Pediatric mental illness dx, drug prescribing vary widely

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Consider integrating mental health support into patient medical home

The integration of mental health services into primary care is an important strategy for increasing access. Future studies that investigate variations in mental health care seen in the primary care setting can help us better understand the quality of this care and consistency with published guidelines.

Dr. Lee Savio Beers

Increased education and support for primary care physicians is essential, as they are at the front lines of providing care to children with mental and behavioral health concerns. However, working together with specialty mental health providers is also important, as they are important partners in the early identification, diagnosis, and treatment of mental disorders.

Education and consultation models such as Child Psychiatry Access Programs can significantly improve a primary care physician’s capacity to care for children with mental health concerns in the medical home, and arrange for appropriate specialty mental health treatment when indicated.

Dr. Lee Savio Beers is the medical director for municipal and regional affairs for the Child Health Advocacy Institute at Children’s National Medical Center, the director of the Washington, D.C., Mental Health Access in Pediatrics (DC MAP) program, and an assistant professor of pediatrics at George Washington University, all in Washington. She had no relevant financial disclosures.




A lack of psychiatrists only partially accounted for substantial variations in rates of mental illness diagnosis and prescriptions for psychotropic medications in practices nationwide, a study has shown.

Although a lack of available specialty care was associated with significantly higher odds of a diagnosis or prescription, the colocation of mental health professionals or percentage of children in foster care treated in a practice did not fully explain the differences.

Among 294,748 children aged 4-18 years, seen one or more times in 43 primary care practices nationwide, 15% received a mental health diagnosis between Jan. 1, 2009, and June 30, 2014. Psychotropic medications were prescribed to 14%, reported lead researcher Stephanie L. Mayne of the center for pediatric clinical effectiveness at the the Children’s Hospital of Philadelphia (Pediatrics. 2016 doi: 10.1542/peds.2015-2974).

The most common diagnosis was attention-deficit/hyperactivity disorder at a rate of between 1% and 16%. Differences in other diagnoses “were smaller, but still meaningful” at ranges of 1%-8% for anxiety, 0%-5% for depression, 0.2%-3% for autism, 0%-3% for conduct disorder, and 0%-2% for oppositional-defiant disorder. Bipolar disorder was “uncommon” at less than 1%, Ms. Mayne and her associates reported.

The rate of children receiving any psychotropic medication was between 4% and 26%, while the proportion of patients receiving two or more medication classes ranged between 1% and 12%. Prescription rates for specific medication classes also varied at between 4% and 18% for stimulants, 1% and 12% for antidepressants, 0.1% and 8% for alpha-agonists, and 0.1% and 5% for second-generation antipsychotics.

“Primary care providers’ level of agreement with current guidelines, perceived self-efficacy in diagnosing or treating particular conditions, training, relationships with schools, and reimbursement from insurers might affect prescribing practices,” Ms. Mayne and her associates wrote.

“Even with colocation, barriers such as financial differences in reimbursement for medical and mental health services, difficulties with information sharing, differing expertise, and limited hours may impede integration,” they commented.

Dr. Alexander G. Fiks is an investigator for Pfizer; the other researchers said they had no relevant financial disclosures. This study was funded by the National Institutes of Health and the National Institute of Child Health and Human Development under the Best Pharmaceuticals for Children Act.

On Twitter @whitneymcknight

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