Severity of mental health concerns in pediatric primary care and the role of child psychiatry access programs

Objective: To describe the clinical severity of patients for whom Primary Care Providers (PCPs) requested consultation from Maryland's Child Psychiatry Access Program (CPAP), and examine the proportion and associated characteristics of severe cases being managed alone by PCPs versus co-managed with mental health specialists. Methods: Data were collected for 872 cases based on calls received between October 2012 and December 2016. Severity was measured by consultant-assigned Clinical Global Impression-Severity (CGI-S) score. The unadjusted odds of a PCP managing a case alone for select patient and provider characteristics was calculated in a sub-sample of 229 severe cases. Results: 73.8% of cases were categorized as mild-moderate (CGI-S 1–4) and 26.3% as severe (CGI-S 5–7). 67.3% of severe cases were managed by a PCP alone; 32.8% were co-managed. The unadjusted odds of a severe case managed alone was lower for cases with greater numbers of psychotropic medications (OR 0.76, 95% CI 0.6, 0.96), prescription of antidepressants (OR 0.51, 95% CI 0.28, 0.95), or antipsychotics (OR 0.45, 95% CI 0.22, 0.94) compared to co-managed cases. Conclusions: PCPs manage patients with severe mental health concerns, often without assistance from specialists. CPAPs should systematically consider how to support the PCPs’ role managing clinically severe cases.