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| PERSPECTIVE/VIEWPOINT |
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| Year : 2022 | Volume
: 4
| Issue : 2 | Page : 78-84 |
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Beyond Shared Care in Child and Adolescent Psychiatry: Collaborative Care and Community Consultations
Vincenzo Di Nicola
Department of Psychiatry and Addiction Medicine, Faculty of Medicine, University of Montreal, Montreal University Institute of Mental Health, Montreal, QC, Canada; Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| Date of Submission | 29-Jun-2022 |
| Date of Decision | 30-Jun-2022 |
| Date of Acceptance | 30-Jun-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Prof. Vincenzo Di Nicola
Department of Psychiatry and Addiction Medicine, Faculty of Medicine, University of Montreal, Montreal University Ianstitute of Mental Health, Montreal, QC, Canada; Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_19_22
Based in the multicultural context of Montreal, Quebec, Canada, this article reviews shared care and collaborative care models which privilege consultations between primary and specialty care in children's mental health. An overview of Canada's two largest child psychiatric epidemiological studies outlines the nonclinical community prevalence in Ontario (18.5%) and Quebec (15%) of children's mental health problems along with salient family and community risk factors. Given the high prevalence of children's mental health problems and the burden of care undertaken by primary care practitioners, the interface between the first line of care and mental health services is crucial yet often characterized by poor communication, a lack of mutual comprehension, and limited collaboration. Collaborative mental health care has been defined as “a family physician or other primary care provider working together with a psychiatrist or other mental health worker in a mutually supportive partnership.” This definition is extended to describe a spectrum of partnerships in child and adolescent psychiatry (CAP): shared care, collaborative care, and related collaborative community practices. The author's experience with these models is presented with an overview of a pilot study on CAP shared care in Montreal. Two other recent trends in Quebec are explored: an innovation called “Medical Specialists Responding in Child and Adolescent Psychiatry” for community mental health-care teams and the pair aidant or “peer helper” model reaching out to patients and families with a member who suffers from mental health problem to serve as a helper, a model, and part of the support network.
Keywords: Children's mental health, collaborative care, community consultations, psychiatric epidemiology, shared care
How to cite this article:
Di Nicola V. Beyond Shared Care in Child and Adolescent Psychiatry: Collaborative Care and Community Consultations. World Soc Psychiatry 2022;4:78-84 |
| Children's Mental Health Services: Access to Care and Mental Health Gaps | |  |
One of the most pressing problems in Canadian health care concerns the access to mental health care for the general population and even more critically for children and youth. This is the territory of the Global Mental Health (GMH) Movement's key notion of mental health gaps, that is, the gap between known mental health problems in the community and access to mental health care.[1],[2] Simply stated in public health terms, our goals should be to improve access to care and to reduce mental health treatment gaps in children's mental health services.
Our Canadian health-care system has responded in the past few decades with a series of innovations and adaptations in the provision of mental health care, starting with shared care and collaborative care (Canadian Collaborative Mental Health Care).[3] This has been both popular and helpful for several reasons. In a context where there are never enough child psychiatrists,[4] “the multiplier effect”[5] expands the outreach of Child and Adolescent Psychiatry (CAP), a medical subspecialty in Canada requiring a minimum of 6 years of postgraduate medical training, first in general psychiatry then in CAP, allowing the transfer of subspecialist knowledge and clinical skills to primary care physicians along with specific advice and supervision for individual cases.
Shared care simply describes the key notion that the health of populations and clinical services from access to care to evidence-based treatment interventions and follow-through services are a shared responsibility.[6],[7],[8] This was just the opening step for an innovative movement in the evolution of a spectrum of services – from shared care and collaborative care to a broader range of collaborative partnerships and practices, including community consultations through the comparatively new role of “Medical Specialists Responding in Child and Adolescent Psychiatry” (MSRCAP) for community mental health teams in Quebec. The goal is for better coordination and where possible integration of primary care with behavioral and mental health services.[9] Ideally, this should start early with the teaching of CAP to family medicine[10] and pediatrics trainees.
Kates,[6] a Canadian leader in shared care, set out the parameters of this approach:
- ”Collaborative mental health care refers to a family physician or other primary care provider working together with a psychiatrist or other mental health worker in a mutually supportive partnership”
- ”The responsibilities of care are shared and apportioned according to the respective skills of the providers and the (changing) treatment needs of the patient”
The key premises for this approach include these salient observations:[6]
- The family doctor or other first-line practitioners play a key role in mental health care
- 25% of individuals seen in general practice have an identifiable psychiatric problem (which is nonetheless not always identified)
- This mental health problem is often anxiety or depression
- The majority of cases are treated by first-line practitioners and are not referred to mental health services.
Complicating matters, the interface between primary care providers and specialized mental health care at all ages, including children and youth, “is characterized by bad communication, a lack of mutual comprehension, and limited collaboration.”[6] Primary care practitioners feel overburdened by clinical demands, do not always feel sufficiently trained or supported, and complain about waiting lists and limited specialized services.
Given the sometimes critical shortage of mental health resources, collaborative partnerships among second-line CAP, first-line children's community mental health services, and primary medical care have become a pressing priority. In this approach, CAPs function as consultants aiding primary care physicians (including pediatricians and family practitioners) to enlarge the range and severity of problems that they can manage. Key factors include rapid and easy access to children's mental health services as they need arises.[6],[11],[12] The Canadian Collaborative Mental Health Care association[3] is very active with an annual conference[13] and offers a Child and Youth Mental Health Toolkit[14] and Child and Youth Mental Health General Screening Questionnaires.[15]
In a study of one specific interface, pediatrician–child psychiatrist partnerships improve access to mental health-care services with a combination of indirect (physician to physician discussions), direct (patient consultations), and follow-through care of patients for more severe cases.[16] This reinforces our approach in CAP deploying the “the multiplier effect.”[5]
The USA has also made significant advances in this area, notably in the partnership between Pediatrics and CAP.[17] The formation of the National Network of Child Psychiatry Access Programs[18] in 2011 and the Massachusetts Child Psychiatry Access Project[19] along with the Washington State model[20] with their Integrated Care Training Program at the University of Washington[21] are proven and effective models of collaboration in children's mental health care.
| The Global Burden of Care: Child Psychiatric Epidemiology | | |
To put the needs of children's mental health care in context, we need to understand the global burden of care that they represent by studying nonclinical community samples. North American and worldwide comparisons in child psychiatric epidemiology are based on populational surveys of 6–14-year-old children, documenting retrospective 6-month community prevalence rates of children's mental disorders. The Isle of Wight surveys undertaken in Britain in the mid-1960s created the conceptual apparatus and methodology for these studies whose principal investigator offered a 25-year review of the advances in children's psychiatric epidemiology.[22] The worldwide average of these studies demonstrates that about 20% of children are affected by mental health problems, broadly defined (not necessarily DSM/ICD psychiatric diagnoses). Prevalence rates vary between 17.6% and 22% of child psychiatric disorders in nonclinical community samples of children and adolescents.[23]
Pioneering child psychiatric epidemiological studies have been conducted in Canada's two largest provinces.
The Ontario Child Health Study (OCHS) conducted at McMaster University in the 1980s established that 18.5% of children 6–14 years in Ontario were affected with a definable mental health problem in the preceding 6 months.[23],[24] Follow-up studies revealed important changes in the profiles of children's mental problems in Ontario. In the two decades between 1983 and 2014, studies revealed:[24]
- Dramatic jump of boys 4–11 with attention-deficit hyperactivity disorder (ADHD)
- Teens saw a steep increase in anxiety and depression in boys and girls
- Substantial drop in the prevalence of conduct disorder among boys
- Among immigrants: 50% drop in prevalence of children's disorders
- Strong evidence that poverty increases the risk for childhood disorder in combination with contextual factors such as neighborhood antisocial behavior
- Geographic shift in prevalence from large urban areas to small-medium urban and rural areas.
Finally, in a component study of access to children's mental health services in Ontario, the proportion of the children's population served increased, but most remained without contact with mental health services.[24]
The Quebec Child Mental Health Survey (QCMHS), conducted a decade later by the child epidemiological research team at the University of Montreal, adapted the research methodology.[25] Previous studies focused more on socioeconomic and sociodemographic characteristics than on family characteristics. The Quebec investigators noted that there were no accepted methods to analyze and interpret the correlates of community studies so the goals of the study were:[25]
- To identify correlates of DSM-III-R internalizing and externalizing disorders according to informant (youth, parent, and teacher), for three age groups (6–8, 9–11, and 12–14 years), including relevant family characteristics
- To interpret the relative importance of risk indicators by ranking correlates according to strength and consistency of association across age groups
The QCMHS results revealed:[25]
- The overall Quebec population shows 15% prevalence of mental health problems in children aged 6–14 years
- This contrasts with an alarming rate of 60% in the substudy of a disadvantaged neighborhood (Hochelaga–Maisonneuve)
- Inconsistency of correlates across informants
- Individual and family characteristics make a more important contribution than do socioeconomic characteristics.
In conclusion, the QCMHS demonstrates the relevance of “proximal variables” (or more psychological factors such as family characteristics) in the development of children's psychopathology, also found in the OCHS.[26] The substudy of a disadvantaged neighborhood in Montreal offers a complex portrait of the negative impacts of Adverse Childhood Events (ACE)[27],[28] and the Social Determinants of Health and Mental Health (SDH/MH)[1],[29] with an alarming four-fold increase of problems (60%) over the provincial average (15%).
In light of the larger findings of the QCMHS that demonstrated the important contribution of individual and family aspects, we undertook a more detailed analysis of single-parent families in the substudy population, to test the hypothesis that single-parenthood increased the risks for children's mental health. Our substudy analysis of single-parent families offers a complex portrait of the negative impacts of ACE and SDH/MH, revealing that:
- SDH/MH are multifactorial and multigenerational
- Affecting both more intimate family attachments and broader social belonging
- Echoing the results of the OCHS.[26]
Informed by ACE, SDH/MH, and QCMHS studies, all children's services must address more complex and subtle social determinants affecting children's lives and reach behind the populational parameters to engage the “narrative resources” that developmental psychologist Jerome Bruner identified.[30] Narrative resources are rich and nourishing when present, yet lead to the impoverishment of affective and social capacities throughout the lifecycle when absent.
Mental health treatment gaps
The WHO Commission on Social Determinants of Health (CSDH) study[1],[31] and the associated literature on GMH reveals significant mental health treatment gaps, that is the gap between known mental health problems in the population and access to care.[2] The WHO has made concrete and specific recommendations to reduce the treatment gaps.[31] The spectrum of services under the rubric of Shared Care and Collaborative Practices can alleviate the treatment gap by multiplying the impact of scarce resources. Related transdisciplinary practices may also be very helpful especially in low- and middle-income countries (LMICs). In Brazil, for example, the integrative community therapy model is a low-cost, low-tech community approach that reaches hundreds, even thousands of people with mental health problems using comparatively few professional resources.[32]
| Hôpital Maisonneuve-Rosemont Pilot Study of Shared Care in Child and Adolescent Psychiatry: Outline and Satisfaction Survey | | |
At the Child Psychiatry Service of the Hôpital Maisonneuve-Rosemont affiliated with the University of Montreal, we developed a pilot study in 2006 to expand outpatient child psychiatry consultations in pediatrics to an extended network of community-based primary care pediatricians and family practitioners caring for children and adolescents. We established clear definitions of our pilot project that limited the CAP consultation to a key medical question to be answered in a single session with rapid access and feedback to the primary care practitioner in our catchment area in Montreal east within a delay of 3 days backed up by telephone follow-up as needed. A social worker acted as intake and liaison worker.
In the first phase, a needs assessment was undertaken with key stakeholders by questionnaire and focus-group follow-ups with administrators and clinicians. The primary care physicians (pediatricians and family physicians) identified their priorities and needs:
- Rapid access to a CAP consultation for diagnosis and treatment recommendations
- Clarify their role as primary care physicians and what to expect from shared care
- Psychopharmacology expertise
- Better understanding of “complex cases” – chronicity, comorbidity, and severity
- Identify difficult to serve and refractory cases and recommend other interventions.
We then created an intake form and process to ensure rapid access to the CAP shared care service. Time slots were reserved specifically for CAP shared care consultations which are also teaching clinics for medical students and residents in psychiatry. An extensive campaign was undertaken to promote the new service which rapidly grew in popularity. The social worker who acted as liaison with primary care physicians ensured ongoing updates and refinements of the process and together we conducted a survey about the level of satisfaction with the CAP shared care service.[33] The pilot study identified the consultation requests received in a 3-month period (36 cases of 48 seen), examining such parameters as age, diagnosis, and orientation after the consultation [Table 1], [Table 2], [Table 3].
The recommendations that flowed from this pilot study included:
- Focusing on ADHD, the most common reason for referrals
- Referral mechanisms were clarified and simplified with a structured intake form
- Clarification of the roles of the teams in CAP, pediatrics, and family medicine for follow-through care
- Continual evaluation of the intake form and process
- Consider expanding the shared care consultation to primary care physicians in the community
We did follow-through studies each year for the next 5 years, which showed a steady increase in service utilization and a high level of satisfaction of both the referring physicians (100% on most parameters, including rapid access and response; 92% for diagnosis; and somewhat lower for recommendations at 71%) as well as the young patients and their families (over 90%). The CAP shared care service was then expanded to all the primary care physicians in the entire catchment area of more than 100,000 youth (up to 18 years of age) in Montreal east.
| Beyond Shared Care: Innovations in Health Care | | |
In related innovations in health care, we have employed the notion of the “patient partner” in the Faculty of Medicine at the University of Montreal.[34] In this approach, patients and their significant others become partners in their own care. This includes partners, spouses, and family members for patients of all ages. This extended network can become an integral part of the treatment team.[35]
The next step in this approach is the “peer helper” or pair aidant in French. The “peer help mediator” becomes a bridge between patients, their families, and the health and social care services. Their presence as mediators improves the patient–therapist relationship and enhances the patient's recovery.[36]
The Province of Quebec has recognized the practice of MSRCAP for community mental health teams for the last dozen years. I have been doing it for 35 years as a community child psychiatrist for which I recently won recognition from the Canadian Academy of Child and Adolescent Psychiatry (CACAP) with the Naomi Rae-Grant Award (2021) for community child psychiatry. This extends the role of consultant from individual providers to entire community mental health teams, offering direct and indirect consultations, peer supervision, and knowledge transfer and team building.
Continuum of collaborative care
We can place these innovations on a “spectrum of care” or a “continuum of collaborative practices.” We start with the traditional medical terms of first-line care (generalist or family physician and first-line psychosocial services) and second-line care (specialty and subspecialty medical services), then we can add Shared Care Consultations and MSRCAP in between them to create bridges, enhancing communication among health-care providers and improving access to care in children's mental health. Doherty[11] calls for a “continuum of collaboration” based on the level of physical integration of services [Figure 1].
In this conceptual model, the organization of service providers range from the traditional (separate but equal partners), to coordinated care (consultations and greater communication), to colocation with either partner visiting the other (as in a CAP doing onsite visits to a pediatric clinic or a pediatrician working at a CAP clinic), and finally, integrated care where both health-care services work together in a collaborative way in the same physical environment.[11] Another way to organize services uses the Four Quadrant Clinical Integration Model[9] in which services are organized according to greater risk in physical versus behavioral or psychiatric health risk and status [Figure 2].
| Conclusions | | |
There are not enough psychiatric specialists and subspecialists in any country, even in an advantaged and progressive country with national health care like Canada, but the issues of access to mental health care in both general and child psychiatry are especially acute in LMICs and the Global South,[37],[38] prompting the Royal College of Psychiatrists (UK) to publish manuals to guide primary care practitioners[4],[39] in those health-care systems.
We must employ ways to “multiply” our impact through indirect consultations to other physicians, mental health professionals, and responding to community health and social care teams to reach more of the population. This increases not only our reach but our effectiveness and level of mutual satisfaction.[5],[40] The ultimate goal is a better integration of psychiatry and child psychiatry with primary medical care.[9],[41]
This is a GMH issue[42] whose slogan, “No health without mental health,”[43] is acutely felt in children's mental health at all levels, from the study of mental health gaps[1],[2],[37] to the provision of care and mentoring trainees for the next generation in the delivery of ever-more responsive clinical models of children's mental health care.[5],[10],[44] It reflects the clinical salience of the SDH/MH,[1],[29] along with the powerful populational data of the ACE study.[28],[29]
While this is relevant and helpful in Canada, it is crucial for the LMICs of the Global South.[37],[38] Furthermore, collaborative care practices must be promoted as low-tech practical clinical tools for the social psychiatrist and a key plank in the platform of 21st century social psychiatry.[45]
Acknowledgments
The author gratefully acknowledges the valuable collaboration of Francyne Brosseau, MSW, in the pilot project and study of Shared Care in Family Medicine and Paediatrics with the research support of the Department of Psychiatry, Hôpital Maisonneuve-Rosement. The author conducted an analysis of the substudy of the QCMHS focusing on single-parent families in a disadvantaged neighborhood of Montreal with Lise Bergeron, PhD, and her associates at the Hôpital Rivières-des-Prairies, affiliated with the Faculty of Medicine, University of Montreal. In 2021, the author was given the Naomi Rae-Grant Award by the CACAP in recognition of his work in collaborative community child psychiatry
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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