Mental health teams give pediatricians a 2d opinion

SPRINGFIELD -- The voicemail delivered an SOS from an anxious pediatrician: "This kid is really out of control. He's basically destroying his family. Can someone please call me?"

Dr. Barry Sarvet, a Yale-trained child psychiatrist, returned the call within minutes, to offer guidance. He has been taking such calls for three years, as part of the Massachusetts Child Psychiatry Access Project, a program that allows virtually any Massachusetts doctor who treats children to call for an immediate consultation about any patient's mental health -- for free.

The first of its kind in the nation, the program has been ramping up since 2004 and now covers virtually the entire state. Psychiatric specialists in six regional teams offer phone advice within half an hour, face-to-face evaluations within days, and help obtaining mental health services for children and teens.

The project, funded by the state Department of Mental Health, provides support at a time when pediatricians are likelier than ever to be asked to prescribe Ritalin, diagnose depression, and screen for emotional distress -- work that many were not trained to do.

It also conserves a scarce resource: child psychiatrists. They are in short supply around the country, and waits for appointments can stretch to months. The new project helps primary care physicians handle relatively simple mental health issues, such as moderate depression or anxiety, freeing up the psychiatrists' time for more complex and severe cases.

"In their heart of hearts, some pediatricians would like to be able to refer a child [to a psychiatrist] as if they were referring to a cardiologist" -- simply handing the patient over to a specialist, said Dr. Joseph Gold, chief medical officer of McLean Hospital. "But given the shortage of child psychiatrists, the pediatricians recognize that in some cases, it's enough if they can just get an opinion."

Massachusetts has the highest per-capita number of child psychiatrists in the nation, said Dr. John Straus, vice president for medical affairs of the Massachusetts Behavioral Health Partnership, which contracts with the state to run the project, among other services and programs. But they are still in short supply here, perhaps because many occupy academic or administrative positions and do not practice, Straus said.

Washington state is about to launch a program modeled on Massachusetts', Straus said, and other states have expressed interest as well.

Handing out psychiatric opinions over the phone may sound like a recipe for a lawsuit.

But Sarvet, chief of child psychiatry at Baystate Medical Center, said that the project's consultants emphasize that their function is essentially educational, sharing information about state-of-the-art psychiatric practices and standards, and recommended drug dosages. Also, he said, its specialists tend toward highly conservative and circumspect opinions. If they are at all unsure, they ask that the child come in for a face-to-face evaluation. And they do not write prescriptions themselves.

A typical opinion, he said, might sound like this: "You describe a history consistent with a diagnosis of depression, and best practice is to refer the patient to a therapist and offer the option of starting medication."

The project essentially provides a systematic version of an age-old practice in medicine, the "curbside" or "hallway" consult, in which a doctor stops a colleague with more expertise and says, "I have a case like this, what would you do?" Straus said.

At Redwood Pediatric and Adolescent Medicine in East Longmeadow, the team's nurse-practitioner and three pediatricians call the project's Springfield office about once a week, said Dr. John Kelley, one of its physicians.

"There's a big problem with access to mental health care for kids," he said. "It's a huge issue for us, because primary care doctors are being asked to take on more and more of a role in something we're absolutely not trained in. This program has been just wonderful because what it gives us is someone I can call."

Kelley said he appreciates the "care coordination" aspect: Each team has a staffer whose job is to find the mental health services a family needs for their child, and that accepts their insurance. The staffer serves as a guide through the confusing world of "family stabilization," "partial hospitalization," and "crisis intervention."

"Before," Kelley said, "we had to beg and grovel to get a kid into mental health services with psychiatric involvement."

In an ideal world, Kelley said, he would be able to simply refer patients to pediatric psychiatrists whenever needed, and they would take over. But "this is a kind of an in-between," he said. "It's a whole heck of a lot better than it was before the program started."

Other pediatricians seem to agree with him; the project has polled them, and found that the great majority think access to child psychiatrists has improved since it began, even though the number of psychiatrists statewide -- about 280 who see patients -- has not increased.

The project does not accept calls from families, therapists, or social workers.

Parents of mentally ill children say that waits for psychiatric help are still too long. But, said Lisa Lambert, director of the Parent/Professional Advocacy League, "we're hearing fewer stories about pediatricians who are uncomfortable or reluctant to deal with mental health needs." The project's most obvious effect, she said, "is that families just aren't telling us as much about how they're sort of hitting a blank wall in pediatricians' offices."

On Tuesday morning, Sarvet exchanged a brief, efficient phone call with a pediatrician concerned about a teenaged boy whose anxiety had become so overwhelming that he was refusing to leave the house. He had missed the first day of school, and seemed to be headed for crisis.

Sarvet told the pediatrician that he had discussed the case with the team's therapist, Jodi Devine, a licensed social worker, and they wanted the boy to come in right away for a "level of care" evaluation, because he might need to be in a partial hospitalization program, and they thought they could find him a spot in one.

The pediatrician had prescribed the antidepressant Zoloft and a tranquilizer, and Sarvet recommended keeping those medications for now.

If not for the project, Sarvet said, the pediatrician would probably have felt compelled to tell the boy simply to go to the emergency room and wait for help.

Carey Goldberg is reachable at goldberg@globe.com.