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Increasing Access to Psychiatric Services in Schools

The Bridge Program

CHO, EVELYN, MA; HERMAN, KEITH C., PhD; SALAU, MUSKINNI, MD; YOUNG-WALKER, LAINE, MD

Journal of Psychiatric Practice®: May 2019 - Volume 25 - Issue 3 - p 227–236
doi: 10.1097/PRA.0000000000000381
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One in 5 youth experience a psychiatric disorder in any given year, but fewer than half of these youth receive mental health services. This lack of service utilization is often attributed to structural and perceptual barriers, and school-based mental health programs have been proposed as a means of addressing these barriers and increasing youths’ access to services. While universal prevention programs and targeted treatments may benefit most youth receiving services in schools, collaborations between schools and child psychiatry may benefit youth with the most severe symptoms and the greatest impairment. This article describes the Bridge Program, a school-based psychiatric program funded by a county-wide mental health tax initiative designed to provide psychiatric services in local schools without any out-of-pocket expenses for youth and families within 10 days of referral. Two case reports provide a description of the delivery of psychiatric services through the Bridge Program. Future research is needed to compare the feasibility and effectiveness of different approaches to increasing access to youth psychiatric care.

CHO: Department of Psychological Sciences, University of Missouri, Columbia, MO

HERMAN: Department of Educational, School & Counseling Psychology, University of Missouri, Columbia, MO

SALAU: Department of Psychiatry, School of Medicine, University of Missouri and Compass Health Network, Columbia, MO

YOUNG-WALKER: Department of Psychiatry, School of Medicine, University of Missouri, Columbia, MO

This project was funded by the Boone County Children’s Services Fund. Permission was obtained from the families involved to present these case descriptions.

The authors declare no conflicts of interest.

Please send correspondence to: Evelyn Cho, MA, Department of Psychological Sciences, 210 McAlester Hall, University of Missouri, Columbia, MO 65211 (e-mail: ecy78@mail.missouri.edu).

While 1 in 5 youth experience mental illness, only a minority of youth with mental health needs receive services.1,2 Fewer than half of youth with psychiatric disorders in the past year3 and a third of youth with a lifetime psychiatric disorder1 access mental health services, suggesting that service utilization may not parallel need. Lack of service utilization has been attributed to several barriers, both structural (eg, shortage of providers, long waitlists) and perceptual (eg, perceptions about psychiatric disorders and their treatment).4 In this article, we (1) highlight several barriers to accessing psychiatric treatment that informed the development of the Bridge Program; (2) describe alternate treatment approaches designed to address unmet need; (3) introduce the Bridge Program, an innovative school-based psychiatry program that aims to address common barriers to care; and (4) present 2 case examples to illustrate how the Bridge Program addresses unmet need.

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BARRIERS TO CARE

Attitudinal Barriers

Identification of mental health problems in youth is one major barrier to youths’ access to timely mental health care.5 Because youth often rely on their caregivers to access mental health services, caregivers’ perceptions and beliefs about mental health problems and treatment are critical to the identification of potential mental health issues and utilization of services.6,7 In a study of parents who reported that their children needed but did not receive mental health services in the past year, parents were asked, using the Services Assessment for Children and Adolescents Parent Report, what they perceived to be barriers to their accessing care in the past year: 25.9% reported barriers related to perceptions of mental health services (eg, “thought treatment would not help”), 23.3% reported barriers related to perceptions about mental health problems (eg, “thought problem not serious,” “decided to handle problems on own”), and 20.7% reported structural barriers (eg, transportation, cost of services).4 Parent perception of need for services predicts youth service utilization,8 and perceptions that youths’ mental health issues are not serious or do not warrant services may hinder identification of mental health problems and their treatment.

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Knowledge Barriers

Even when parents are aware of youths’ mental health problems and are inclined to seek treatment, they may have difficulties navigating the mental health system. Lack of information about appropriate and available mental health services is a commonly reported barrier to youths’ accessing care. For example, parents of youth with mental health needs in rural Ontario reported that not knowing what mental health services are available is a major barrier to accessing care,9 and “not knowing where to go” is often one of the most frequently cited barriers to accessing needed care.4,10 Conversely, caregivers who are provided with multiple options (eg, 1 study reported that 300 families were offered >2000 services over the course of a year11) may have difficulty deciding on the most appropriate treatment. Without information on what services are available and most appropriate, and where and how to access these services, parents may lack guidance in making decisions for their youth’s mental health concerns which may ultimately delay timely care.

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Provider Shortage

While the previous barriers apply broadly to mental health services regardless of sector and specialty, provider availability is a particularly pronounced obstacle for youths’ access to psychiatric care due to a workforce shortage of child and adolescent psychiatrists (CAPs) in the United States.12 In 2006, Thomas and Holzer13 reported a national mean of 8.7 CAPs per 100,000 youth, but estimates varied greatly across states (ranging from 3.1 CAPs in Alaska to 21.3 CAPs in Massachusetts). There was also a trend for fewer CAPs in rural regions and in regions with more youth living in poverty. Although they reported an increase in the absolute number of CAPs from previous years, the authors noted that this increase fell short of the increase in the population of youth, resulting in a shortage of CAPs at the time of the study.13 More recently, the US Bureau of Health Professions projected that the current number of practicing CAPs (8000) will increase to 8300 by 2020 only if funding and recruitment remain stable, a number far short of the estimated need for 12,624 CAPs to meet expected demand.14 These projections, compounded with the recent decrease in practicing psychiatrists15 and the increased demand for CAPs,16 suggest that the CAPs workforce shortage may continue.

This shortage of CAPs is reflected in limited appointment availability and long wait times for psychiatric appointments. A mystery shopper study spanning 5 cities across the country found that appointments could be made with 40% of pediatricians versus 17% of CAPs, with a mean waiting time of 12.7 days for pediatric appointments versus 42.9 days for CAP appointments.17 Similarly, Steinman et al18 found a median wait time of 50 days (range=1 to 354 d) for CAP appointments in Ohio, and Holt19 reported that wait times for CAP appointments typically range from 4 to 6 weeks in Massachusetts. The workforce shortage is also an issue when youth are identified as needing psychiatric care by professionals in other sectors of care. More than two-thirds of primary care physicians (PCPs) report difficulties finding outpatient referrals for mental health services,20 with physicians reporting waitlists of up to a year for psychiatric referrals.21 Long wait times are associated with increased likelihood for cancellations and no-shows for first appointments,22 decreased intent to attend the first appointment,23 risk for refusing services after referral,24 lower satisfaction with services,24,25 and greater distress and decreased functioning in multiple domains including at home and in school,26 making it critical that efforts to increase access to psychiatric care focus on providing expedient care.

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Financial Barriers

Cost of services is another frequently reported barrier to accessing and receiving mental health services.27 Both parents and youth report that cost of services (help is too expensive) is a major barrier to seeking care.4,28,29 While lack of insurance coverage is associated with less service utilization than having public or private insurance,2,30,31 youth and families with health insurance may still struggle with accessing affordable care if their insurance does not pay enough for services32 or is not accepted by CAPs.33 In addition, out-of-pocket expenses necessary for the process of getting care (eg, transportation, parents taking time off work) may also take a toll on families, especially those who are low-income or live in areas without many service options.9

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INNOVATIVE APPROACHES TO INCREASE ACCESS TO PSYCHIATRIC CARE

To address these barriers, careful consideration has been given to designing alternative treatment models to increase access to psychiatric care for youth and families. We discuss several innovative and collaborative approaches between child psychiatry and primary care and schools.

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Primary Care

Mental health problems are often brought to physicians’ attention in medical settings,34 frequently before any contact with specialty mental health providers.35 Pediatricians report that, despite their perceptions of inadequate training in treating psychiatric problems, they often treat youth with psychiatric problems because of the scarcity of timely psychiatric referral options.20,36,37 Providing support to PCPs who are already serving youth with psychiatric problems in primary care settings has been the focus of several collaborative efforts between child psychiatry and primary care designed to increase youths’ access to psychiatric care. For example, through the Massachusetts Child Psychiatric Access Project (MCPAP),38 pediatricians can access a child psychiatrist (ie, psychiatric medication or differential diagnosis), a psychotherapist (ie, behavior management, treatment planning), or an MCPAP care coordinator (ie, care coordination with community providers) for immediate consultation while they are serving youth in the office regardless of the youth’s insurance status. Pediatricians enrolled in MCPAP have reported satisfaction with the program and an increased ability to serve youths’ psychiatric needs.38 Similarly, the Partnership Access Line (PAL) funded by the state of Washington provides immediate telephone psychiatric consultation with a child psychiatrist but also allows for televideo appointments between a PAL child psychiatrist and a publicly funded youth for more detailed consultation.39 The American Telemedicine Association reported that >48 state Medicaid agencies provide coverage for telehealth services,40 suggesting that services like MCPAP and PAL have been and may continue to be widely adopted.

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Schools

Schools are a promising setting for serving youth with psychiatric needs. With >52 million youth attending schools on any given day, schools are an accessible setting and have the potential to reach a vast number of youth.41 School-based services reach traditionally underserved youth (eg, racial/ethnic minority, low socioeconomic status, rural settings),9,42–44 and follow-through on recommended mental health services may be more likely in on-site school-based programs than in other community-based settings.45,46 Furthermore, schools serve an important role as the point of service entry for many youth while also providing services for youth already receiving care in other sectors (eg, specialty mental health and primary care)47 and may assist in facilitating efficient care coordination, which may improve service utilization and symptom improvement.48

Indeed, schools are the most frequently tapped source for past-year mental health service utilization (24%), followed by specialty mental health (23%) and general medicine (10%)3 and the second most frequently tapped source for lifetime utilization (35%), surpassed only by specialty mental health (47%).1 Psychologists, counselors, and social workers in schools often provide universal prevention, early intervention, and targeted intervention services to youth with subclinical and elevated emotional and behavior problems, but there remains a relative lag in the provision of school-based psychiatric care.49 National surveys of school mental health programs suggest that only a minority of schools employ psychiatrists (2% vs. 77% for school counselors)49 and that psychiatric consultation and medication management are among the least frequently offered mental health services in school settings.50 Services commonly provided in school settings may meet the needs of the majority of youth with mental health concerns, but collaborations between schools and child psychiatry may better meet the needs of the most severe cases who might not otherwise access timely psychiatric care.51

Historically, psychiatrists provided consultation to schools to improve school personnel’s awareness about and sensitivity to mental health issues broadly, and over time, this focus shifted to consultation about individual students and their specific mental health concerns.5 Today, community-based psychiatrists and, less frequently, psychiatrists employed by schools assess and provide recommendations for school-based services for individual youth they treat. Psychiatrists who are part of school-based health centers also provide assessment and treatment to youth in the school setting. While psychiatrists have provided direct consultation services on-site in schools, given the cost of on-site psychiatric services (eg, psychiatrist appointment availability, workforce scarcity, psychiatrist travel time), collaborations between schools and psychiatry have increasingly capitalized on telepsychiatry while reserving direct psychiatric services for the youth with the most severe problems and the greatest need.51,52 For example, through the Prince George’s School Mental Health Initiative, psychiatrists provide telephone consultation with school counselors and case managers but also use videoconferencing technology to conduct assessments with youth and parents.52 CAP fellows at the National Center for School Mental Health at the University of Maryland School of Medicine use telepsychiatry to provide consultation to school personnel and direct service provision.51 These psychiatrists have regular time blocks that are reserved for telepsychiatry consultations about differential diagnosis, comorbid medical problems, psychotropic medications, and community referrals. When they provide direct consultations via telepsychiatry with youth and families, the school case manager or counselor coordinates the appointment and shares necessary data with the psychiatrist to maximize the use of the psychiatrist’s direct, face-to-face time with the youth. While telepsychiatry allows for greater efficiency and higher volume of service delivery to youth, especially to those who may not otherwise be able to access psychiatric services (eg, due to lack of transportation or insurance coverage), youth and families have reported concerns about privacy, psychiatrists’ engagement, feeling uncomfortable during videoconferencing, problems with technology (eg, audio problems that necessitate frequent repetition by youth), and that they find face-to-face services more personal.53 Providers have also reported nonverbal communication may be a concern in telepsychiatry practice.53 Given these concerns, there are some proponents of continued on-site services and hybrid models of care that integrate telepsychiatry consultation and direct service provision.51 Psychiatrists also report that in-person services provide valuable training in working in a multidisciplinary team with schools to provide the best care for youth with serious mental health concerns.51 Further research comparing the feasibility and effectiveness of in-person, telepsychiatry, and hybrid models designed to increase psychiatric care to youth is needed.

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THE BRIDGE PROGRAM

The Bridge Program is an on-site, in-person transitional psychiatric program designed to increase youth and families’ access to timely and affordable psychiatric services by providing free-of-cost psychiatric assessment and treatment in schools with ongoing follow-up appointments until youth transition to a longer-term community-based provider. The program is funded by a county-wide mental health tax, an initiative that began in 2012 when voters in Boone County, Missouri approved a ballot measure to create a Children’s Services Fund by adding a one-fourth cent sales tax to purchases made in the county (www.showmeboone.com/community-services). This initiative in Boone County—one of 9 counties in Missouri that have passed similar initiatives—can be traced to earlier bills that were passed in 1993 and 2000 by the Missouri legislature that allowed counties to use property and sales tax to create such funds.54 The initiative in Boone County was championed by a strong contingent of early childhood advocates who canvassed the county in support of the measure, and the fund, which now generates over $6 million annually, supports a wide range of mental health services for youth and families in the county.

The Bridge Program, funded by this initiative, was launched in 2015 in response to a recognized need for increased access to youth psychiatric services (eg, youth being turned away from services, long wait times55). Youth and families often must wait 2 to 3 months for a CAP appointment in the county; the goal of the Bridge Program is to bridge the gap between youth and families’ need for timely services and the availability of local CAPs. As a transition program, Bridge provides services within 10 days of referral and provides continuing care until youth are stabilized and are connected to an ongoing, longer-term community-based psychiatrist. In addition, services are provided at local schools to address structural barriers such as transportation. Youth can be referred by any source to address caregiver knowledge and attitudinal barriers, and youth and caregivers are provided psychoeducation following assessment to increase mental health literacy. Finally, services are provided without any out-of-pocket costs for families regardless of insurance status to ease financial burdens.

The Bridge Program consists of one 0.5 full-time equivalent child psychiatrist and 2 psychiatric nurse case managers who provide services across 52 schools in the 6 public school districts in the county. To receive services, youth, caregivers, school personnel, or other providers (eg, PCPs) contact the school counselors or the Bridge Program directly. When referrals are made through the school (eg, a teacher identifies need), the school informs the caregiver about the youth’s mental health concerns, provides information about Bridge, and obtains consent. The school then sends a referral to Bridge and Bridge staff contact the caregiver to schedule an appointment. At the initial appointment, which occurs within 10 days of referral, a child psychiatrist conducts a psychiatric assessment and provides treatment recommendations. For youth who have never received psychiatric care, are 6 years old or younger, or whose behavior, mood, or activity level do not significantly disrupt their functioning, the psychiatrist recommends psychotherapy before starting medications. Even when medications are prescribed, psychotherapy [eg, behavioral parent training provided in the community for parents of youth with disruptive behavior disorders or attention-deficit/hyperactivity disorder (ADHD)] is often recommended. To ensure follow-up, the psychiatric registered nurse case manager (RN CM) makes the referral while the child receives Bridge services. When medications are prescribed, care is continued at the school, with 3 to 4 follow-up appointments up until the child’s transition to a community CAP. The RN CMs provide education to youth and caregivers about mental health problems and their treatment, and they support adherence to the prescribed medications and recommended psychological treatment. Once the youth are stabilized, the RN CMs schedule appointments with community providers to ensure a smooth transfer of care. In addition, for uninsured youth, RN CMs help families apply for Medicaid, and for families with high need, RN CMs facilitate wraparound services for the youth.

Data from the first year of operation indicate the promise of the Bridge Program. The program provided psychiatric assessment and care coordination services to 394 youth, 67% of whom were living at or below the poverty level, all within 10 days of referral.55 Presenting concerns spanned both internalizing and externalizing problems, as evidenced by the pretreatment Vanderbilt Assessment Scales (VAS) completed by caregivers and teachers. On caregiver reports, 34% of youth exceeded the cutoff for ADHD, predominantly inattentive presentation; 25% for ADHD, combined presentation; 53% for oppositional defiant disorder (ODD); 10% for conduct disorder (CD); and 41% for anxiety/depression. On teacher reports, 40% exceeded the cutoff for ADHD, predominantly inattentive presentation; 25% for ADHD, combined presentation; 21% for ODD/CD; and 21% for anxiety/depression. At posttreatment, teachers reported improvement on all scales, while parents reported improvements on all scales except CD. Using the reliable change index, parent-report indicated that 59% and teacher-report indicated that 39% of youth improved on at least 1 of the scales. Further, levels of medication adherence for youth prescribed psychiatric medications and of follow-through with community referrals were both high. Caregivers, youth, and school personnel also reported high levels of satisfaction with the Bridge Program. On average, all informants indicated satisfaction with increased accessibility of psychiatric services and that they would recommend the Bridge Program to others. School personnel and caregivers reported high levels of satisfaction with the coordination of the transfer of care from Bridge to their community provider, and caregivers reported they were better informed about the youth’s mental health concerns and whom to contact for appropriate services. We present 2 cases to further illustrate how youth receive care through the Bridge Program and how it addresses frequently reported barriers to accessing psychiatric care.

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Case Report 1

This child, a 6-year-old white male kindergarten student living at home with his parents, was referred to the Bridge Program on the advice of the school by his parents and PCP due to concerns about attention and hyperactivity problems, as well as disruptive and “explosive” behaviors at home and school. His parents reported that problematic behaviors started years earlier in preschool where he was hyperactive, fidgety, and irritable, leading to him being expelled from 3 different day care centers. He received additional support in his schools [eg, Title 1 program in preschool, individualized education plan (IEP) in kindergarten], but these problems persisted, and he frequently missed out on instructional time due to being in a “safe seat” or “safe room” after outbursts in the classroom, not following instructions, annoying his peers, and being aggressive. In the month before his Bridge assessment, his parents had to pick him up from school on 3 separate occasions due to these behaviors.

At the time of the Bridge assessment, the child’s only previous encounters with mental health services had been with school providers during his IEP evaluation and his school counselors. He had been born of a full-term pregnancy, vaginally, and he had no exposure to illicit substances in utero, although his mother smoked cigarettes for the first 2 months of pregnancy. There were no significant developmental delays. His medical history was significant for 4 febrile seizures between the ages of 18 months and almost 5 years due to ear infections, as well as an adenotonsillectomy before his Bridge assessment. His family history was significant for congenital cardiac abnormalities and maternal history of major depressive disorder. Scores on parent-reported and 2 teacher-reported VAS at baseline exceeded the clinical cutoff for hyperactivity. He was diagnosed with ADHD, predominantly hyperactive/impulsive presentation, and ODD. He was prescribed a nonstimulant ADHD medication, guanfacine (due to history of febrile seizures and family history of cardiovascular problems), which was titrated until there was a reduction in ADHD symptoms. The child was also referred to psychotherapy for the oppositional and aggressive behaviors. His parents and school reported positive outcomes following this treatment regimen. Incidences of the child being sent to the “safe seat” were reduced, his parents reported no calls from school for adverse behaviors, and importantly, his focus, hyperactivity, and time receiving instruction in the classroom all improved. He was followed for 4 months before discharge to his PCP to continue managing his medication, his mental health service provider to continue behavior therapy for his behavior problems, and with a plan to continue his IEP in school.

The Bridge program provided timely and time limited specialty mental health care in the school setting to prevent further deterioration, and to improve school and institutional adjustment for this child. In this case, early intervention with Title 1, IEP, and basic intervention by the school counseling office had not sufficiently addressed his struggles, indicating a need for more intensive specialty mental health services. This child was referred to the Bridge Program and assessed within 2 weeks, compared with the 2 to 3 months it normally takes to see a child psychiatrist in the local area, allowing for timely care. In addition to providing psychiatric services, the Bridge Program provided case management, including referrals to behavioral therapy. The program staff also coordinated with the child’s school concerning his IEP and to get feedback on his progress on referral concerns. In this way, the Bridge Program served as an efficient service delivery system after other less intensive services were exhausted and it coordinated appropriate care (psychiatric, psychological, school accommodations) for the child’s presenting concerns.

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Case Report 2

This child, a 10-year-old white male in the fourth grade living at home with his mother and two siblings, was referred to Bridge by his school counselor due to difficulties with attention, hyperactivity, and oppositional behaviors. At the initial assessment, he presented with a history of inattentiveness, becoming easily distracted at school and during homework time, not getting his work done in a timely manner, fidgeting, hyperactivity, and disruptive behavior in the classroom. In addition, he was often antagonistic, argumentative with parent and teachers, oppositional, quick to get into a fight, and prone to throwing fits (eg, yelling, stomping, throwing objects, and hitting). He had been missing out on classroom time due to being kicked out of school once and multiple referrals to the office or “safe room.”

At the time he was assessed by Bridge, he had received previous treatment from PCPs, a therapist, and a psychiatrist for ADHD and ODD but had been out of treatment for about 3 months. During his previous treatment, he had been prescribed atomoxetine, which he stopped because it made him “depressed,” extended release guanfacine, which was discontinued because it made him too sleepy, and extended release methylphenidate, which was discontinued because it made him too emotional. He had no severe aggression or other symptoms indicative of CD. He did witness his father and his then girlfriend argue and fight a lot and, on at least one occasion, he was spanked by his father which left a bruise. Neither he nor his mother endorsed other symptoms of posttraumatic stress disorder. There were no significant medical problems apart from having his frenulum clipped when he was 18 months old. He was born of a spontaneous vaginal delivery after a full-term pregnancy with no exposures to cigarette, alcohol, or illicit substances in utero. There were no significant developmental delays in his major milestones. His family history was significant for major depressive disorder in his mother and possible ADHD in his father, who also had a long history of alcohol and drug use as well as cardiac arrhythmia. His father was also incarcerated several times and, in fact, was incarcerated while the child was in treatment with the Bridge Program. In addition, other members of the family suffered from other medical problems including arthritis, sarcoidosis, and myasthenia gravis.

At the initial assessment with Bridge, parent-report and teacher-report VAS scores exceeded the cutoff for the inattentive and hyperactivity/impulsivity subscales. The child was diagnosed with ADHD, combined presentation, and with ODD. He was prescribed a mixed salt amphetamine for the ADHD and was referred for behavioral parent training. He showed some improvements in attention, focus, and hyperactivity as the mixed salt amphetamine was titrated to 7.5 mg twice a day, but his irritability and outbursts increased, leading to relationship problems at home with family members. He was thus switched to dexmethylphenidate (eventually changed to the extended release formulation), which was titrated to 15 mg in the morning, which led to a significant reduction in most of his inattention and hyperactivity symptoms. However, he continued to have a lot of difficulties with sleep and continuing oppositional and occasional aggressive behaviors toward siblings and school peers; he was therefore started on extended release clonidine to augment the dexmethylphenidate. In addition to these treatments, he continued with individual behavioral therapy. His mother and particularly school staff reported significant progress while he was on this treatment regimen; incidences of being sent out of the class or to the “safe room” were reduced, his focus improved, and his hyperactivity diminished. At discharge, VAS scores from his parents were subclinical on the inattention and hyperactivity/impulsivity subscales, while his 2 teacher-reported scores were zero on both subscales. In fact, a month before his discharge from the program, he was awarded a leadership medal in school. Because of his more complicated course and multiple medication changes, he was followed for 9 months before discharge back to his PCP and was also recommended to continue psychotherapy in the community.

This child’s case illustrates the program’s provision of timely specialist mental health treatment even for children who had previously been in the mental health system but had been lost to follow-up, either due to inadequate access to services, or, as in this case, despair, because they feared that treatment, if provided, would be ineffective, hence leading them to give up on services. Service provision in schools has been associated with greater follow-through with recommended treatment services, and for this child, receiving services at his school through Bridge may have been particularly opportune given his previous experiences with psychiatric and psychological treatment. The role of the RN CMs was critical in addressing parental attitudinal barriers (ie, that treatment would be ineffective) and keeping the family informed and engaged when changes were made to the child’s regimen due to side effects or lack of efficacy. Addressing these barriers was key to preventing disengagement from services and further setback in school. Finally, this case illustrates how Bridge serves as a transition program; while most youth receive only a few follow-up appointments, Bridge collaborated with the school to obtain routine feedback on the child’s treatment progress and continued to treat him until he was stabilized and ready to be discharged to his PCP for ongoing care.

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CONCLUSIONS

The Bridge Program is an on-site school-based psychiatric program designed to increase access to psychiatric care by providing psychiatric services to youth and families directly in local schools. In the first year of implementation, the program provided care to nearly 400 youth with a team consisting of a half-time psychiatrist and 2 nurse case managers, indicating that timely psychiatric care can be provided efficiently through an on-site, in-person psychiatric program. By taking referrals from all sources (eg, teachers, parents, physicians, youth), Bridge attempts to minimize attitudinal barriers and refer youth to needed services even when parents have not identified a mental health problem. Parents may not be aware of youths’ mental health problems,4 but other professionals who frequently work with youth with mental health issues (eg, teachers)56 may be able to identify problems, especially behavior problems in the classroom.46 Having an on-site program in the schools supports school personnel in identifying youth at risk for mental health concerns and connecting them to easily accessible, appropriate assessment and treatment services.46 Bridge also aims to address the long wait times for CAP appointments by conducting assessments within 10 days of referral and providing care until youths’ first appointments with a community provider, thus serving as an intermediary transition program that offers timely care until youth are connected to longer-term, community-based CAPs. Finally, youth are seen free of charge to ease the financial burden associated with seeking and receiving psychiatric services.

While the Bridge Program addresses several key barriers to accessing youth psychiatric care, it is also important to note several limitations. First, while attitudinal barriers (eg, parent stigma related to mental health problems and their treatment) are a key barrier to accessing care, the Bridge Program did not have data on parent attitudes toward mental health problems and treatment during the first year of implementation, although parents did report that they were better informed about their children’s mental health and available service options. It should also be noted that the program increases youths’ access to CAPs by bringing CAPs into schools but it does not increase the absolute number of CAPs in the locality. Also, while Bridge services are provided free of cost to the family and Bridge staff help parents of eligible youth apply for public insurance, once youth are transferred to a community provider, families have to bear the cost of accessing services including transportation, child care, and direct service costs. In addition, while teachers have reported confidence in identifying mental health concerns in some studies,46 both parents and teachers have more difficulty identifying internalizing problems (particularly depression) compared with externalizing problems, suggesting that relying heavily on school personnel to identify at-risk youth without a systematic means to assess their symptoms may limit access to care among youth who fly under the radar.57

The Bridge Program also has certain relative advantages and drawbacks compared with other innovative approaches. Telepsychiatry collaborations between primary care and child psychiatry (eg, MCPAP) are feasible and widely adopted, and they allow child psychiatrists to efficiently maximize their reach.38 Telepsychiatry programs may reduce cost for all parties (eg, travel burden) and increase likelihood of utilization (ie, convenient location, familiar setting).51 Taking a similar approach by establishing collaborations between child psychiatry and schools, the most frequently tapped sector and often the first point of contact for youth mental health care,3,58 may allow more youth to access psychiatric services than through traditional or in-person pathways. While telepsychiatry programs might enable greater reach, in-person psychiatric programs like the Bridge Program allow psychiatrists to collaborate with school administrators and provide care within a multidisciplinary team,51 while face-to-face interactions with youth and families may circumvent some of the concerns with engagement and technology that may arise during the implementation of telepsychiatry discussed above.53

Building on the successes of these previous approaches to increasing care, future modifications to the Bridge Program may improve the efficiency of the model. Currently, the program provides timely care in a highly accessible location and facilitates transitions to ongoing care in the community for all referred youth. Future collaboration with schools to identify youth at greatest risk or with greatest impairment and prioritizing these youth for the Bridge Program while triaging youth with less severe problems to other less intensive services may maximize the reach of the Bridge Program. Future research should also empirically compare the relative advantages and disadvantages (eg, feasibility, acceptability, cost-effectiveness) of the various models currently in place to inform future program development and policy that maximizes the effectiveness and efficiency with which youth access quality psychiatric services.

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Keywords:

school mental health; child and adolescent psychiatry; youth mental health; psychiatric services; implementation

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