January 2017, VOLUME139 /ISSUE 1

Closing the Gap: Improving Access to Mental Health Care Through Enhanced Training in Residency

  1. Gauri R. Raval, MD, MPHa,b,c and
  2. Stephanie K. Doupnik, MDd,e,f
  1. aMorgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center, New York, New York;
  2. bDepartment of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia;
  3. cDepartment of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York;
  4. dPolicyLab, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;
  5. eLeonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
  6. fCenter for Pediatric Clinical Effectiveness, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
  1. Drs Raval and Doupnik conceptualized the manuscript, collaboratively drafted and edited the manuscript, and approved the final manuscript as submitted.

“Daniel,” a previously healthy teenager, complained of chest pain at his annual well child visit. His doctor, a second-year pediatric resident, quickly and confidently evaluated Daniel for cardiac or pulmonary causes of chest pain. She recognized that his pain was associated with anxiety and provided Daniel with a referral to a clinical psychologist. After several counseling sessions, his symptoms improved and the two agreed he no longer required therapy. But when Daniel returned to primary care several months later, his depression screen was positive. He had been having frequent panic attacks on the subway, difficulty concentrating at school, and feelings of hopelessness. The pediatric resident caring for him realized he needed additional mental health treatment, but she was unable to persuade him to seek care with a psychologist or psychiatrist. He was firm in his refusal to see a specialist, leaving his resident provider unsure what to do next. Her skills and expertise were not sufficient to deliver initial therapies for depression and anxiety, nor was she able to coordinate follow-up with a mental health specialist.

Daniel’s situation is not uncommon; although 1 in 5 children in the United States experiences a severe mental health disorder, nearly 80% of children with mental health disorders do not receive mental health care.1,2 Daniel’s reluctance to see a psychologist or psychiatrist may have stemmed from denial that his symptoms signaled a mental health condition, lack of comfort with a specialist provider, or the stigma associated with mental health disorders in Daniel’s Hispanic community.3 For patients motivated to see a mental health specialist, other barriers exist: late recognition of symptoms in primary care settings, a shortage of mental health providers, long wait times for an initial specialist appointment, high costs, and insurance restrictions. These barriers contribute to median delays of 6 to 23 years from the onset of mental health problems to first contact with a treatment provider.4 Lack of treatment is associated with poor long-term outcomes, including suicidality, substance abuse, unemployment, and physical health problems.1,2

Even when children and adolescents with mental health conditions are identified in primary care and referred for specialty mental health services, follow-up with specialty providers remains low.5 However, many patients have strong relationships with their primary pediatricians and return to them for follow-up,5 creating a unique opportunity for primary care providers to intervene. In Daniel’s case, the pediatric resident’s lack of training in mental health interventions prevented her from taking advantage of primary care follow-up visits to initiate appropriate treatments like antidepressant medication therapy or counseling to address anxiety. This gap in skills among pediatric trainees represents a missed opportunity to prevent the negative sequelae of untreated childhood mental health disorders.1

The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry recognize the instrumental role of pediatricians in closing the gap between the recognition of mental health problems and the initiation of effective treatments.68 Both organizations support the implementation of collaborative models where pediatric and psychiatry trainees learn to deliver mental health care in integrated settings.79 Despite interdisciplinary agreement about pediatric trainees’ need for clinical mental health skills, current pediatric residency training lags behind these expectations. Pediatricians cite lack of adequate training in the diagnosis, counseling, and treatment of mental health conditions as a barrier to the development of mental health care plans.2,10 Pediatric trainees report low availability of faculty oversight and mentorship in mental health treatment, and many residents find themselves ignoring or glossing over mental health concerns during patient visits.11 Although Accreditation Council for Graduate Medical Education requirements ensure that pediatric trainees complete 1 month each of developmental–behavioral pediatrics and adolescent medicine,12 these rotations alone do not ensure adequate depth of experience in mental health evaluation and treatment. Pediatric residents are eager for opportunities to deliver mental health care with supervision from mental health specialists so they can enter practice equipped to provide appropriate evaluation and initial treatments for patients with common mental health conditions.11

Pediatric residency programs can use 3 strategies to prepare trainees to evaluate, triage, and initiate treatment of mental health concerns. First, programs can encourage participation in elective child and adolescent psychiatry rotations. Although pediatric residents who complete a psychiatry rotation report greater confidence in providing mental health care, few pediatric residents take advantage of such rotations.13 Psychiatry rotations can provide pediatric residents opportunities to develop clinical relationships with mental health clinicians and to gain first-hand experience treating common conditions, such as anxiety, depression, and attention-deficit/hyperactivity disorder. Pediatric residency programs can encourage residents to complete these rotations by creating a culture where both mental health training experiences and mentorship with mental health specialists are prioritized. Second, programs can take advantage of opportunities for mental health education within currently required training experiences. For example, during an emergency medicine rotation, pediatric trainees could rotate with mental health crisis response teams, where they can learn to recognize patients who require emergent psychiatric treatment and quickly connect such patients with crisis mental health care. During primary care or adolescent medicine rotations, trainees might observe depression, anxiety, or substance abuse counseling sessions conducted by a psychologist or social worker. Such experiences can help trainees learn brief, effective counseling methods that they may be able to incorporate in their own practice. In settings with limited local access to mental health clinicians, trainees could participate in phone consultations via telepsychiatry programs like the Massachusetts Child Psychiatry Access Project.14 Third, structured didactics in common first-line mental health treatments can provide trainees with the medical knowledge to safely initiate mental health treatments. Such didactics could include topics like initiation and monitoring of antidepressant medications or techniques for substance abuse counseling. Interactive platforms, like the American Academy of Pediatrics Residency Curriculum and OPENPediatrics,15 could serve as a guide for developing mental health learning modules.

Beyond being essential for pediatric residents who intend to practice in primary care, skills in mental health evaluation and knowledge about treatment options are important for trainees who plan to practice in acute hospital-based or subspecialty care settings. One in 5 pediatric hospitalizations is for a mental health condition, and these hospitalizations, along with emergency department visits for mental health–related complaints, are becoming increasingly common.16 Moreover, children with chronic physical health conditions are at particularly high risk of mental health comorbidity, and the presence of concomitant mental health disorders results in worse clinical and quality of life outcomes and higher health care use.17 With robust training in mental health evaluation and treatments, all trainees will be better prepared to collaborate in the development of comprehensive care plans that address both the physical and mental needs of their patients.

The goal of closing the gap between the first presentation of mental health concerns and the initiation of treatment is within reach. Pediatricians serve a vital role in recognizing mental health conditions and initiating treatment, particularly in the face of a shortage of pediatric mental health specialists. Equipping the pediatric workforce to better address mental health begins with pediatric residency. Opportunities to train with mental health specialists and in collaborative models of mental health care can allow pediatric trainees to develop higher levels of comfort and competence in engaging patients in mental health treatments.1,2,11,13 Such training will empower pediatricians to manage treatments for common mental health conditions in primary care settings while also ensuring mental health subspecialty follow-up for patients with complex mental health needs.


    • Accepted September 26, 2016.
  • Address correspondence to Gauri Raval, MD, MPH, Department of Pediatrics, University of Virginia School of Medicine, P.O. Box 800386, Charlottesville, VA 22908. E-mail: raval{at}
  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • FUNDING: Dr Doupnik was supported by Ruth L. Kirschstein National Research Service Award institutional training grant T32-HP010026-11. Funded by the National Institutes of Health (NIH).

  • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.