IMPORTANCEEmerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children Յ12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined.OBJECTIVE To identify and describe the key components of effective pediatric integrated mental health care models. EVIDENCE REVIEWThe PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019.FINDINGS Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment. CONCLUSIONS AND RELEVANCEThis review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.

Objective To examine whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization. Design History of seven childhood adversities (physical neglect, verbal abuse, physical abuse, sexual abuse, parental death, parental incarceration, and child welfare system placement) was gathered through in-person interviews. Multivariate models examined associations between history of childhood adversities and moderate to severe depressive symptoms, lifetime history of suicide attempt, or lifetime history of psychiatric hospitalization. Setting General community. Participants The study enrolled 350 homeless adults, aged 50 and older, in Oakland, CA using population-based sampling methods. Measurements Moderate to severe depressive symptoms measured on a Center for Epidemiologic Studies–Depression Scale (CES-D ≥22), self-reported lifetime history of suicide attempt, and self-reported lifetime history of psychiatric hospitalization. Results Participants with exposure to one childhood adversity had elevated odds of reporting moderate to severe depressive symptoms (adjusted odds ratio [AOR] 2.0; 95% confidence interval [CI] 1.1–3.7) and lifetime history of suicide attempt (AOR 4.6; 95% CI 1.0–21.6) when compared to those who had none; the odds of these two outcomes increased with exposure to additional childhood adversities. Participants with four or more childhood adversities had higher odds of having a lifetime history of psychiatric hospitalization (AOR 7.1; 95% CI 2.8–18.0); there was no increase with fewer adversities. Conclusion Childhood adversities are associated with poor mental health outcomes among older homeless adults. Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations.

In this report, we offer three examples of how economic data could promote greater adoption of behavioral and psychosocial interventions in clinical settings where primary or specialty medical care is delivered to patients. The examples are collaborative care for depression, chronic pain management, and cognitive–behavioral therapy for insomnia. These interventions illustrate differences in the availability of cost and cost-effectiveness data and in the extent of intervention adoption and integration into routine delivery of medical care. Collaborative care has been widely studied from an economic perspective, with most studies demonstrating its relative cost-effectiveness per quality-adjusted life year (QALY) and some studies demonstrating its potential for cost neutrality or cost savings. The success of collaborative care for depression can be viewed as a model for how to promote greater adoption of other interventions, such as psychological therapies for chronic pain and insomnia.

Objectives. To determine the economic benefit of “modern” nonemergency medical transportation (NEMT) that utilizes digital transportation networks compared with traditional NEMT in the United States. Methods. We used the National Academies’ NEMT cost-effectiveness model to perform a baseline cost savings analysis for provision of NEMT for transportation-disadvantaged Medicaid beneficiaries. On the basis of a review of the literature, commercial information, and structured expert interviews, we performed a sensitivity analysis to determine the incremental economic benefit of using modern NEMT. We estimated confidence intervals (CIs) by using Monte Carlo simulation. Results. Total annual net savings for traditional NEMT in Medicaid was approximately $4 billion. For modern NEMT, estimated savings on ride costs varied from 30% to 70%. In comparison with traditional, modern NEMT was estimated to save $268 per expected user (95% CI = $248, $288 per member per year) and $537 million annually (95% CI = $496 million, $577 million) when scaled nationally. Conclusions. Modern NEMT has the potential to yield greater cost savings than traditional NEMT while also improving patient experience. Public Health Implications: Barriers to NEMT are a health risk affecting high-need, economically disadvantaged patients. Economic arguments supporting modern NEMT are important given decreased support for human services spending.

Due to a national shortage of child and adolescent psychiatrists, pediatric primary care providers (PCPs) are often responsible for the screening, evaluation, and treatment of mental health disorders. COVID-19 pandemic stay-at-home orders decreased access to mental health care and increased behavioral and emotional difficulties in children and adolescents. Despite increased demand upon clinicians, little is known about mental health care delivery in the pediatric primary care setting during the pandemic. This focus group study explored the experiences of pediatric PCPs and clinical staff delivering mental health care during the pandemic. Transcripts from nine focus groups with San Francisco Bay Area primary care practices between April and August 2020 were analyzed using a thematic analysis approach. Providers expressed challenges at the patient-, provider-, and system-levels. Many providers reported increased patient mental health symptomatology during the pandemic, which was often intertwined with patients’ social determinants of health. Clinicians discussed the burden of the pandemic their own wellness, and how the rapid shift to telehealth primary care and mental health services seemed to hinder the availability and effectiveness of many resources. The findings from this study can inform the creation of new supports for PCPs and clinical staff providing mental health care.

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