MC3 was highlighted in a Detroit Free Press article about the shortage of child and adolescent mental health professionals. In the article, family medicine doctor Dr. Rachel Klamo refers to prescribers utilizing MC3 as a “best practice that’s probably underutilized.”
*Please note that you need a subscription to the Detroit Free Press to read the full article.
MC3 is featured in a new video and story from the U-M Public Engagement & Impact office’s “This Is Michigan” stories series. Special thanks to Drs. Lia Gaggino and Shimia Isaac for sharing their experiences consulting with MC3.
The following article, which highlights MC3 and features MC3 psychiatrists Dr. Sheila Marcus, Dr. Maria Muzik, Dr. Joanna Quigley, and Dr. Nasuh Malas, was originally published in the Medicine at Michigan magazine’s Summer 2022 edition.
Katie Whitney | SUMMER 2022
“People are calling me, saying, ‘I and my child have been in the ER for a couple of days now, waiting for a bed. My child is suicidal. We can’t go home … and I’m terrified. What do I do? How can you help?’” says Donna Martin, M.D., Ph.D., chair of pediatrics, the Ravitz Foundation Endowed Professor of Pediatrics and Communicable Diseases, and professor of human genetics.
“And that’s just wrong.”
The situation is severe. But it is not new.
“We were shouting from the rooftops, saying we are in crisis,” says Emily Fredericks, Ph.D., professor of pediatrics and director of the pediatric psychology division at Michigan Medicine. “There are not enough mental health providers to meet needs of children in our state. We knew we were in a dire situation.
“The pandemic has exacerbated that. Infinitely.”
“I’ve said it so often it sounds trite,” says Gregory Dalack, M.D., the Daniel E. Offutt, III Professor of Psychiatry and chair of the department. “All these needs were there. The pandemic has really just squeezed the vise on the system.”
That squeeze prompted an unprecedented event last fall when the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in child and adolescent mental health.
“We have thousands of patients waiting to get access to child psychiatric ambulatory services within our health system and in the community,” says Nasuh Malas, M.D., associate professor of psychiatry and of pediatrics and service chief for child psychiatry at C.S. Mott Children’s Hospital. Malas and his colleagues published a study in Clinical Pediatrics in January showing an 18% rise in initial psychiatry consults at Mott from July 2020 to January 2021 compared with the 2019-2020 time period. This is a four-fold increase in mental health consultation demand compared with the rate of increase from previous years.
And it’s not just the sheer volume of demand that has increased, but also the acuity of distress for individual patients. A Michigan Medicine study published in Clinical Child Psychology and Psychiatry in March shows that pediatric patients receiving psychiatry and/or psychology services during the pandemic were more likely to require restraints and antipsychotics than those treated just before the pandemic. “We used to see middle-of-the-road severity,” says Fredericks. “Now every patient worries me.”
We have a tsunami of need across the country, and we have little more than sandbags to meet it.
As with natural disasters, there are heroes of this crisis — both visionaries who have seen this coming and have spent many years preparing, as well as those who have been called to action at this sharp pain point. But according to the myriad mental health experts interviewed for this article, what is needed even more than individual heroes is broad systemic change.
Below are seven actions that we in health care and as a country can take to help alleviate this crisis. Most of these are already underway at Michigan Medicine — at C.S. Mott Children’s Hospital, the Nyman Family Unit for Child & Adolescent Mental Health & Wellness, the Eisenberg Family Depression Center, and the many clinics that address children’s mental health.
1. Train More Providers
“The number of child psychiatrists has always been tiny, miniscule — never anywhere close to a reasonable number for the population,” says Laura Hirshbein, M.D., Ph.D., professor of psychiatry, who is also a historian currently writing a couple of books on the history of children’s mental health. In Michigan, only one county (Washtenaw) has an adequate number of child and perinatal psychiatrists.
Historically, “child psychiatrists were pretty poorly paid among medical specialties,” says Sheila Marcus, M.D., professor of psychiatry. “And at the end of five years of training following medical school, these early-career physicians had difficulty with student loans.” The Michigan Department of Health & Human Services now has a loan repayment program for mental health care providers who spend two years working at a non-profit health clinic in health profession shortage areas or in child and adolescent psychiatry hospital-based settings.
“We are training more pediatric psychologists,” says Fredericks. “[But] there is more interest than there are spots available. On a national level, there is advocacy going on to increase federal funding for training child and adolescent psychologists.” However, we are still far from where we need to be. “As a health system, we need more investment in psychologists,” says Martin. “We could easily have four times as many psychologists as we do right now, and still not have enough.”
“What we do have now that we didn’t used to have is that pediatricians are taking on the role of becoming primary mental health providers,” says Hirshbein. Most prescribing of psychiatric medications for kids is done by primary care physicians. “Families like to be treated in primary care because they have comfort with their doctor and because of the issues around stigma,” says Marcus. “The question is, ‘How can we spread out expertise so that people know what to do [when families come to them with mental health concerns]?’” says Hirshbein.
One answer is the Michigan Child Collaborative Care Program (MC3). Marcus founded the program ten years ago, when she saw how difficult it was for primary care physicians to meet the growing demand for psychiatric care. MC3 partners with the Michigan Department of Health & Human Services to support PCPs who are responding to mental health crises.
When a primary care provider initiates a consult with MC3, a behavioral health consultant triages the request, responding to questions within the scope of their expertise and forwarding appropriate cases to a psychiatrist at Michigan Medicine for same-day phone consultation. In many cases, the behavioral health consultant will also identify local resources for the patient.
MC3 has been able to leverage the psychiatric expertise of a handful of psychiatrists at Michigan Medicine to meet the needs of children and women across the state. As of March 2022, MC3 has enrolled 3,100 providers, responded to 38,000 service requests, and helped 16,000 patients.
The MC3 Program is also one of several in the country that has a thriving perinatal consultation program, providing consults to primary care physicians caring for women during pregnancy and postpartum. “When mothers with depression and trauma are identified early, it makes it possible for consultants to guide them toward infant mental health specialists who help foster healthy, secure attachment relationships with their babies,” says Marcus. “This early bonding helps ensure a healthy developmental trajectory for infants from the start.”
MC3 has also given primary care providers continuing education in mental health care, through its educational modules on topics like eating disorders, ADHD, and other mental health issues. Training these providers to become better mental health caregivers is one way that MC3 has helped to increase the number of providers who can meet the demands of the crisis.
2. Innovate to Increase Access
Mental health concerns are common. About 1 in 5 children has a diagnosable mental health condition, but only half of them get proper care. Though holistic medicine and whole-person care are widely accepted and generally touted as important, mental health care is too often siloed in specialty practices that remain inaccessible for many families.
“We need to make sure mental health care is accessible to everybody in the way that physical health care is accessible,” says Joanna Quigley, M.D., associate professor of psychiatry and of pediatrics, as well as associate medical director of child and adolescent ambulatory psychiatry services. “It should be just as easy as accessing a primary care provider for a well-child check.”
This is an area where the broader health care community could use large health systems like Michigan Medicine as a role model. At C.S. Mott Children’s Hospital, psychology and psychiatry services are fully integrated into children’s medical care. “Having psychologists integrated where kids are getting care provides better care and better access,” says Kristin Kullgren, Ph.D., associate professor of pediatrics.
“We’re thinking about how we can be more thoughtful about integrating care, embedding mental health professionals in medical settings. We’re working with medical providers to ensure we’re screening early and providing preventive services,” says Malas, who directs the psychiatric consult service at Mott.
Another innovation that has improved access to mental health care is telehealth. It’s hard to believe that just two years ago, telehealth was relatively rare. “Pre-pandemic, I did a total of one virtual visit with patients,” says Kullgren. But now she is a big proponent of telehealth, especially for children’s mental health. “For me and my patients, there are a lot of positives to virtual care. Access is huge for kids. They can log on from home, from school, the McDonald’s parking lot, wherever they happen to be, and I can give them care. Whereas before, what used to take half a day or a day to come to the appointment, now takes just the appointment time.”
In addition to integrating mental health care with medical care and continuing to expand access to mental health care via telehealth, we also need to think of innovative ways to relieve the current pressure on psychiatric emergency services.
Right now, psychiatric beds for children are at 95% capacity at the Nyman Family Unit, says Malas. “At any given time, we may have 6 to 8 kids in our health system waiting on a psychiatric bed.” Some may wait for several days.
The answer is not necessarily more beds. “We need to get care to patients locally and early in way that is feasible, sustainable, and natural, rather than having people coming to ER in the middle of the night in crisis,” says Malas. He also recommends expanding mental health services “so it’s not just an outpatient/inpatient model.” He says we need urgent care centers that are equipped to handle mental health issues, respite centers for adolescents who need a cooling-off period, and partial hospitalization programs.
Malas and Quigley are part of a group that is developing a partial hospitalization program for children and adolescents. A program like this could provide intermediate-level psychiatric care, similar to the partial hospitalization program that already exists for adults.
“We have to shift our framework to not think about mental health care as something that only happens at a psychiatric clinic,” says Quigley. “We need to integrate this care into all aspects of the health care delivery process.”
3. Improve Insurance Coverage
For many families, having access to mental health care is almost synonymous with having insurance coverage. But from an insurance standpoint, mental and physical health are not treated equally. “Insurance companies have turned toward very aggressively managing mental health care to make providers show that someone really needs it, in a way that they don’t with other illness,” says Hirshbein.
“From a purely insurance-based perspective, we need federal regulatory changes,” says Jack Kaufman, Ph.D., an associate professor of physical medicine and rehabilitation who conducts neuropsychological testing for children, which, like all other mental health services, has seen an increase in demand. “We need to not have insurance companies telling us how many units of something they’re going to give us to solve it before we even [have a diagnosis].”
Kaufman also says we need to make sure the same services are reimbursed by insurance at the same rate — regardless of who provides the service. For example, she says a psychotherapy session might get reimbursed at a higher rate for a physician than a psychologist, even though conducting that kind of session does not require a medical degree. “There are services that I, as a psychologist, can’t do that cost more, and that makes sense. But the service should be charged the same, if it’s the same service.”
Making this change to insurance reimbursement could incentivize the hiring of a broader range of mental health care providers to meet the demands for psychological services.
We also need to make it easier for mental health care providers in the community to be covered by insurance. One reason that large health systems, like Michigan Medicine, have such long waitlists is because they are often the only recourse for families who cannot afford to pay out-of-pocket for mental health care.
4. Learn More about Kids’ Brains
“The period of preadolescence through adolescence into early adulthood is really when mental health problems emerge,” says Mary Heitzeg, Ph.D., professor of psychiatry. “It’s also when the brain is going through critical developmental processes.”
She and Chandra Sripada, M.D., Ph.D., associate professor of psychiatry, are principal investigators in the Adolescent Brain Cognitive Development Study (ABCD). The groundbreaking nationwide study includes 21 sites where data is being collected on 11,800 youth (720 of them are enrolled at Michigan Medicine). Before this study began six years ago, a really impressive sample size for a study like this would have been 100, says Heitzeg.
Every year, each of the enrolled youth and one of their parents undergoes an eight-hour assessment. That includes neurocognitive tasks as well as a sizable set of questionnaires that glean data on everything from sleep quality and substance use to screen time and extracurricular activities. At baseline, and every other year afterwards, the assessment includes fMRI to record brain changes. Researchers also collect data at the midpoint of each year.
But how can simply having all of this data improve children’s mental health?
That’s where another technological advancement comes in: data sharing. Data from the study is accessible to researchers around the world, and some 400 studies based on ABCD have been published so far, says Sripada. The richness of the data set allows for an astounding array of interpretations that could have profound implications for kids.
“One of the things that ABCD has helped us to definitively establish is that socioeconomic factors — resources of the household, income relative to needs, neighborhood disadvantage, and parental education — have big effects on kids’ brains, in the brain structure, in connectivity patterns, and in the ways the brain responds to tasks,” says Sripada. “This might have some policy implications.”
Heitzeg points out that the longitudinal nature of the study will also allow researchers to see the outcomes associated with these brain changes. “Are they more at risk for mental health problems, doing worse in school, etc.?”
Heitzeg says another richness of the study is that “we have all this other info. For example, organized sports. We can, in theory, have a group of kids with the same socioeconomic status and same brain changes, but they’re in sports and another group is not. We can see how a potential protective factor like [sports] may moderate the outcome.”
“The last piece of the puzzle is the influence of macro-environmental events, for example, COVID-19, or the profound and long-term impact of major wartime disaster, like that in Ukraine,” says Robert Zucker, Ph.D., active emeritus professor of psychiatry and psychology, director emeritus of the Michigan Medicine Addiction Center, and one of the original principal investigators on the ABCD study.
Zucker has had a career-long interest in the causes and treatment of mental health problems and conducted a study on the origins of behavioral problems and substance abuse in children to examine these questions. The study ran for 31 years, beginning in 1985 with children ages 3-5, the earliest developmental age that had ever been studied in this way. It also included data on those children’s parents, and Zucker says it has been the longest running study of the family interactional matrix and how it might contribute to the development of these problems or protect against it.
Zucker stresses the importance of understanding that the effects of major historical events on the health of a generation are probably an interaction with the mental health adaptation and the social resources of the youth experiencing those events. ABCD investigators have understood this, too. When the pandemic began, he says, ABCD researchers pivoted quickly to include questions in their assessments about the effects of COVID-19 on families. That study is already tracking those effects over time, and early results show such interactions.
“Most mental health problems and concerns are long-term and chronic,” says Zucker. “They remit. But a cure — a complete cure — is relatively rare. The solution to that from a public health standpoint is to prevent. The detailed knowledge obtained by ABCD has the potential to identify what the targets need to be for this long-term prevention.”
5. Prevent Mental Illness
What is the ideal age to begin helping kids in order to promote mental health and prevent mental illness? At Zero To Thrive, the answer is before birth.
Housed within the psychiatry department, Zero to Thrive delivers mental health services to individuals and families from conception through early childhood.
“The science is clear: brain development in the earliest years lays a critical foundation for later well-being, and intervention to promote early relational health has demonstrated a strong return on investment,” says Maria Muzik, M.D., M.Sc., co-director of Zero to Thrive and associate professor of psychiatry and of obstetrics and gynecology. “Effective programs need to address critical mental health needs not only through access to psychiatric care, but also by reducing the social isolation that so many families experience, supporting parents in meeting their own and their child’s emotional needs, and connecting families to resources in the community to meet the full range of family needs.”
Zero to Thrive teaches the importance of early relational health and what it looks like to build a responsive relationship between a caregiver and an infant. When caregivers are positive and responsive, a baby’s brain gets the stimulation needed to form the neural pathways to build resilience and thrive. Trainees at the Medical School work in both a perinatal clinic that serves pregnant and postpartum people, and in the Infant and Early Childhood Clinic that serves families from birth through age 6 using cutting-edge video-observation and feedback technology to support and nurture family strengths.
“While our clinic-based services are critical, if we wait for families to reach us in psychiatry, we will have only reached the tip of the iceberg,” says Katherine Rosenblum, Ph.D., co-director of Zero to Thrive and professor of psychiatry, of pediatrics, and of obstetrics and gynecology. “That is why we place a great deal of emphasis on partnering with community providers, offering training to multidisciplinary providers in perinatal and early childhood mental health, and thereby reaching families where they already are — from pediatric primary care, to early care and education, to other community-based programs.”
A key part of Zero To Thrive is a series of Strong Roots programs that help kids by building resilience in families, especially those who have been exposed to adversity such as trauma, economic oppression, or inequity. Studies of these programs have demonstrated positive impacts for both parents and children, including improved early relationships, changes in parental brain circuitry that are associated with reduced parenting stress, increased social connection with other parents, and increased utilization of community services. There are programs for moms (“Mom Power”), dads (“Fraternity of Fathers”), and military families, as well as a program for early childhood educators who work with infants and children in preschools and nurseries. Zero To Thrive has trained professionals who are rolling out these programs in community-based organizations all over the country. Zero To Thrive also conducts research, education initiatives, and a clinical enterprise to help pregnant and postpartum people with mental health issues.
“Schools, primary care providers, and local community resources need to find ways to integrate mental health and well-being in everything they do,” says Malas. “We need to see mental health as a shared responsibility of all professionals who interface with children and families.”
Another program started at Michigan Medicine that takes that integrated mental health model to heart is TRAILS (Transforming Research into Action to Improve the Lives of Students). TRAILS equips school staff with the training, resources, and clinical tools necessary to implement its three tiers of programming: 1) Social and emotional learning to promote resiliency and build students’ self-regulation skills, and self-care strategies for staff to counter stress and burnout; 2) Early intervention for students with mental health concerns; and 3) suicide risk management and care coordination for students in crisis.
Studies show that students who receive the cognitive behavioral therapy and mindfulness training offered by TRAILS demonstrate a 16.9% decrease in symptoms of depression and/or anxiety, as well as an increased use of self-regulation and coping skills.
The Eisenberg Family Depression Center also offers a Peer-to-Peer program that began in 2009. The program educates middle and high school students about depression and depressive illnesses and helps them find creative ways to convey this knowledge to their peers. The program received the American Psychiatric Association’s Gold Award for academic programs in 2019.
6. Help the Helpers
Attending to the needs of mental health care providers is a key component of protecting children’s mental health.
A small change that could help these providers is to increase understanding of the many mental health specializations. “Would you send someone with a tummy ache to a dermatologist?” Kaufman asks. She often receives inappropriate referrals because referring providers are not aware of the full range of subspecialties within psychology and where to go for a given concern. For example, the neuropsychological testing that Kaufman does targets primarily cognitive concerns and diagnostics as opposed to behavioral or mood treatment, but someone might assume that she handles patients with those latter concerns because she is a psychologist. It’s not just that it’s frustrating to get an inappropriate referral, but it is an inefficiency in the system of mental health care that, if corrected, could free up specialized providers to offer the right care to the right patient at the right time.
A bigger challenge is offering better support to providers. “The mental health of the mental health providers is really low right now,” says Kaufman. “We’re the people who listen to everyone in crisis.”
At the beginning of the pandemic, she and other mental health care providers at Michigan Medicine banded together to support frontline health care workers. There were 200 volunteers who provided in-person and virtual counseling to their Michigan Medicine colleagues who were seeing the worst of the pandemic. They also helped to educate them about the way trauma affects mental health and what they might expect to experience over time.
Now those volunteers are the ones experiencing an enormous burden, as the demand for mental health care far outstrips the supply of providers. Kaufman believes a meaningful first step towards helping mental health care providers would be to honestly acknowledge the ways they are suffering. “Appreciation is [best] shown by listening and hearing and being engaged in what’s happening.”
7. Change the Conversation
In the late 1960s, Congress commissioned a study that resulted in a report called Crisis in Child Mental Health. Hirshbein says, “It called out things like systemic racism, [showing] there’s no way poor black kids can survive and thrive if living in these conditions. What’s striking about this report is there’s nothing in it about psychiatric diagnoses or medication.
“Child psychiatrists at the time were mostly psychoanalytical, but they were also activists,” says Hirshbein. “They wanted government to do things to help kids. They were about big social changes.” The Crisis in Child Mental Health report was initiated under President Johnson’s administration, “but it landed on President Nixon’s desk, where it promptly died.” There were no big social changes coming.
Then, in the 1990s and 2000s, psychiatric medications for children became more accessible and commercialized, says Hirshbein. “The idea of diagnosing, treating, and focusing on mental illness was really a shift for child psychiatry. Yet the numbers of kids who are meeting criteria for mental illness are not going down. Something is happening, and we’re going in the wrong direction.”
Hirshbein believes it could be helpful to shift the conversation back to the question guiding the 500 experts who worked on the Crisis in Child Mental Health report: “What does it mean to raise a child to be healthy?”
One answer to that question involves helping kids learn basic social skills and rules of civility, assets Martin sees as casualties of the pandemic. “The skills we need to function as a society are under threat now,” she says. “We’ve lost the social fabric of our community interactions, and Zoom is not a replacement for in-person communication.”
Martin believes the isolation caused by the pandemic is especially fraught for children, who are just learning how to be social. She also worries about the increasingly uncivil tone of online discourse. “How do we course correct in a society where being vitriolic or accusatory or, frankly, abusive becomes the norm?
“If you’re a child growing up in this environment, I worry about what you’re going to look like 10 years from now. It’s really scary. How do we create those meaningful interactions for families, individuals, and communities?”
A positive of the pandemic has been a shift in public conversations about mental health. “We’ve come a long way in addressing the problem of stigma in mental health,” says Martin.
“I think it’s great that we’ve declared this mental health crisis and that it’s been acknowledged by several professional organizations and in the State of the Union address,” says Quigley. “But this was brewing long before COVID-19, and I hope it continues to sustain people’s attention and investment, because this is not going anywhere. There will be a generation of kids impacted by COVID-19 who will have needs ongoing. I think about my 3.5-year-old … COVID-19 is the life she remembers. The repercussions will be felt for a long time.”
The following is a press release originally published on the Michigan.gov website. It features a mention of Gov. Whitmer’s proposal to fund a $5 million on-demand help of school-based clinicians initiative via the MC3 program.
LANSING, Mich. — Today, Governor Gretchen Whitmer sat down with students, parents, educators, and mental health professionals at Pontiac High School to advocate for additional mental health investments in schools at the beginning of Student Appreciation Week. The governor’s fiscal year 2023 School Aid Fund budget recommendation would invest $361 million for school-based mental health services, including hiring and retaining mental health professionals and opening 40 new clinics for students across the state.
“Last year, I made largest education investment in Michigan history and delivered resources to hire over 560 mental health professionals, including nurses, social workers, and psychologists,” said Governor Whitmer. “In my budget for the next school year, I’m proposing another historic investment in on-campus mental health supports for our kids. We can and must work together to expand access to mental health care to help our kids thrive in and out of the classroom. My budget includes the highest per-student investment in Michigan history – I look forward to making that investment reality. Let’s get it done.”
Governor Whitmer’s Proposed Mental Health Investment
The fiscal year 2023 School Aid Fund Executive Recommendation includes $361 million for school-based mental health services. Today’s visit highlights the increased need for school-based mental health services and the Governor’s proposed response. Governor Whitmer’s proposed budget includes:
School-based health centers, also known as child and adolescent health centers, are housed in school buildings and staffed by clinicians. There are over 100 sites across Michigan, serving more than 200,000 students annually in communities where families lack access to medical services. Governor Whitmer proposes adding 40 more sites.
The following article was written by Estelle Slootmaker and originally published by Second Wave Michigan. It mentions the MC3 program in reference to MC3’s collaboration with the Inter-Tribal Council of Michigan to improve mental health outcomes for members of Michigan’s tribal communities.
This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.
Even as mental health issues have risen worldwide, Michigan has fallen behind on having enough health professionals to address that trend. According to National Alliance on Mental Illness (NAMI) data, there were 421,000 Michiganders who did not receive needed mental health care in 2021, but only 38.4% cited cost as the reason. A Kaiser Family Foundation analysis illustrates one of the other key reasons people aren’t getting the care they need. That study finds that more than four million Michiganders live in communities with a shortage of mental health professionals, ranking fifth worst in the nation, behind Texas, California, Alaska, and Missouri.
“There’s a systemic shortage. We don’t have enough providers to meet the needs of the population. The shortage has progressively gotten worse over the last five or 10 years. And we’re feeling the impact even more due to COVID,” says Timothy Michling, research associate in health affairs at the Citizens Research Council of Michigan and author of a report entitled “Michigan Falls Short on Mental Health Services.” “When we look at projections going forward, we see the gap between demand and supply of providers widening. If we don’t address the issue now, it’s only going to get worse in the future.”
According to Michling, this shortage spans the mental health professions, from direct caregivers to master’s-level therapists to social workers to psychiatrists to psychologists. Many Michigan counties have no psychiatrists, particularly for children and adolescents.
“Mental health underpins our wellness as a society. We see much worse outcomes in a variety of health conditions when you have an untreated mental health disorder. This affects our economy and our society at large,” Michling says. “Students are not able to do as well in school if they have an undiagnosed or untreated mental health condition. And that follows children into adulthood. It affects their career readiness. It affects our rates of homelessness, our rates of unemployment and workforce participation.”
Filling the void for tribal communities
Effects of the mental health professional shortage vary by geographic region in Michigan. Six Upper Peninsula counties and nine Lower Peninsula counties have no psychiatrists, and three UP counties and seven Lower Peninsula counties have neither psychiatrists or psychologists. Michelle Schulte, maternal infant child health division director for the Inter-Tribal Council of Michigan (ITCMI), works with Northern Michigan tribal communities located in some of these areas of need.
“The shortage of mental health professionals is impacting people in our communities in a very bad way,” Schulte says. “We have long waiting lists … People who have needs can’t get in. In our rural areas, especially the UP, many people have to travel two to four hours to get the kind of care that they need. Some tribal communities have a limited contract with a local psychiatrist or psychologist that comes in maybe once a month and sees everybody on that same day. If you miss your appointment or can’t make it on that day, you’re stuck.”
Schulte and her ITCMI colleagues have collaborated with a wide range of partners to create projects and programs that shore up the lack of mental health services, especially for children and young families. MIchigan Medicine’s Michigan Child Collaborative Care program provides mental health services via telehealth. The Michigan Public Health Institute and Michigan Association for Infant Mental Health programs train early childhood teachers to address children’s mental health in Head Start programs and tribal schools, and to equip designated child behavior specialists from within the community to support families.
“We’re seeing children who have a high influx of behaviors that our early childhood providers have never had to deal with before or feel ill-equipped to deal with,” Schulte says. “A child may have disruptions at home, … may not have slept well, may not have been bathed, or may feel run down. How do we address it in a way that the child gets what they need, as far as nurturing attention or care?”
ITCMI social media campaigns enlist aunts, uncles, and grandparents to play traditional cultural roles in raising children within extended families. An ITCMI focus group with tribal elders explored Anishinaabe words for resiliency, producing rich definitions that strengthen that concept in community.
“Our goal is to support healthy development and resiliency in children,” Schulte says.
NAMI Michigan a first responder for many
Kevin Fischer, executive director of NAMI’s Michigan chapter, agrees that the state is experiencing a dire shortage of mental health professionals. That may be one reason that NAMI affiliates across the country have seen requests for help increase between 80% and 100% over the last year. The nature of the calls for help has changed, as well. More people are calling with an urgent need for services. NAMI’s education and support programs also are seeing huge increases in enrollment.
“People are calling to get a better understanding of what’s going on, what a mental health diagnosis means,” Fischer says. “For example, they ask, ‘What is schizophrenia? What does bipolar mean?’ They may have a family member and want to better understand how they can help them.”
NAMI Michigan’s peer-support volunteers help the nonprofit meet this increasing need. These peers have lived experience of mental illness. That experience may be helpful to a person initially diagnosed with a mental illness, who may feel uncomfortable talking to friends or family members about it.
“They really want to talk to somebody who’s walked in their shoes already, to get an understanding of what their recovery process would look like,” Fischer says. “Peer supports have become tremendously valuable.”
Fischer notes that unless more mental health professionals enter the field, Michigan communities will be ill prepared for increasing demand for mental health services. For example, from 1999 to 2019, suicide rates have increased in the general population by 35%. Other groups have seen even more severe increases. Among Black male adolescents, suicide attempts increased by nearly 80% between 1991 and 2019.
“We’re seeing another significant uptick in needs for mental health services among young people because of social distancing and closing the schools,” Fischer says. “There’s a significant increase in mild to moderate mental illness — depression, anxiety, some self-harm like cutting. Across the board, there’s been a significant increase.”
More strategies for increasing the ranks
Fischer notes that the surge in telehealth usage has helped address the shortage of mental health professionals, especially when COVID-19 limited face-to-face health care visits. While virtual video calls are not the answer for every person living with mental illness, the modality has had surprising success. Another strategy that could help relieve the shortage is better equipping primary care providers to offer mental health services.
“We’re in this age now where we’re talking about integrated health care. Our primary care physicians really should be our first responders for behavioral health care,” Fischer says. “They are able to diagnose and prescribe medication for people who are experiencing mild to moderate mental health diagnoses, or refer them to a psychiatrist or psychologist if they think something more serious is going on, like schizophrenia or bipolar disorder. But that’s not the norm.”
Michling concurs. However, even though primary care physicians may have received mental health care training in medical school, many are not comfortable — or not willing — to tackle mental health issues during office visits. Additional options to address the shortage include policy changes that allow nurse practitioners to have a wider scope of practice, school loan forgiveness for college graduates entering behavioral health care fields, and better insurance reimbursement levels for behavioral health services.
“We also want to look at ways to incentivize people to stay in the field so we don’t have high rates of atrophy and people leaving the field for other professions. That requires research on why folks are leaving,” Michling says. “Recruitment efforts at the undergraduate or high school level could make a really clear talent pipeline and career trajectory for folks to get into various behavioral health careers. Beyond that, providing grants to help hospital emergency departments deal with psychiatric or other mental health emergencies, or supplemental training for physicians, nurses, and other emergency department personnel, could make them better equipped to deal with what we’re seeing.”
While finding ways to increase the ranks of mental health professionals is essential, Michling feels it is even more important to address the root causes of growing mental illness among Michiganders.
“Much in the way that we treat chronic disease, we want to focus our public health resources on strategies to deal with stress, improved nutrition, improved sleep, mitigating the community-level factors that we know can put people at greater risk for experiencing a mental health disorder,” Michling says. “That prevention piece, I think, is what’s really lost.”
The following article was written by Beata Mostafavi and originally published by the Michigan Health blog. It mentions the MC3 program in reference to guidance from experts recommending that parents of adolescents reach out to primary care providers for help in finding a mental health provider and support from their communities.
Amid growing concerns for children’s mental health during the pandemic era, more than a quarter of parents say their adolescent-aged child has seen a mental health specialist – with nearly 60% of those reporting a visit within the past year – a new national poll suggests.
But screening and navigating the mental health care system remains difficult for many parents. While almost all parents say they’re confident they would recognize a possible mental health issue in their child, much fewer say their child is regularly screened for mental health by their provider or that it’s easy to get the care they need once they recognize a problem.
The findings come from a nationally representative report conducted by the University of Michigan Health C.S. Mott Children’s Hospital National Poll on Children’s Health in collaboration with the Children’s Hospital Association. The report, which comes less than six months after children’s mental health was declared a national emergency in the United States, is based on responses from 1,201 parents of children ages 11-18 surveyed in October 2021.
“Even before the pandemic, mental health disorders in adolescents, such as depression and anxiety, were prevalent,” said Mott Poll co-director and Mott pediatrician Gary L. Freed, M.D., M.P.H.
“The pandemic caused significant stress and social disruption for kids that likely exacerbated these problems, as we’re seeing a growing number of young people face mental health concerns. This places a heavier burden on parents, health providers and other trusted adults in their lives to be aware of potential warning signs.”
While a third of parents say their adolescent has completed a mental health screening questionnaire at their primary care office, only four in ten say their adolescent’s provider asks about mental health concerns at all well child visits. One in seven say their provider never asks about mental health concerns.
“Regular check-ups are the best time for providers to discuss potential mental health concerns,” Freed said. “If parents feel their adolescent’s provider is not being proactive in raising these issues, they should bring it up with them.”
It’s also important for adolescents themselves to feel comfortable seeking help, Freed notes.
Only a quarter of parents polled, however, thought their adolescent would definitely talk to them about a possible mental issue, and even fewer thought their adolescent would open up with their primary care provider.
There are some steps parents can take to help, Freed notes. He recommends having open conversations with kids that give them opportunities to discuss issues and emphasize that asking for help “isn’t a sign of weakness but of strength.” They can also prepare them for health visits by reinforcing the importance of sharing concerns with providers and also allow their child privacy during the visit.
“Being good listeners and initiating open, non-judgmental conversations about mental health can help reduce stigma and make kids feel more comfortable,” Freed said. “It may also be helpful for parents to share any of their own experiences with mental health challenges.”
“Before seeing a doctor, adolescents should understand that their doctor is there to help and that they should be as honest as possible about any physical or mental health problems.”
Even before the added stress and disruption of the pandemic, one in five adolescents had a diagnosable mental health disorder, including depression and anxiety. Several reports indicate that these challenges may have worsened during the pandemic.
While it may be difficult for parents to tell the difference between their adolescent’s normal ups and downs and mental illness, parents polled seemed to know what to look for. Among signs that would prompt their concern were frequent comments about being worried or anxious, moodiness, decreased interaction with family, a drop in grades or changes in sleep or eating patterns.
SEE ALSO: How to Talk to Children and Teens About Suicide: A Guide for Parents
If parents notice a possible mental health issue, most say their first response would be to talk with their adolescent or keep a closer eye on them. Fewer parents’ first response would be to make an appointment with a healthcare provider, check in with their adolescent’s teacher or get advice from family or friends.
The stigma of mental illness may make parents hesitant to seek help or delay seeking care for their adolescent as they may think the symptoms will go away on their own, Freed says. But it’s important to take the next step if needed.
“Signs of struggles with mental health can look different for every child, and some may be easier to recognize than others,” Freed said. “Parents should take seriously any major changes to their baseline behavior that could be a symptom of something more concerning.
“If adolescents seem overwhelmed by trying to manage challenges, parents should seek professional help.”
More than half of parents say they decided on their own to have their adolescent see a mental health specialist while less than one in five got a referral from their adolescent’s primary care provider or school.
But even after recognizing a problem, some parents also have trouble navigating the health system to find a mental healthcare evaluation or treatment options for their adolescent, the poll finds.
Nearly half of parents who tried to do so, describe difficulties getting their adolescent care with a mental health specialist, including long waits for appointments, finding a provider who took their insurance or saw children. Ten percent of parents also said they simply just didn’t know where to go.
Experts say parents should reach out to their adolescent’s primary care giver for help in finding a mental health provider and support from their communities. Some programs, such as the MC3 program at University of Michigan, helps connect primary care providers with psychiatrists and behavioral specialists for consultation and training to help address mental health needs in local clinics.
“Difficulties finding and getting mental health care for youth reflects strains in our current mental health system and highlights the need for more ways to support parents and their children,” added Amy Wimpey Knight, president of CHA.
“Parents whose children need mental health help should remember they aren’t alone. But they may need to be proactive and persistent in seeking support from a provider, their school, or family or friends in caring for mental health issues.”
Original article written by Estelle Slootmaker and published by Second Wave Michigan on Jan., 13, 2022.
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This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.
Across the country, more kids than ever are struggling with mental illness. 20% live with a diagnosable mental illness and 10% are experiencing a significant impairment. Over the past 10 years, twice as many teens and young adults have had major depressive episodes, and suicide is now the second leading cause of death for Americans aged 15-19. To make matters worse, more than 33% of Michigan’s littles, adolescents, and young adults with mental health issues do not have access to care.
In 2012, Dr. Sheila Marcus and her colleagues at Michigan Medicine launched a program to address this mental health epidemic: Michigan Child Collaborative Care (MC3). MC3 helps primary care providers (PCPs) address their young patients’ mental health by offering same-day phone consultations, scheduling telepsychiatry sessions with patients, connecting families to local mental health resources, and providing educational opportunities for PCPs to expand their expertise in diagnosis and treatment. In addition, MC3 has expanded its reach to women experiencing mental illness during pregnancy and postpartum.
Marcus, a clinical professor at the University of Michigan (U-M) and section chief for child and adolescent psychiatry at Michigan Medicine, says MC3 aims to improve access to mental health care, as well as PCPs’ “competence and confidence.”
In addition to drawing upon Michigan Medicine’s psychiatry department, MC3 collaborates with the Michigan State University College of Human Medicine, which provides group case consultations and educational programming, and the Michigan Department of Health and Human Services (MDHHS). Since launching in 2012, MC3 has enrolled approximately 3,500 PCPs and provided about 18,000 consultations.
“I became aware of the increasingly dire straits of mental health care for children, young adults and women in the state of Michigan,” Marcus says. ” … MC3 was designed to leverage getting mental health expertise from big academic centers into the communities. The goal is to provide diagnostic clarification to clinicians who are really puzzled by what they’re seeing in front of them and are not sure what to call it — and to improve evidence-based treatments, including advice about psycho-pharmaceutical medicines as well as psychotherapies.”
For example, Marcus notes that pediatricians may misdiagnose children who have experienced trauma as having bipolar illness or ADHD. When those pediatricians consult with an MC3 psychiatrist, they are equipped to make better diagnoses.
“We’re providing access to people who otherwise would not have access,” Marcus says. “We’re seeing high rates of trauma among the population that we serve, high rates of suicidality — patients who have been hospitalized and are coming out, or patients who have some degree of suicidality. When they went to the emergency room, they were not severe enough to be admitted. So they come back to the PCP office.”
“I was bowled over.”
One of those PCPs, Dr. Lia Gaggino, practiced as a pediatrician with Bronson Rambling Road Pediatrics – Oshtemo for 33 years. She joined the MC3 program when Marcus, whom she did not know at the time, recruited her via Facebook in 2012.
“At the time I trained, we basically learned how to manage ADHD, which I think pediatricians are really good at. I was always interested in mental health, so I took psychopharmacology courses, went to lots of conferences, did lots of reading, and worked with some other pediatricians that were really gifted,” Gaggino says. “When Dr. Marcus described that MC3 could be a support, that I could talk to a child psychiatrist on the same day [of a patient’s visit], I was bowled over. Even if she had said, ‘We can get back with you in two weeks,’ I would have been ecstatic because prior to MC3, I had to manage everything without a psychiatrist.”
Gaggino’s retirement from active practice launched her into her role with MC3, where she now consults with, educates, and recruits Michigan pediatricians, family practice doctors, and obstetricians into the program.
“Now more than ever, mental health is a significant concern for kids. Both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry have declared a mental health crisis,” Gaggino says. “Behavioral health concerns account for well over a third of patient visits. … For most pediatricians it is a daily occurrence.”
Gaggino says those patient visits reveal that too many kids live with anxiety, depression, and suicidal ideation. Parents may bring kids in because they have chronic stomach aches, chronic headaches, or sleep disturbances. When physical causes are ruled out, their doctor can quickly consult with an MC3 psychiatrist and receive guidance the same day.
“We are finding that much of the time, PCPs are just unsure about what to call things,” Marcus says. “Children who have trauma backgrounds are often being misdiagnosed with bipolar illness or ADHD. We’re trying to rectify some of that.”
A phone conversation with a child psychiatrist helps clarify the diagnosis and sets the child on the way with the correct medication and treatment plan. That plan might include a telepsychiatry visit with one of MC3’s behavioral health consultants, referral to a local mental health resource, or simply continued follow-up with the PCP. MC3 also consults with over 75 school-based health centers and provides educational programming to PCPs as well as schools.
“The MC3 behavioral health consultants are all regionally dispersed and are very knowledgeable about which resources exist in the home community,” Marcus says.
Mental health help for the youngest among us
With funding from the MDHHS Healthy Moms, Healthy Babies initiative, MC3 has expanded its reach to Michigan’s perinatal providers, who serve new moms in the weeks immediately before and after birth. Dr. Maria Muzik, who leads the U-M psychiatry department’s Zero to Thrive women and infant mental health programs, shared her insights in a September 2019 State of Health series story on new moms and mood disorders.
“These are natural points where moms are being seen by the medical professionals,” Muzik said. “We know this is a time when women are vulnerable for mental health issues and that preexisting conditions are exacerbated by the hormonal changes, sleep deprivation, and birth trauma.”
Through MC3, pregnant women identified as at risk for mental health issues receive brief interventions and same-day access to virtual counseling and care coordination through remote behavioral health consultants. In some cases, MC3 sets up telepsychiatry consultations with psychiatrists who focus on the perinatal period. When mothers have access to mental health services, infants and children are better poised to experience better mental health in the future as well.
Through COVID and beyond
COVID-19 has hit Michiganders’ mental health especially hard, especially in families who have lost jobs or found themselves food-insecure. And, for both rural and urban residents, the long-term mental health outlook is not bright. Delivering virtual care for years before the pandemic struck, MC3 has been a shining example of how mental health care can be expanded to meet this increasing need.
“There is no question that there is ‘a surge after the surge’ during COVID,” Marcus says. “There are increased rates of suicidality, especially among teens. There are increased rates of trauma. If you think about families who are quarantined together with their aggressor, that’s a huge issue. There are issues with children with special needs, like autism and developmental disorders, who have had their primary treatments interrupted.”
Because of MC3, Michigan communities lacking mental health services or a practicing psychiatrist have an alternative. Organizers hope that as this model of care becomes more broadly recognized, health care systems and payers will step up with funding to expand it – and reduce reliance on grant dollars.
Gaggino says MC3 made her a better clinician and “totally changed” her prescribing habits.
“You do the best you can, but you can do better when you have help,” she says. “MC3 is really brilliant in being able to amplify that support.”
Dr. Sheila Marcus photo by Doug Coombe.
MC3 Pediatrics Director Dr. Sheila Marcus was interviewed on the Paul W. Smith radio show, commenting on the mental health implications for the November 30 Oxford High School shooting. She also explained what MC3 and how primary care providers in Michigan can sign up. Listen to the interview below:
This article, written by Kara Gavin, originally appeared on the M Health Lab website.
Most mental health care in America doesn’t happen in psychiatrists’ offices – especially when it comes to children, teens and young adults.
Instead, young people with depression, anxiety and more turn to the same people they already go to for all kinds of other health issues: their pediatricians, family doctors, school-based clinics and other primary care providers.
But where do those providers turn when they need more help in handling the mental health concerns of their patients – especially more serious issues that they’re not trained to handle?
If they’re anywhere in Michigan, they can turn to the team at MC3.
For nearly a decade, the MC3 program has helped thousands of primary care providers throughout the state care for the mental health needs of young people up to age 26. It also aids providers caring for pregnant women and new mothers of any age who have mental health needs.
More than 16,000 times since 2012, MC3’s psychiatrists and pediatric behavior specialists from the University of Michigan have connected directly with more than 1,800 primary care providers by phone, for consultations about their patients.
Together, they’ve mapped out plans for handling ADHD in young children, suicide-prevention safety planning for teens and symptoms that might signal schizophrenia in young adults.
There’s no charge to providers or their patients, thanks to the program’s funding from state and federal grants.
For providers whose patients recently had a mental health emergency or are waiting for an appointment with a child psychiatrist or a psychiatric inpatient bed, the service can literally be a lifeline: one in five of the consults involve a patient who has expressed suicidal thoughts or harmed themselves.
MC3 also offers video-based telehealth appointments to connect patients of participating providers with psychiatrists. U-M and Michigan State University experts have also created a wide range of training options for professionals available on the MC3 website.
Though the demand has grown in recent years thanks to the pandemic, the program has room for more Michigan providers to join the network and get access to its services.
Each connection starts by contacting one of the trained professionals in MC3’s network of Behavioral Health Consultants, located throughout the state. MC3 also works closely with the state-funded Community Mental Health agencies across the state.
“Only about 3% of the children, teens, young adults and moms that our participating providers have consulted with us about are in treatment with a psychiatrist. We’re providing access to specialist-informed care to young people who wouldn’t otherwise have it,” said Sheila Marcus, M.D., who heads the pediatric component of MC3 and is a professor of psychiatry at Michigan Medicine, the University of Michigan’s academic medical center.
“The reality is that no matter where they live and no matter what their family’s income level, most of these patients would not have easy access to a specialist because of the critical shortage of such providers,” she added. “In some counties, there are no local providers trained to provide this level of care.”
Primary care providers inside and outside Michigan can also access MC3’s free online resources, even if they’re not enrolled in the program.
These include prescribing guides for mental health medications and online provider education, to equip them to provide diagnosis and care that might not have been part of their formal professional training. Much of that training offers continuing education credits that can help physicians, nurse practitioners, physician assistants and certified nurse midwives keep up their license.
“For me, MC3 has been a game changer,” said Lia Gaggino, M.D., who first interacted with the MC3 team through her pediatrics practice in Portage, Michigan and now is the team’s consulting pediatrician. “Since its inception I have used their services for children and teens who presented with very complicated mental health concerns. I wished I had had a psychiatrist to help me and then MC3 appeared and offered me a lifeline. Their services changed my prescribing practices and improved my skills and I am so grateful for their advice and support. I encourage my colleagues to sign up and call –MC3 is there to help us!”
As the nation grapples with a national emergency of rising mental health concerns among young people, MC3 and similar programs in other states are expanding access to critical psychiatric services at a time when demand is soaring.
The national organizations that declared that emergency in October called for more support of mental health care in primary care settings, as well as efforts to overcome the national shortage of mental health specialists for young people, especially in rural and low-income areas.
That shortage is what drove the creation of MC3 in the first place.
Michigan is third from the bottom among all states in supply of mental health professionals for young people. Only Washtenaw County, where the University of Michigan is located, meets national population-based criteria for having enough mental health providers specializing in children and teens.
The pandemic has made matters worse across Michigan and the United States. A national report from November 2020 showed that anxiety and depression in pregnant women have more than doubled, and emergency department visits for mental health concerns in children had risen by double digits since the pandemic began.
Joanna Quigley, M.D., another MC3 consulting psychiatrist from Michigan Medicine, recently presented data at a national meeting showing that 30% of MC3 consults during 2020 focused on pandemic-related concerns.
The pandemic has prompted MC3’s team to plan to offer extra training to help providers identify the needs and handle the concerns of children traumatized by experiences they or their families have had during COVID-19.
Trauma-informed care is also important for children who even before the pandemic experienced very disruptive life events.
Terri Rosel, NP-C, a nurse practitioner at Cherry Health in northern Michigan, wrote to the MC3 team: “I work in a small student health center in Cedar Springs and am the sole provider in the office. Since starting this job four years ago I have had the pleasure of seeing so many students with mental health concerns. I felt ill-equipped at times to help them with my degree as a family practice nurse practitioner. I would utilize MC3 often to help with treatment plans for these wonderful kids who needed help but could not get into psychiatric services soon enough.”
As the program continues to grow, it will partner more with schools through a direct connection with the TRAILS program that offers mental health awareness and support services.
The MC3 team has surveyed participating providers and found that 99% agreed with the statement that “following phone consultation(s) I felt more confident that I could effectively treat patients’ behavioral health problems.”
The team published other findings from its survey of providers, and responded to feedback by making changes.
The quotes they received from providers are equally compelling.
“This service has been absolutely ‘practice- changing’,” said one. “As we have more and more patients with mental health issues and limited local resources- we are essentially the only option for these kids. Having MC3 support helps us make good treatment decisions and is also ‘on the job training’ which we can apply to future patients.”
In fact, MC3 data show that 25% of the interactions help the patient avoid a higher-level of care that may be difficult to access, such as a psychiatric hospital bed or emergency psychiatric visit.
One of the maternal health providers who joined MC3 recently said, “I can’t even express how this service has enhanced the care I can provide. In the past, we’d screen and diagnose and then send moms out. We’d place referrals and hope that folks could navigate the complex system. Now, with MC3, I can collaborate with psychiatry, start meds or treatment, and access community resources that I am confident they will be able to access. It’s really been invaluable.”
Paper cited: “Michigan Child Collaborative Care program (MC3): Ten years of growth, adaptation, and learning,” American Academy of Child and Adolescent Psychiatry annual meeting. DOI: 10.1016/j.jaac.2021.07.142
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