Integrated care – primary care that combines health and mental health services – is an idea that has taken off. Many doctors' offices and clinics have begun to provide mental health services where you get your medical services.
There are two basic types of integrated care. One involves having a psychologist, or sometimes a clinical social worker, in the primary care office to collect background information on the problem, offer brief counseling and, if needed, a referral to a specialist. This behavioral health consultant sees patients with all kinds of behavioral concerns, from sleep problems to severe mental illness.
Another type of clinic offers collaborative care, in which there is a mental health care manager, a nurse or social worker working with a consulting psychiatrist who routinely speaks with the manager. This is usually focused on patients who have depression or anxiety. Both systems work, but for different patient populations.
A recent article in the Journal of Adolescent Health asked if an integrated clinic is effective for teens who have depression. Are they more likely to be seen in primary care and follow up there for treatment? The study showed research is not clear and more information is needed.
Integrated care works because adult and child patients routinely see a primary care provider, generally once a year. But for otherwise healthy adolescents, it may be a different story. They may only see their primary care provider once every one to two years for a check-up.
Many teens don't want to go to a pediatrician after they get to high school and may use pharmacy- or school-based clinics for their needs. For teens, we have to ask, what do they need, and where is the best place for mental health services? Using a model developed for adults may not be a great fit.
Further, the American Academy of Child and Adolescent Psychiatry recommends that for mild to moderate depression, psychotherapy should be the first treatment, not medicine. To achieve that end, we have to get the teen and the therapist together, which can happen in a number of places.
Providing integrated care for teens at school-based health clinics is a logical solution. It's convenient and the teens control when to go to the appointments, they don't have to depend on a parent, and it provides an additional level of comfort and confidentiality.
For over 25 years, since the administration of Gov. Tom Carper in Delaware has had school-based clinics in most public high schools. Usually staffed by a nurse practitioner and a clinical social worker, school health clinics are run by a local hospital. In addition, schools have counselors and school psychologists. All of these professionals can deliver effective therapy for depression, anxiety and adjustment problems.
Integrated care is a great idea, but it needs to be patient-focused. For teens, that focus may be best if the care is delivered in schools.