The ABC’s of Mental health Assessment and Treatment in Primary Care James M Wallace MD Child and Adolescent Psychiatrist University of Rochester CAPPC/Project TEACH

Why Care About Mental Health Issues? For the first time in 50 years, the top 5 reasons for childhood disability are mental health related, far surpassing the impact of physical problems (Slomski 2012).

Who is treating them? 1/5 have onset of some Mental Illness before age 18 1/5 of these get MH services by a MH provider Therefor, 4/5 receive services from Primary Care Provider and School only

Where are the Child and Adolescent Psychiatrists? Child and Adolescent Psychiatry is the top medical manpower shortage in the US The current supply meets 25% of the estimated need The number of trainees does not outnumber the pending retirees CAP is the only specialty where a fellowship decreases income (non-billable services)

Who Takes Care of all the Childhood Mental Health Issues? Currently, primary care providers (PCPs) prescribe the vast majority, about 85%, of the psychiatric medications prescribed in the pediatric population (Pidano 2012).

So Where Do We Start? Assessment for the psychiatric problems of childhood relies on clinical interviewing skills and the use of evidence-based screening tools Having a standard approach decreases provider stress and burn out and increases accuracy and efficiency

Chief Complaint and History of the Present Illness Psychiatric symptoms should be systematically explored just any medical symptoms C haracteristics O nset L ocation D uration E xacerbation R elief

Review of Systems Many psychiatric symptoms and disorders are comorbid with medical (pain, asthma, sleep problems, headaches, GI distress) and other psychiatric problems (anxiety, depression, LD) It helps to know common comorbid patterns (anxiety and depression, ADHD and ODD, pain and anxiety, chronic illness and anxiety/depression)

Physical Exam It is useful to ask about psychiatric symptoms during physical exam (ear exam and “voices”, listen to breath sounds and ask about panic symptoms, palpate belly and ask about butterflies, loss of appetite), look at left forearm!! Observing for mental status information is the psychiatric physical exam (mood, hygiene, relatedness, eye contact, language, anxiety, insight, activity level, tics, etc.)

Lab Results Very few lab tests generate information about psychiatric problems unless there is also a medical basis for the test Evidence-based screening tools often are our lab tests and generate critical information to support a diagnosis or narrow the differential diagnosis

What Screening Tools Should I Use? ADHD – Vanderbilt Behavioral Checklist parent, teacher, child Anxiety – SCARED Depression – PHQ9, Columbia Depression Rating Scale (CDRS) OCD – Yale Brown Obsessive Compulsive Scale Aggression – Manifest Overt Aggression Scale (MOAS)

Where Do I Find These Scales? Free, Public Domain, Validated CAPPCNY.ORG website has them all and more They are becoming the standard of practice and are endorsed by AAP, AAFP There are billing codes and reimbursement for these in many areas

Differential Diagnosis Clinical observations, exploration of nature and history of presenting symptoms and comorbid symptoms, physical exam, mental status observations and screening tool results generate and narrow the differential diagnosis Relax, it is often necessary to have a return appointment (s) to complete the assessment before planning treatment

Treatment Planning Ongoing safety assessment should be part every plan Engagement and education of family and child is a crucial first step in treatment Bemoaning unavailable services is not a plan Being familiar with local providers, schools and agencies is necessary

Treatment Planning Creating treatment templates that can be individualized for common psychiatric diagnosis allows provider to be clear and succinct The main priorities can vary ADHD = VDB scales and meds Anxiety/Depression = CBT therapy +/- meds Aggression = Family work, ? comorbidity

Connecting to Consultants Available phone consultation – TEACH/CAPPC (M-Th 8-7, F 8-5) Local resources – Crisis services, in home services, wraparound services, CMHC, private practitioners School resources – MH providers in the schools, special education, grief counseling, preventative and early intervention

Augment Your Training CAPPCNY.org website has archives of many trainings Project Teach/CAPPC offers one and two hour trainings and webinars, quarterly newsletter, four hour workshops and a hours intensive course on MH Issues in Primary Care. All offer free CME through the project grant.

Summary The childhood burden illness for MH Issues is growing and resources for treating them are spotty at best in many communities Most MH Issues (mild to moderate) are (and should) treated by the school and Primary Care Provider Augmenting your training and using live or phone consultation services can improve MH services within Primary Care settings