Robert J. Hilt

The Partnership Access Line: Evaluating a Child Psychiatry Consult Program in Washington State

OBJECTIVE To evaluate a telephone-based child mental health consult service for primary care providers (PCPs). DESIGN Record review, provider surveys, and Medicaid database analysis. SETTING Washington State Partnership Access Line (PAL) program. PARTICIPANTS A total of 2285 PAL consultations by 592 PCPs between April 1, 2008, and April 30, 2011. INTERVENTIONS Primary care provider-initiated consultations with PAL service. MAIN OUTCOME MEASURES The PAL call characteristics, PCP feedback surveys, and Medicaid claims between April 2007 and December 2009 for fee-for-service Medicaid children before and after a PAL call. RESULTS Sixty-nine percent of calls were about children with serious emotional disturbances, and 66% of calls were about children taking psychiatric medications. Primary care providers nearly always received new psychosocial treatment advice (87% of calls) and were more likely to receive advice to start rather than stop a medication (46% vs 24% of calls). Primary care provider feedback surveys reported uniformly positive satisfaction with the program. Among Medicaid children, there was significant increases in attention-deficit/hyperactivity disorder and antidepressant medication use after the PAL call but no significant change in reimbursements for mental health medications (P < .05). Children with a history of foster care experienced a 132% increase in outpatient mental health visits after the PAL call (P < .05). CONCLUSIONS Primary care providers used PAL for psychosocial and medication treatment assistance for particularly high-needs children and were satisfied with the service. Furthermore, PAL was associated with increased use of outpatient mental health care for some children.

Second Opinions Improve ADHD Prescribing in a Medicaid-Insured Community Population

OBJECTIVE The appropriate use of psychotropic medications in youths is an important public health concern. In this article, we describe a review process developed to monitor the use of stimulants and atomoxetine for attention-deficit/hyperactivity syndrome (ADHD) in youths receiving fee-for-service Medicaid services. METHOD Washington State Medicaid developed threshold safety parameters for ADHD medications through a process involving the community. A second opinion was mandated when safety thresholds based on dose, combination therapies, or age was exceeded. Use and cost were compared 2 years before and after the program began. RESULTS From May 2006 to April 2008, 5.35% of ADHD prescriptions exceeded safety thresholds, resulting in 1,046 second-opinion reviews. Of those, 538 (51.4%) resulted in a prescription adjustment. Adjustments were made to primary care physician (52%), psychiatrist (50%), nurse practitioner (54%), and physician assistant-written (51%) prescriptions. When the preperiod and postperiod were compared, second opinions reduced ADHD medication at high doses (53%), in combinations (44%), and for patients 5 years of age and younger (23%). The review process resulted in a savings of

Side Effects from Use of One or More Psychiatric Medications in a Population-Based Sample of Children and Adolescents

1.2 million, with 538 fewer patients exceeding safety thresholds. This was a 10:1 return over administrative costs; however, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and the preferential use by clinicians of newer brands entering the market. CONCLUSIONS A statewide second-opinion process reduced outlier ADHD medication prescription practices and was cost-effective. Suggestions for process and quality improvements in prescribing to children diagnosed with ADHD are discussed.

Evaluating Integrated Mental Health Care Programs for Children and Youth

OBJECTIVE The purpose of this study was to investigate the side effect risks from using one or more psychiatric medications (including antipsychotics, antidepressants, α-2 agonists, benzodiazepines, mood stabilizers, and stimulants) among a national cohort of children and adolescents. METHODS A questionnaire survey was administered to parents who filled a prescription for a psychiatric medication for their child at a large national retail pharmacy chain. Primary outcome variables were the total count of side effects from a list of 12 problem areas, as well as parent-reported side effect intensity (mild/moderate/severe). Modifiers investigated included specific medication and number of medications utilized, demographics, and difficulties with access to care. RESULTS A total of 1347 parents of study subjects ages 3-17 years from 30 U.S. states who were taking psychiatric medications for any indication purchased at one retail pharmacy chain enrolled following a single mail invitation (7.5% response). Of the study subjects, 80% were white/non-Hispanic, 64% were male, 63% had private health insurance, and 67% had used a current medication for >1year. Most (84%) had one or more parent-reported side effect. After adjusting for covariates, subjects with two medications reported 17% (p<0.001) and with three or more medications reported 38% (p=0.002) increases in their average number of side effects than did children taking one medication. Parental reporting of difficulties in accessing care also predicted a 42% (p<0.001) greater number of side effects than for those who had no access difficulties. Side effects were particularly more common in medication combinations including either selective serotonin reuptake inhibitors (SSRIs) (77% higher odds, p<0.001) or antipsychotics (99% higher odds, p<0.001). CONCLUSIONS Side effects from psychiatric medications appear to be both more common and more severe overall with increasing numbers of medications utilized, and with perceived difficulty in accessing care. Polypharmacy regimens including either SSRIs or antipsychotics were especially associated with experiencing side effects, within this study sample.

SSRIs for Anxiety and Depression in Children and Adolescents

Evaluations of integrated care programs share many characteristics of evaluations of other complex health system interventions. However, evaluating integrated care for child and adolescent mental health poses special challenges that stem from the broad range of social, emotional, and developmental problems that need to be addressed; the need to integrate care for other family members; and the lack of evidence-based interventions already adapted for primary care settings. Integrated care programs for childrens mental health need to adapt and learn on the fly, so that evaluations may best be viewed through the lens of continuous quality improvement rather than evaluations of fixed programs.

Monitoring Psychiatric Medications in Children

Selective serotonin reuptake inhibitors are the most commonly prescribed medications for pediatric anxiety and depression. Despite widespread use, providers who primarily work with adults can vary widely in their knowledge base about use of this class of medication for children. This article therefore reviews the child-specific indications, side effects, and recommended monitoring parameters that prescribers should know when prescribing this class of medication to young people. Selective serotonin reuptake inhibitors (SSRIs) are once-a-day medications that selectively inhibit the reuptake of serotonin from neuronal synapses in the brain. This selectivity distinguishes them from the older tricyclic antidepressants (TCAs) and certain newer antidepressants such as the serotonin-norepinephrine reuptake inhibitors (SNRIs), both of which are less selective and impact both the serotonin and norepinephSSRIs for Anxiety and Depression in Children and Adolescents

Evaluation and Management of Psychiatric Emergencies in Children

Psychiatric medications can be prescribed effectively and safely in primary care when families receive adequate informed consent; when they learn the key side effects to watch for; and when an appropriate monitoring plan is followed. Toward that end, a brief and practical guide to the safe use of these medications can be valuable. This article presents a general overview of three major classes of psychiatric medications: (attention-defi cit/ hyperactivity disorder [ADHD] medications; selective serotonin reuptake inhibitors [SSRIs]; and antipsychotics) and the informed consent and monitoring steps one should generally follow while prescribing them. Although both common and potentially serious medication side effects are highlighted, not every possible medication side effect is intended to be addressed in this review.

Pediatric Mental Health Disorders

Mental illness among children and adolescents is an increasing burden, projected to become one of the worlds leading disabilities in near future. A dearth of specialized services and personnel to provide optimal care affects the disease burden, prevalence, health care services, and health care costs. The increasing demand weighs down on generalized systems of care such as emergency department (ED) services, in which the lack of specific training, personnel, and specialized protocols tends to prolong length of stay, recidivism, and suboptimal care. This article reviews outcomes and trends of overburdened ED systems in the context of pediatric mental health care management, guidelines of care, and strategies to manage common pediatric mental health emergencies and expand services within the ED. [Pediatr Ann. 2018;47(8):e328-e333.].

Telemedicine for Child Collaborative or Integrated Care

In the United States, 1 in 4 children will experience a functionally impairing mental health disorder.1 Thus, wherever you work in the child health care system, you will regularly encounter children with mental or behavioral health challenges. What each of us does in response to these challenges faced by our patients depends on our workplace setting, our behavioral health knowledge base, and the mental health support systems we have available. In a primary care setting, there has been an increasing acceptance of the role of providing basic supportive behavioral health services. Most mental health medications, for instance, are prescribed by primary care providers rather than by child mental health specialists. However, it is unusual for a primary care setting to be equipped to provide psychotherapy or child behavior management services, which are fairly common recommendations for best practice care. Many efforts are underway to design the delivery of collaborative or integrated behavioral health care in primary care settings, which would bring more supports to primary care settings as they address child mental health challenges. In the meantime, we can keep up with best practice prescribing practices by reading the first article in this issue, “Update on Common Psychiatric Medications for Children,” by Dr. Aditi Sharma. The ways in which we can approach the behavioral health needs of young parents and very young children in our practices have been making several advancements. Developmental brain science has now shown something long suspected—that healthy emotional behavioral and social development in infancy and toddlerhood can yield a lifetime of improved functioning. Supporting the healthy development of young children has long been a core goal of pediatric primary care, which makes the article, “Starting Early: Promoting Emotional and Behavioral Well-Being in Infant and Toddler Well-Child Care,” by Drs. Douglas Russell and Mary Margaret Gleason pertinent to most of us who provide pediatric services. In a medical hospital setting, children may arrive with comorbid behavioral health concerns that affect their treatment or may develop mental health challenges as a reaction to their physical health condition. Anxiety disorders, depression, or just generalized oppositionality may lead to poor adherence to a recommended medical care plan, increased length of stay, and poorer medical outcomes. If this happens in a large tertiary care hospital, then you may have access to a child psychiatry consult service that can visit with the patient and family to help sort out an effective intervention. Without such a consultant available, we are faced with having to sort through these issues in greater detail ourselves and come up with an intervention. In the third article, “Behavioral Health Care for Children Who Are Medically Hospitalized,” Dr. Ian Kodish reviews the common issues and approaches used for behavioral health management for children who are hospitalized. There has unfortunately been a steady increase in families who turn to emergency departments (EDs) for help at times of crisis. The cause of the increase is multifactorial, including limited access to outpatient mental health care services, increases in youth self-harm and suicidality, and increased awareness of behavioral health care needs. EDs can play a useful role in calming down a crisis, giving families time and a safe space for sorting through the next best steps to take, and helping decide the need for inpatient versus outpatient mental health care. Unfortunately, many EDs do not have large or continuous staffing with behavioral health specialists to help emergency physicians and families make the best of an ED visit. The final article, “Evaluation and Management of Psychiatric Emergencies in Children,” by Dr. Cecilia P. Margret and myself discusses common ED evaluation scenarios and some of the intervention approaches that may be taken.

Integrated Care for Pediatric Substance Abuse

Telemedicine with child psychiatry specialists is a useful tool for collaborative and integrated care systems. This article reviews the workforce and care process rationale for using child psychiatric telemedicine for collaborative care, and discusses practical ways to address the technical challenges that arise when using telemedicine. Different systems of using telemedicine discussed include child psychiatry access programs, collaborative and integrated care use of telephone consultations, televideo consultations, and televideo care delivery. Telemedicine can also be used for collaboratively conducted but care review requested by third-party consultations with treatment providers or care teams.