There is a 15 minute window to solve a riddle. Physical symptoms aren’t adding up. The waiting room is packed with sniffling children and anxious parents. Everyone seems restless and impatient. There are tests to run, prescriptions to manage, questions to answer. The clock is always against you.
This is how Dr. Marilyn Griffin, psychiatrist at University of Illinois at Chicago and consultant for Illinois DocAssist depicts a typical pediatrician’s office on a typical day.
In short, it’s hectic.
To make matters more complicated, primary care settings are often the de facto mental health provider for many Illinois residents. There are less than 300 psychiatric professionals qualified to provide care to more than 3 million children in the state. A staggering 90 percent of these professionals are concentrated in and around the Chicago area—leaving the more rural portions of the state facing greater challenges. One out of every five children experiences some type of mental health problem, yet in Illinois only 20 percent, around 600,000 of those children, receive any sort of treatment for it. These figures don’t account for other barriers either: lack of insurance coverage, issues of reimbursement, long waiting list, and even longer commutes to see a qualified professional.
Enter DocAssist, a virtual psychiatric consultancy based at UIC, which provides free, telephonic mental health consultation and education service to support primary care physicians (PCPs) who find themselves working in areas of great need, but outside their areas of expertise.
“We provide on average 200 consultations per month or approximately 2,500 consultations per year and train more than 700 clinicians on screening, assessment, and treatment of pediatric mental health disorders,” Dr. Griffin explains.
DocAssist is an expert resource that primary care physicians, pediatricians, nurses, and other health providers can lean on to sort out complicated issues beyond the immediate scope of their expertise. DocAssist staff—composed of child psychiatrists and social workers—provide information on medications, diagnosis, screening tools, effective interventions, treatment planning, and even resources in the area. At times, these conversations can be as simple as coaching a physician on how to have difficult conversations with a parent or clarify how best to intervene around mental health in general.
Griffin first became aware of DocAssist when she was still completing a triple board residency in adult psychiatry, child & adolescent psychiatry, and general pediatrics at University of Pittsburgh Medical Center. Later, after joining faculty at the College of Medicine in Rockford, she began working for the program.
“There are a handful of child and adolescent psychiatrists in the Rockford area. The closest was maybe an hour and a half drive away.” she observes, “When I first opened my office my schedule was booked out 3 months in advance.”
Her interest in integrated care models, including mental health and primary care made her a natural fit as a consultant for Illinois DocAssist. Initially, she worked as the Northern Illinois Regional Consultant and later moved to Chicago to increase her involvement as a consultant on services, enhance her advisory role with the College of Medicine’s Urban Health Program, and start an ADHD Clinic.
Each consult typically involves a number of calls to provide resources, address medication concerns, offer support or explore treatment options. Calls range in complexity and duration from a few minutes to a couple months, with everything handled as close to “real time” as possible. DocAssist professionals often help to discuss screening results or look up local resources in addition to inquiries about medication and treatment options.
“We are not trying to train a physician to be a behavioral health specialist,” Rhapsody Mason, a social worker with DocAssist clarifies. “We are trying to help M.D.s understand their important role in identifying behavioral health concerns and facilitating appropriate care.”
Mason handles seven cases a week on average. As a social worker, her focus is often helping the callers to access or navigate systems, but she often works with the broader DocAssist team to provide more nuanced answers into some of the areas outside her own expertise.
This underlying principle of helping a PCP clarify her behavioral health role is exemplified in a case Griffin worked recently. A developmental pediatrician contacted DocAssist with a complicated, somewhat “messy” case.
She was seeing a child suffering anxiety, emotional outbursts, and some learning challenges with medications by various prescribers that didn’t completely match. Two stimulants, an antipsychotic, and an anti-anxiety medication had all been prescribed.
“It was complicated,” Griffin expresses with an audible sigh, “all of these professionals in the mix, but nobody working together. Too many cooks in the kitchen, so to speak. There was little to no communication between those providing care and in some instances they weren’t even aware of one another.”
Griffin helped the developmental pediatrician to take a step back and assess all the moving pieces and players.
“She felt like she was under a lot of pressure to figure all of this out on her own,” Griffin notes, “but, I helped her to see what she really needed was clarity and information. ‘Where did these diagnoses come from? Who actually did the testing? Can she have a copy of the reports?’ Then she could actually be a leader to the team involved in the case.”
By slowing the conversation down and discussing options Griffin provided the physician with a new perspective.
“A lot of time it helps just talking through it.” Mason says of the service overall. “It helps that we are based at a University hospital setting because we can leverage a lot of specialized expertise and recently published research from faculty and staff that someone in private practice might not have access to.”
In addition to the direct consultations, other members of the DocAssist team work on maintaining an updated library of resources to this aim.
For Mason, this dynamic played out with an equally complex call she received involving a pregnant woman who experienced severe perinatal depression during her first pregnancy and her physician was calling to discuss treatment options that might be available for this second pregnancy.
“There was a lot going on with her,” Mason details on the intricacies of the call, “and a lot going on in the home. Knowing all of these psychosocial stressors on top of a history of postpartum depression it was really great that her pediatrician had a place to turn.”
Perinatal depression and associated disorders often go unrecognized. They are masked by other discomforts of pregnancy that can easily be overlooked by an experienced OBGYN who may not think to explore a history of depression preceding pregnancy and consider it hormonal shifts during the puerperium period. Often providers will try to normalize the feelings of depression as an aspect of the pregnancy—an attempt to reassure that can have negative consequences.
Women are twice as likely as men to experience depression over their lifespan.
For the next six months, Mason and the DocAssist team developed a relationship with the pediatrician by providing an ongoing consultancy regarding the case. “We discussed next steps she could take to help move mom forward and prepare for the birth.” Mason notes. “She would do a screening and call us and let us know what the results were and we would talk through the specific symptoms we are seeing and talk through making the decision with mom on what treatments she would be most comfortable with.”
Repeat callers are not unusual. Once PCPs establish a relationship with DocAssist they are likely to call back either on an ongoing basis with updates tracking a patient’s progress, like the aforementioned instance, or with different cases, patients, and situations.
“We ended up getting her into a pretty comprehensive perinatal mental health treatment program,” Mason concludes about the case, noting that while there was a depression relapse after giving birth having her enrolled in therapy and monitoring her mood helped to provide mom with more support than she’d have had otherwise.
DocAssist provides real time research, support, and expertise that can enhance and amplify what a PCP is able to do working with a child and adolescent patient. It provides resources and coaching that can inform a physician’s next move in a behavioral/ mental health situation—but, perhaps most importantly, it lets a physician know that they are not alone. If you are a primary care physician and have any mental health related questions, concerns, or a need for guidance contact DocAssist Monday through Friday 9AM-5PM at 1-866-986-2778 or DocAssistpsych [dot] uic [dot] edu