Researchers call for child mental health ‘shared care model’

Anastasia Tsirtsakis

11/11/2020 4:28:25 PM

Experts say better integrating GPs could help address extensive wait times for costly private mental health support.

Child talking to GP
A number of psychologists and psychiatrists do not offer services to children aged 12 and younger, the study found.

One in seven.
That is the number of Australian children aged four to 17 that met the criteria for a mental health disorder in 2013–14. Yet only half had accessed mental health services.
With just 3% of child and adolescent cases managed by the public health system, the majority of care in Australia is delivered privately.
But new research has provided the first objective local data on the extent of wait times and substantial out-of-pocket costs families face in seeking that care.
Led by the Murdoch Children’s Research Institute (MCRI), researchers used a ‘secret shopper’ approach to pose as a parent seeking an appointment for their child with anxiety or attention deficit hyperactivity disorder (ADHD) – the two most common child mental health issues – at 317 private practices across Victoria and South Australia.
Conducted between 12 March and 5 May 2019, the average wait time was 44 days for paediatricians, 41 days for psychiatrists, and 34 days for psychologists. Only 43% could offer an appointment with the requested clinician.
A third of practices were closed to new referrals.
Meanwhile, average out-of-pocket costs for an initial appointment were $120 for paediatricians, $176 for psychiatrists, and $85 for psychologists.
Study co-author, paediatrician Professor Harriet Hiscock, told newsGP the findings are particularly concerning given the projected mental health impacts of the pandemic.
‘This was pre-COVID, [so] these things are going to worsen. We’re going to see longer wait times and potentially higher out-of-pocket costs,’ she said.
‘For families who can’t afford this, they go to the public mental health care system where wait times can be … potentially even longer.
‘We’ve [already] seen a side effect of this with increased mental health presentations to Victorian emergency departments for those under the age of 17 during the COVID pandemic, at a time when all other presentations largely dropped.’
RACGP Specific Interests Child and Young Person’s Health network Chair Dr James Best told newsGP the findings, while concerning, only confirm what many GPs already know of the very limited options available.
‘Children and adolescents with mental health problems are often under recognised in the first place, and when they are recognised, nearly always, the management is left down to the GP,’ he said.
‘The current situation is crisis-only in the public system and, even then, poorly available. This is a huge area of need, and I’ve said it before that I think it’s a disgrace, and I’ll say it again.’
In addition to having too many current patients, the main reason cited by psychologists and psychiatrists for not being able to offer an appointment was that they do not offer services to children aged 12 and younger.
‘For kids under the age of 12 there’s a big gap, and that’s where the problems often start,’ Professor Hiscock said.
‘If they don’t get the care they need, they progress and then someone goes, “Oh, I’ve got a teenager who’s depressed and suicidal”.
‘Well, they don’t wake up with that. That usually started in primary school for that kid.’
Given than mental health disorders are more prevalent in rural and lower socioeconomic areas, the study highlights the need for a larger and more equitably distributed child mental health workforce to ensure children receive the care they need. 
In addition to salaried clinicians and added incentives for medical students to complete specialist training in child psychiatry, Professor Hiscock and her colleagues also propose a shared care model, such as Project ECHO.
Currently being piloted in Queensland for children with ADHD, with initial promising results, GPs would work with child mental health specialists to co-manage children with mental health problems.
‘That’s a model that we need to be thinking about,’ Professor Hiscock said.
‘It originally came from the States and there are Project ECHO groups cropping up around Australia in different disease areas or groups.
‘They run monthly and the first 15 minutes might be some formal education for GPs on a certain topic like how to manage bullying in kids, for example. Then the next 45 minutes is case discussions where the GP typically presents the case and then gets expert input from those different disciplines about how to manage the kid.
‘So everyone starts to learn from each other.
‘They’ve done qualitative work with the GPs [in Queensland] who report that it’s really beneficial to their practice and really given them confidence in managing it [ADHD].’
Dr Best is an advocate for the shared care model.
‘[It] just makes sense because at the moment it’s being left down to the GP anyway,’ he said.  
‘So the GPs are already prepared to try and help out in this space. But there needs to be funding because at the moment there is no funding, so it just doesn’t happen or [it does happen, but] in a very limited way.’
Professor Hiscock agrees.
‘You need to be properly remunerated for this work because it’s usually more complex than physical health problems, and should really involve interaction with other providers,’ she said.
‘I know the Productivity Commission was looking at item numbers for GP psychiatry consults, which is a start. But that’s missing out on the paediatricians and psychologists.’
With the pandemic already increasing demand on mental health services, both Dr Best and Professor Hiscock hope the research will lead to governmental action.
‘Developing and testing new care models that upskill our existing workforces should be a priority,’ Professor Hiscock said.
‘Especially as mental distress has risen sharply for children and adolescents during the COVID-19 pandemic. [W]e expect children to continue presenting with COVID-related mental health issues for some time, even as restrictions are eased.’
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