisfaction ratings,” Harris added.

Richardson and colleagues agreed that because of the critical role adolescent and young adult care plays in life-long health behaviors, care management and psychiatric supervision for adolescents needs to be reprioritized, and new avenues of effective care, such as collaborative care models, should be explored based on the observed effectiveness of those care models.

Richardson's study and Harris's study both appeared in the March 2017 issue of the Journal of Adolescent Health.

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