By Robert Glatter, MD
October 14, 2015
According to results of a new study, primary care physicians and pediatricians–as opposed to psychiatrists–were the main providers for children with mental health conditions such as anxiety and ADHD.
Findings from the study were published online in the Journal Pediatrics October 12th.
Researchers from Massachusetts General Hospital in Boston studied over 43,000 patients ages 2-21 who were evaluated in outpatient settings from 2008-2011 in the U.S. They found that nearly 35% of children who received care for mental health conditions in office-based settings were treated by primary care physicians, 26% were treated by psychiatrists, and the remaining 15% were taken care of by social workers or psychologists.
The study found that more children with ADHD saw a primary care physician compared to those with anxiety or mood disorders (42% to 17%). Interestingly, primary care physicians and pediatricians also prescribed medications to children more often than psychiatrists. And pediatricians were more likely to prescribe psychotropic or mood-altering medications compared with psychiatrists, 74% vs. 61%.
The study highlighted the substantial role of primary care physicians in caring for mental illness in children, said lead study author Dr. Jeanne Van Cleave, a pediatrician at Massachusetts General Hospital in Boston.
Van Cleave emphasized that because there are not enough child psychiatrists to care for all the children in the U.S with mental health conditions, primary care physicians such as family physicians and pediatricians provide the bulk of psychiatric care. Nearly 1 in 10 school-age children in the U.S, she pointed out, suffers from a mental illness.
Reasons behind higher prescribing rates among primary care physicians compared with child psychiatrists for ADHD and anxiety, as well as mood disorders, were not analyzed by the study. That said, Van Cleave suggests that child psychiatrists may deal with more treatment-resistant cases, as well as parents who may be reluctant to have their children take additional medications.
As a result of guidelines issued by the American Academy of Pediatrics (AAP) in 2009 for managing ADHD and depression in teens, Van Cleave explains that most pediatricians and family physicians have become comfortable in managing ADHD as well as anxiety in children.
Of note, the research revealed that primary care physicians were prescribing more stimulants and alpha-agonists to treat children with ADHD, compared to other available medications. Whether this was related to level of training, bias or experience was not clear from the study. Van Cleave explained that “while this was an interesting finding, the study wasn’t designed to explain this phenomenon, but it would be a good goal for future studies.”
Van Cleave emphasized that a substantial portion of children receiving mental healthcare receive that care from primary care clinicians, “which might suggest that investing in supports for primary care clinicians to deliver that care more effectively would be of high value.”
“Supports that would be helpful would be not only additional training, but also ongoing access to mental health specialists for advice and co-management of patients, additional staff in primary care offices to provide psychotherapy and coordinate care with mental health specialists, and reimbursement strategies that allow for the extra time it takes to care for children with mental health conditions,” said Van Cleave.
Greater cooperation among medical providers caring for children with mental illness would ideally result in better lines of communication and improved outcomes, added Van Cleave.
Another expert, Dr. Amanda Itzkoff, Assistant Professor, Department of Psychiatry at Mount Sinai Hospital in New York City, who also maintains a private practice concurred with Dr. Van Cleave, explaining that “some of these patients can appropriately be cared for by primary care physicians.”
“In areas where there are too few psychiatrists, the most effective systems link primary care physicians and pediatricians to psychiatrists and child psychiatric consultants,” said Itzkoff. “But ultimately it depends on the level of training of the pediatrician– which can be highly variable.”
“What many primary care physicians truly need is good mental health training, an established link to a skilled child psychiatrist for slightly complicated cases, and the knowledge of when to appropriately refer patients,” emphasized Itzkoff.
Ultimately, however, “child psychiatrists are more skilled at treating mental illness–but there are few of them, and seeing one may be less acceptable to many parents,” said Itzkoff. ”The fact that one in three pediatric patients in this study are treated by a pediatrician demonstrates how prevalent psychiatric illness is, and how much a link to more robust care is needed by pediatricians.”