Universal anxiety screening in youth sets stage for PCPs to integrate behavioral health

In October, the U.S. Preventive Services Task Force released a final recommendation advocating for anxiety screening in asymptomatic youth aged 8 to 18 years and major depressive disorder screening in asymptomatic youth aged 12 to 18 years.

It is the first time that the task force has recommended universal screening for anxiety in youth.

The recommendations coincide with a push from the AMA and several other leading medical organizations to integrate behavioral health services in primary care settings.

According to Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, president of the American Academy of Family Physicians (AAFP), family medicine physicians have the clinical resources to provide certain mental health services, but under current payment models in the United States, they are seldom reimbursed for this.

“We may not be getting paid for it, but we’re doing them,” she said.

Healio spoke with Iroku-Malize and other experts about the role of family medicine physicians in addressing mental health in children, what efforts are needed to support them and how behavioral health integration may reshape the U.S. health care system.

The mental health crisis in children

Last year, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Associations joined other pediatric societies in declaring a national emergency over the “worsening crisis in child and adolescent mental health,” which has been exacerbated by COVID-19.

An HHS study published in JAMA Pediatrics found that from 2016 to 2020, there was a 7.1% to 9.2% increase in anxiety and a 3.1% to 4% increase in depression among 174,551 children and adolescents aged 0 to 17 years. In addition, researchers reported increases in child behavioral or conduct problems (6.7% to 8.1%) and decreases in preventive medical visits (81% to 74.1%) from 2019 to 2020.

In the early days of the pandemic, there was no apparent increase in the number of young patients seeking mental health treatment since most clinics were closed, according to Tami Benton, MD, psychiatrist-in-chief, executive director and chair of the department of child and adolescent psychiatry and behavioral sciences at the Children’s Hospital of Philadelphia.

“We very quickly switched to telehealth. Then we started to see more kids coming in with worsening depression and anxiety,” she told Healio.

Benton and May Lau, MD, MPH, FSAHM, FAAP, an associate professor of pediatrics at UT Southwestern Medical Center, both attributed worsening mental health to disruptions in school and normal routines. Lau also pointed to societal issues like racism, oppression and violence as further causes.

“I think it all adds up. Some youth are more resilient and can move from one situation to another seamlessly, while others are more affected,” she told Healio.

As a result, Benton said that physicians saw an uptick in mental health-related ED visits, which according to MMWR data increased by 24% in children aged 5 to 11 years and 31% in adolescents aged 12 to 17 years from 2019 to 2020.

These patients were more often presenting to the ED with suicidality, suicidal thinking, depression, self-injurious behavior and panic, Benton said.

“Where we are now is that we’re getting an increased number of young people who are seeking mental health treatment,” she said. “Those rates haven’t started to go down as we’ve moved through the pandemic. We’re still seeing the same things and trying to get a handle on what’s happening.”

‘Sounding the alarms’: AAP’s push for universal screening

The USPSTF’s recent recommendations proceed long-running efforts by AAP to advocate for universal mental health screening and recent efforts to promote suicide screening.

After the task force issued its draft recommendations earlier this year, the AAP — noting it was “sounding the alarms” on these issues — urged clinicians to screen adolescents for suicide regardless of risk status, despite USPSTF concluding that more research is needed to assess the harms and benefits.

“By screening all youth for suicide, we can identify those that are at risk and connect them with the services they need,” Lau said in the release.

In its own draft guidance, the AAP recommended universal suicide risk screening for youth aged 12 years and older, as well as those aged 8 to 11 years when clinically indicated.

Lau said that the AAP’s policies advise universal depression screening for adolescents aged 12 years and older, aligning with the USPSTF’s guidelines.

“For anxiety, we also recommend anxiety screening as part of the standard behavioral, social, emotional screening during the adolescent preventive health care visits,” she said.

Behavioral health integration

Iroku-Malize and Yalda Jabbarpour, MD, medical director of the AAFP’s Robert Graham Center for Policy Studies in Washington, D.C., told Healio they are confident that family medicine and general providers are well-equipped to address behavioral health issues in children.

Family medicine, according to Iroku-Malize, provides services for almost a third of all serious mental health issues and a quarter of prescriptions for those illnesses. As part of training in family medicine, Iroku-Malize said “we have continuous medical education with AAFP so that all of our physicians can avail themselves of various modalities to address behavioral health.”

That training includes interprofessional experience, highlighted by Jabbarpour as a valuable resource for ensuring smoother transitions of integrated practices.

“It’s not only that we are very well trained to handle mental and behavioral health issues, but in many residences, we work hand-in-hand with a behavioral health specialist,” she said.

Trust — part of a physician’s repertoire with patients — can also factor in. Iroku-Malize said this is apparent in a National Mental Health Association survey, in which 72% of diagnosed patients and 61% of undiagnosed but symptomatic patients said they wanted their PCP to be more involved in their mental health treatment.

“That continuity of care, the relationship between the patient and the physician, lends itself to our ability to handle behavioral health issues within our practices and to work with others,” she said.

Despite this, there are barriers to providing mental health services in primary care. One limitation that family medicine and general practitioners consistently face is the lack of treatments they can offer, Benton said. They often are only able to access pharmacological treatments for certain conditions instead of services like psychotherapy, “the treatment of choice” for most diagnoses, according to Benton. Physicians, she added, should understand which situations warrant referrals to mental health specialists who may be able to better address conditions.

"I believe once you start getting into situations where people are not responding to the standard treatments and are expressing worsening symptoms or suicidal or self-injurious behavior, it’s really important to make sure that you refer that individual for a higher level of care,” Benton said. “It would be important for primary care clinicians to have protocols to help them decide when to do that.”

However, mental health specialists are not always needed either, Benton pointed out.

“You don’t need a psychiatrist for every person who has anxiety or depression,” she said. “What you really need are people who can provide brief psychosocial interventions in partnership with our colleagues and other medical specialties who can provide some of the medication treatments for mental health conditions.”

Initiating mental health conversations

Integrating behavioral health in practice will require family medicine and general practitioners to initiate the conversation about mental health.

According to a national survey conducted by the genomic company Myriad Genetics, 83% of physicians wish their patients would talk to them about mental health. However, more than half of PCPs said they wait to discuss mental health such as depression and anxiety until the patient raises a concern. In addition, one in four patients reported that their PCP has never screened them for depression.

Young patients may be more adept at hiding their emotions, according to Lau. Therefore, she said the AAP advocates for physicians “to take time to speak with the adolescents alone, because they may feel more comfortable expressing their feelings or concerns regarding mental health.”

Since the start of the pandemic, Benton said there have been a lot more conversations on a national level around mental health, “not just the things that we’re dealing with related to COVID itself, but the mental health impacts of COVID.” Mental health discussions and screenings, she added, should be approached “from a health and well-being perspective.”

“This is preventive, right? Identifying anxiety, depression and even suicidal thinking early on can prevent worse outcomes down the road and they don’t all require a mental health professional to address,” Benton said.

Resources and costs

When making its recommendations, the USPSTF does not consider coverage and costs “in assigning grades to preventive services,” according to its website. But since the recommendations for anxiety and major depressive disorder screening received a B grade, these services should be covered by most private insurance plans with no copay. Ultimately, “coverage decisions are determined by payors and policymakers,” the USPSTF site said.

Still, integrating behavioral health into primary care will require human and physical resources that are not necessarily reimbursed under the fee-for-service model, Jabbapour said. In her own research, Jabbapour found that a more blended model that incorporates fee-for-service, value-based care and other payment methods was “one of the things a lot of the practices we talk to said was necessary.”

According to Iroku-Malize, this blended approach is one that the AAFP continues to advocate for allowing physicians to be part of this process regardless of whether they practice in collocated sites or independently.

“We have been pushing Congress to pass legislation on this, which will establish some Medicare add-ons and codes for primary care physicians to allow for that integrated behavioral health service to be provided,” she said.

These legislations highlighted by Iroku-Malize include:

• the Collaborate in an Orderly and Cohesive Act, a bipartisan bill that would provide grants to practices implementing behavioral health; and
• the Children’s Mental Health Access Act, which would reauthorize Pediatric Mental Health Care Access — a program that offers behavioral health consultation, training and support to pediatric primary care providers — for 5 years while expanding it to all states.

Timeline for behavioral health integration

The timeline of universal behavioral health integration is difficult to project. Iroku-Malize noted that it depends on when Congress will pass legislation on models that support integration.

“We may not have the payment model changed just yet, but if we can at least get legislations started, it would help to enhance that,” she said. “In terms of continuing medical education and the tools to help our physicians stay educated and up-to-date, we have that right now.”

However, physicians will not sit idly waiting for resources and legislation to come into play.

“We need those resources, but independent of that, family physicians are going to continue to do what's best for their patients. Integrated behavioral health works, we know it works,” Jabbarpour said.

In an ideal world, Iroku-Malize said there will be a number of integrated models.

“Even in my own office, I have some practices where I have a psychiatrist embedded in the practice, and some sites I have a social worker who comes in. The primary care and family doctors are in one building and the psychiatrist in another building, but they share notes as needed.”

Regardless of the model, behavioral health integration “is how it’s going to be going forward,” Iroku-Malize said.

“We have to address the mental health issue. It’s very important,” she said. “This is affecting a lot of people in our communities, especially since the pandemic. A lot of younger members of our communities — the young adults, the adolescents — we've seen a spike in that. I think this is going to be how primary care is done in the future, that it’s going to absolutely be integrated.”

References:

AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/. Accessed Nov. 15, 2022.

AAP urges suicide screening despite USPSTF call for more research. https://publications.aap.org/aapnews/news/19948/AAP-urges-suicide-screening-despite-USPSTF-call?autologincheck=redirected?nfToken=00000000-0000-0000-0000-000000000000. Published April 12, 2022. Accessed Nov. 21, 2022.

Lebrun-Harris L, et al. JAMA Pediatr. 2022;doi:10.1001/jamapediatrics.2022.0056.

Leeb R, et al. MMWR Morb Mortal Wkly Rep. 2020;doi:10.15585/mmwr.mm6945a3.

Mangione CM, et al. JAMA. 2022;doi:10.1001/jama.2022.16936.

Mangione CM, et al. JAMA. 2022;doi:10.1001/jama.2022.16936.

Screening for suicide risk in clinical practice. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/screening-for-suicide-risk-in-clinical-practice/. Accessed Nov. 22, 2022.

Survey reveals primary care providers want more patients to talk to them about mental health. http://genesight.multimedia-newsroom.com/index.php/2022/11/17/survey-reveals-primary-care-providers-want-more-patients-to-talk-to-them-about-mental-health/. Published Nov. 17, 2022. Accessed Nov. 17, 2022.

USPSTF: Who we are & how we work. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/uspstf-briefing-packet-20118.pdf. Accessed. Dec. 27, 2022.