Feature

One New York City hospital is bringing mental health directly to local underserved residents through a program that represents a burgeoning new method for delivering mental health services. The New York-Presbyterian Hospital's Integrated Mental Health Primary Care Program helps both children and parents who require mental health services by placing mental health professionals in settings where children are--pediatric clinics.

The program, which began in 2002 with a staff of just three people, now employs eight mental health professionals--four psychiatrists, three psychologists and a psychology graduate student--who perform mental health evaluations and provide services to children in six clinics throughout the northern Manhattan neighborhood of Washington Heights.

For example, if a child with stomachaches that seemingly have no medical basis visits a pediatrician at a clinic, the pediatrician can tap a psychologist down the hall to evaluate the child on-site without delay. The psychologist then co-manages the case with the pediatrician and can refer complex cases to specialty clinics.

"Our pediatricians ask parents at every visit for any medical problem if they are concerned about their kid's behavior or performance in school," says the program's director, psychologist Trish Gallagher, PhD. "We make that connection to mental health right on the spot."

New York Presbyterian's program represents an emerging direction for psychological practice, and one in which only a handful of programs nationwide participate: integrated mental health services, says psychologist Susan McDaniel, PhD, a psychiatry professor and associate chair of family medicine at the University of Rochester Medical Center in New York and former president of APA's Div. 43 (Family).

"What this hospital is doing is not nearly common enough," McDaniel says. "Regardless of what problem a patient comes in with, it's easy for a psychologist to be valuable to a medical team. Before you know it, you're fully integrated into their care."

Stamping out stigma

Building a connection to patients, especially children, is key for the program's staff, Gallagher says. The integrated program serves Washington Heights, a mainly Latino community composed largely of immigrants from the Dominican Republic. The community has more than its share of troubles, says Gallagher. Nearly half of its children live at or below the poverty line, and the neighborhood has one of the highest levels of violent crime in New York City. Children often witness or are victims of those crimes, she adds.

To effectively assist the community, most of the primary-care program's staff members speak both English and Spanish. The program's pediatric and adult components served about 3,500 patients in 2003 and another 5,400 last year, Gallagher says. She and David Weng, MD, the director of the adult component, expect even more in 2005.

One reason to account for the growth in number of patients is the program's ability to reduce the stigma some community members feel when they receive mental health services, says Claudia Patino, PsyD, one of the integrated program's psychologists.

"These pediatricians have known some of these kids and families for years, and they've really connected," she says. "The families come in already trusting me based on my relationship with the pediatrician."

Since program psychologists and psychiatrists perform evaluations on-site as part of the overall care of the child, such care is easier for people to accept than going to a large, overwhelming hospital setting for treatment, Gallagher adds.

"The stigmatization involved with visiting a mental health practitioner is decreased because we're already there," explains Gallagher. "Our pediatricians can simply say, 'Let me introduce you to Dr. Gallagher; she works here too.' Patients aren't as concerned when we are part of the overall care."

Also, Gallagher notes, such immediate, integrated care ensures that the first check on the mental health of a child who needs assistance won't be done at the hospital's emergency room--which is where some children go when problems escalate.

"This approach is emerging as a truly effective way to help underserved communities," says James Bray, PhD, director of the Family Psychology Clinic at the Baylor College of Medicine in Houston and a member of APA's Council of Representatives and Div. 43. "Integrated programs are the wave of the future in psychology and present a real growth area for psychologists. And pediatric psychologists have taken the lead in many of these integrated programs. The unique thing about this clinic is that it serves people who often don't have access to mental health services of any kind."

And the program is winning converts. In a 2004 survey on the integrated program, 86 percent of physicians in clinics noted improved access to mental health services for their patients, while 95 percent of patients reported being satisfied with the service.

Expanding the model

The collaborative nature of the program has another side-benefit, Gallagher says: It educates pediatricians about children's mental health issues.

She says mental health problems usually emerge in anywhere from 12 to 29 percent of children in the general population seen in primary-care clinics, but that only 10 to 22 percent of those children actually receive a diagnosis.

"We're educating physicians about what mental health disorders like depression and [attention-deficit disorder] look like in kids," she says.

Gallagher's next goal is to export the program to other communities. Already, she is advising two New York State hospitals beginning similar programs on ways to get up and running. She says the collaborative model is essential--and she's learned that from experience.

"In my private practice, I consult with pediatricians all the time," she explains. "We work hand-in-hand. I'd like to see us continue to move beyond isolated practice to a more collaborative approach, and this is a great way to do that."

Patino agrees. As a recent graduate, this is her first job working in an integrated setting. But she says she wouldn't have it any other way.

"When I see the wide range of issues that some patients face, I most like being able to help before the problem gets severe," she says. "Thanks to the pediatricians, the patients trust us, and that we are so accessible to them is what makes this program unique."