Why medication can’t be the only solution to the behavioral health crisis

A few months ago, I met a 10-year old diagnosed with a history of anxiety, panic symptoms, Tourette’s disorder, migraines, and ADHD. This individual had a PCP, neurologist, and psychotherapist when they came to me, a psychiatrist, due to worsening anxiety. They were already on 6 medications (including 2 controlled substances). 

It turns out that their parents were going through a divorce. The patient was worsening with panic attacks, acting out, and had more hyperactivity. They had stopped therapy due to lack of adherence, and a prescribed increase in stimulants was resulting in panic attacks.  However, I found that the core issue with anxiety resulted from parental separation.

In many cases, the wait to see a psychiatrist would have meant continued medication management by the primary care team. Fortunately, the PCP participated in an enhanced collaborative care model (CoCM)¹, where they could enroll the family directly with a behavioral health team that included collaboration, therapy and medication management.

As the psychiatrist on this case, my team facilitated collaboration across the separate providers and the family’s new practitioners. We started the patient on an anxiety and focus care program and began the process to decrease the existing polypharmacy.  Improvements in symptoms were seen within 2 weeks of starting care with Bend Health.

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Why medication can’t be the only solution

Medication is an important piece of the puzzle. When patients experience clinically-significant symptoms, medication is necessary to ‘reset’ the neural pathways in the brain. 

However, as the AAP notes² medication alone does not create a path for long term recovery. For kids and teens especially, skill-building and therapy are critical elements of a treatment plan. Understanding the factors influencing their own feelings and behaviors and having the tools to manage them, is critical to building resilience and wellness for a lifetime. 

But the sad reality is that for those kids and teens that do receive behavioral care, only 1 in 5 receive the AAP recommended treatment of therapy with medication.³ In fact, studies^{4, 5, 6} also show that many kids and teens get better with behavioral interventions, therapy and parent skills training without medications.

We all know the reason. But I’m unwilling to allow the shortage of behavioral health clinicians to mean we wait years to help families that need help today.

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How the collaborative care model is changing the game 

As I described above, it’s critical to look at the full ecosystem of a patient’s life and family while also surrounding them with a team of experts and champions who work together. That’s why the collaborative care model (CoCM) is so effective, offering pediatric patients quick access to psychiatry, therapy, coaching, and parent skills training, all while allowing pediatricians to stay in the loop and retain medical home. In fact CoCM is one of the most studied evidence-based treatments for mental health conditions with over 90 randomized controlled studies⁷ showing superior outcomes to treatment as usual.

In enhanced CoCM, pediatric practices enroll patients directly with a behavioral health team which includes a dedicated behavioral care manager. In the case of Bend Health, the enrollment process for families takes minutes. Parents and caregivers can secure appointments as quickly as next-day.

The psychiatry-led team decreases time to precise diagnosis, designs a personalized evidence-based care plan, and actively collaborates with the primary care team ensuring medical and behavioral care are in sync. The pediatric practice is able to bill for CoCM CPT codes through the family’s existing insurance, removing another frequent barrier to care.  

Even in less acute cases, this model is highly effective. Through relationships with practices that include over 500 pediatricians, Bend Health co-manages the care of patients with behavioral health concerns that range from mild to severe. The outcomes are compelling: in two peer-reviewed studies 70% of patients reported improvement of symptoms for inattention⁸ and nearly 75% reported symptom improvement for anxiety and depression⁹.

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The path forward

As a practicing child and adolescent psychiatrist (and parent), I know how excruciating it can be to look a panicked caregiver in the eyes and tell them that they have to wait 6 months before they can get their child the support they need. 

I urge all pediatric practices to explore the enhanced collaborative care model to be able to offer families a highly effective behavioral care option.