The adolescent mental health crisis: Bolstering primary care capabilities

The mental health crisis among children and teens shows no sign of abating, and COVID-19 has clearly made matters worse. A recent study found that suicide attempts and self-harm were among the few indications for hospitalization that didn’t drop during the first waves of the pandemic. On the contrary, the past year has seen a spike in suicidal thoughts and attempts.

“We’ve seen an exponential increase in anxiety and depression, exacerbated by the stress and social isolation of the pandemic,” says Fred Kern, MD, a pediatrician and managing partner at Bridgewater Pediatrics, a member of the Boston Children’s Primary Care Alliance.

Unfortunately, unless families are paying out of pocket, most adolescents struggle to access specialty mental health care. Because of low reimbursement rates, many child psychotherapists and psychiatrists do not accept insurance, and those who do tend to have a long wait list.

“There simply aren’t enough behavioral health providers in the community that accept insurance to meet the need,” says Nanci Ginty Butler, a licensed clinical social worker and director of mental health services in the Division of Adolescent and Young Adult Medicine at Boston Children’s.

Despite the shortage, there are some ways primary care pediatric practices and their patients can access help, and improvements may be coming. Below are a few initiatives to be aware of.

1. Embedded behavioral health providers

Pediatric practices affiliated with larger providers such as Boston Children’s are starting to “embed” behavioral health professionals. Through its Behavioral Health Integration Program (BHIP), Boston Children’s collaborates with the 80+ practices in the Pediatric Physicians’ Organization at Children’s (PPOC). Many of these practices have at least one behavioral health practitioner on-site, providing psychotherapy visits and medication prescribing for ADHD, anxiety, and depression.

Bridgewater Pediatrics was an early adopter of the BHIP model and now employs three embedded behavioral health providers — equal to its number of full-time pediatricians. All were screened, vetted, and trained by the behavioral health team at Boston Children’s, which also conducts regular case reviews to monitor care.

A recent five-year study led by the PPOC’s associate medical director for behavioral health, Heather Walter, MD, MPH, showed that the BHIP increased children’s access to behavioral health services with only minor increases in cost and high marks from participating practices.

“Eight years ago, if a teen presented with a behavioral health problem, we would give them a list of five practitioners in the community and say, ‘good luck,’” says Kern. “Now, the care occurs in the context of the pediatric medical home, where teens and parents have years of trust, without the barriers and the stigma. When you’re seen as willing to help teens with the significant challenges they face — anxiety, depression, suicidal ideation, trauma, bullying, substance use — that’s a tremendous blessing to the practice.” 

To learn more about BHIP, email program director Jonas Bromberg, PsyD, at jonas.bromberg@childrens.harvard.edu.

2. Web-based behavioral health training

In the future, Boston Children’s will be providing web-based behavioral health training in partnership with Open Pediatrics, the hospital’s clinical training platform. “This is allowing us to expand our training to a national and international audience, greatly enhancing the capacity of pediatricians to provide evidence-based behavioral health care to their patients,” says Walter.

3. Expanded services through MassHealth

As the result of a class action lawsuit, MassHealth (Massachusetts Medicaid) provides a set of services under the Children’s Behavioral Health Initiative (CBHI). The core services are three-fold: in-home psychotherapy; intensive care coordination for youth with complex emotional or behavioral issues; and 24/7 emergency mobile crisis support.

MassHealth maintains a list of CBHI providers, and some commercial insurances have also agreed to pay for CBHI services. “I often advise parents to check with their insurance carrier to see if they will reimburse for these services,” says Ginty Butler.

4. Expert consults: The Mass Child Psychiatry Access Project (MCPAP)

Through MCPAP’s partnership with Boston Children’s, pediatric providers can have telephone consultations with child and adolescent psychiatrists. Services are free for all children and families regardless of insurance, funded primarily by the Massachusetts Department of Mental Health with some support by major payers. Consultations can cover diagnosis, level of care needed, and treatment recommendations. In severe circumstances, consulting psychiatrists can facilitate patient referral to urgent or specialty services. For less severe but complex cases in which diagnosis or treatment remain uncertain, MCPAP can schedule telephone or video child psychiatrist consultations directly with the patient and family, providing feedback to the pediatrician about ongoing behavioral health management.

5. Care coordination

Practices affiliated with an accountable care organization (ACO), such as the Tufts Health Together with Boston Children’s ACO, can access a continuum of supportive and preventive care. Services include care coordination and connection of families to housing, food, SSI, transportation, behavioral health services, and other necessities that can affect teens’ physical and mental health outcomes.

“ACO care coordination teams can assist patients and families with solving problems such as homelessness, food insecurity, accessing specialty medical care, navigating the transition to adulthood and adult care, intimate partner violence, and behavioral health crises,” says Ginty Butler. “Thanks to the ACO partnership, we can provide extra support for families trying to navigate complex systems of care.”

6. Family-Based Crisis Intervention

Family-Based Crisis Intervention (FBCI) is a short intervention developed at Boston Children’s to avoid the need for psychiatric hospitalization. Originally designed for emergency departments, FBCI stabilizes suicidal adolescents and gives them and their families training and tools to safely manage crises at home. The FBCI team is adapting it for the primary care setting and is currently piloting it in four pediatric practices in urban, suburban, and rural Massachusetts, with promising results so far. To learn more, email Elizabeth.Wharff@childrens.harvard.edu or Abigail.Ross@childrens.harvard.edu.

Looking to the future

Much more needs to happen to make behavioral health care truly accessible. Earlier this year, the Commonwealth of Massachusetts announced a Roadmap for Behavioral Health Reform. The program creates a centralized “front door” to connect people with behavioral health and addiction treatment before a crisis occurs. As this initiative rolls out, it should expand access to care by funding Community Behavioral Health Centers and expanding the integration of behavioral health services in primary care practices.

“Lots of programs are being looked at and developed because of the acute need,” says Kern. “I think increasing the number and availability of behavioral health clinicians in pediatric practices is the direction we need to go in.”

Visit the Boston Children’s Hospital Department of Psychiatry and Behavioral Sciences