Dr. Greg Fritz (Host 1): Welcome back to Mindcast, a podcast from the experts on children's mental health at Bradley Hospital. I'm Dr. Greg Fritz.

Dr. Tanuja Gandhi (Host 2): And I'm Dr. Tanuja Gandhi, your co-host. Today, we are tackling an important issue, addressing mental health in primary care settings. And we have a new guest with us, Dr. Alison Manning. She's a pediatrician and child psychiatrist at Bradley and Hasbro Hospitals and the Clinical Director of a program called PediPRN. Dr. Manning, thank you for joining us.

Dr. Alison Manning: Thanks for having me.

Host 2: Mental health conditions in children are more common than many realize. Up to 1 in 5 children experience a mental health disorder in a given year.

Host 1: Despite this prevalence, there are significant barriers to accessing specialized care with a severe shortage of child psychiatrists. One thing that I'm very certain of is that patients and families often prefer to have mental health concerns addressed in the familiar setting of their primary care office. I mean, I know that's true, but why do you think that is? What reasons are behind that?

Dr. Alison Manning: Yeah. You know, I think many families have been seeing their PCP since their child's birth. There's a comfort and familiarity there. There's usually a longstanding relationship and established trust. It's generally convenient and easy to access. I think the biggest thing though is that there's far less stigma associated with seeking mental health care in a medical setting than in a specialized mental health care office.

Host 2: I heard from some of my colleagues, and have had these conversations with pediatricians and PCPs before, that sometimes, given the complexity of the cases they are seeing in their offices, they might feel like there's a lack of training to effectively manage some of the more complicated psychiatric conditions. What are some of the common gaps in training that you have observed?

Dr. Alison Manning: Yeah, this is a major issue. Thanks for bringing this up, Tanuja. I think we don't want PCPs to be managing complex psychiatric disorders, but even basic anxiety, depression, ADHD, there are significant gaps in training. Programs that train pediatric primary care providers have really not caught up with the mental health epidemic that we're seeing. And while trainees are taught the basics of psychiatric disorders, there's really limited exposure to assessment, diagnosis, and managing pediatric mental health conditions during the training. We really haven't done a good enough job in preparing graduating trainees for practicing in a busy clinic where up to 70% of their patients come in with mental and behavioral health complaints. But thankfully, this is an area that the AVP is working to address with new mandatory trainings for pediatric residents.

Host 1: So, this is also where PediPRN comes in, right? Will you tell us a little bit more about what PediPRN is and its main objectives, what you're really trying to get done with this?

Dr. Alison Manning: PediPRN stands for the Pediatric Psychiatry Resource Network. This is Rhode Island's Child Psychiatry Access phone line, and this resource actually exists in almost all 50 states. It's part of a national network of child psychiatry access programs that's working to support pediatric primary care providers in managing children's mental health in primary care. So, that's a main objective of our program and also to educate PCPs on the management of pediatric mental health.

Host 2: So, one of the key resources PediPRN offers, to my understanding, is direct consultation with child psychiatrists, right? How does this work? Do they just call in and say, you know, "I might need help on a certain case?" Or do they call in when these cases are coming to their office?

Dr. Alison Manning: That's a great question, and it's a little bit of both. So, PCPs can call for immediate consultation. They can also schedule a consult online at a time that's convenient for them. Not only is there direct telephone consultation with a child psychiatrist, but also direct access to our resource specialist, who helps coordinate resources and referrals for patients and families that may need other levels of care or support.

Through the call line, PCPs have access to in-person assessment as well for complex cases. So, we'll see the child, do a full assessment, make recommendations, and hand those back to the PCP. In cases of severe complexity, we have a limited capacity for bridging patients to community providers. So, seeing patients for a short period of time, getting them stable, and then passing them off to a psychiatrist or psychotherapist in the community. Then, we also offer group consultation for PCPs. This operates kind of like scheduled office hours for individual practices, typically on a monthly basis.

Host 1: It's quite a smorgasbord of opportunities.

Dr. Alison Manning: It is.

Host 1: And you also provide educational programming, right?

Dr. Alison Manning: Yes.

Host 1: Tell us a little more about that.

Dr. Alison Manning: Absolutely. This is my favorite part of our program. So, educating PCPs is a large part of our program. We have a monthly seminar series focusing on specific mental health topics and how to address and treat them in primary care settings. The sessions are taught by local experts and facilitated by PediPRN faculty. We cover a range of topics from anxiety, depression, ADHD, trauma. Typically, we like to keep the group small, around 15 to 18 PCPs to facilitate discussion, and usually our sessions are very highly rated.

Host 2: So, we've talked about PCPs and pediatricians, and most of our listeners may not be familiar with the different terminology we use in the medical world. Are PCPs the same as pediatricians, or is it different?

Dr. Alison Manning: We use the term PCP, which stands for primary care provider, to refer to pediatricians, family medicine doctors who may be providing care to pediatric patients, nurse practitioners, or physician assistant providers as well who may be providing primary care to pediatric patients.

Host 2: So if a family physician or a family doctor needs help with taking care of a child, and they might have known the family for generations, they can call PediPRN?

Dr. Alison Manning: Absolutely. Any provider who treats any child patient, even those up to age 21, if they're seeing a pediatric provider, that provider may call PediPRN.

Host 2: Moving on, I heard that, you know, there are a lot of success stories from PCPs and pediatricians who've actually used the PediPRN service. What feedback have you received?

Dr. Alison Manning: It's been wonderful to hear. Generally, PCPs report increased just comfort and confidence with managing these patients, and these are oftentimes very challenging patients and families who have a lot of struggles. There's typically a reduced need for immediate referral to the emergency department, which can be very helpful for many families. The vast majority of calls that we receive, PCPs continue to manage the patient, so these patients are able to continue to receive their care in the primary care setting.

PCPs generally also provide feedback that our service not only helps them address the mental health needs of their patients, but is also a resource for the provider themselves in kind of getting validation that their experience with a challenging case is really hard, and there's not much that we would do differently as specialists. We often reassure them that what they're doing is exactly what they should be doing, and they feel very seen and validated by this. So, we help them recognize that the limits of mental health work is very different than addressing physical ailments and something that they aren't taught in training.

Host 2: Also, I'm assuming that when things get a little out of hand or complicated and a doctor may not know what to do next, this helps with risk stratification and thinking about next steps.

Dr. Alison Manning: Absolutely. We can definitely help the PCP think about the best level of care, the best next step for their patient. We have other call lines in Rhode Island for patients in crisis. So, PediPRN is not a crisis service necessarily, but we can help PCPs think through what the best next steps are for their patients and families.

Host 1: I know you've done a lot of evaluation on this, and that is somewhat what we're talking about. But it seems to me that the best examples of success and satisfaction is return and usage. Do a fair percentage of the primary care docs come back and use the service with other patients after they've started?

Dr. Alison Manning: We do have a fair number of what we call high utilizers. So, providers who we're familiar with who call frequently about different patients, and what we find, and this is true among other child psychiatry access programs across the country, is that providers are feeling more comfortable and confident managing straightforward basic anxiety, depression, ADHD, and they're calling us for more complex cases, which tells us we're doing our job.

Host 1: I think that's very cool. So, what about from the patient and family perspective, is there any sense that they directly experience benefits and appreciate it?

Dr. Alison Manning: You know, I think patients and families are getting quicker access to mental health care, which is a big challenge in and of itself. So, I think they appreciate faster responses, being able to avoid navigating a complex mental health system because they can remain in primary care and get treatment from a provider they trust and know.

Host 2: And I'm assuming in areas which do not have direct access to mental health resources, and there are some of those in Rhode Island, being able to get the treatment you need from a doctor you're familiar with makes the access at least that much more easier.

Dr. Alison Manning: Absolutely.

Host 2: I wanted to ask you a question before we wrap up. in my experience, when you're dealing with other doctors or physicians or providers and patients, there are always some really heartwarming stories that come. Is there anything that you'd like to share that comes to mind today?

Dr. Alison Manning: You know, I think of a case of a provider who I interact with regularly at Hasbro and who's called the line and spoken to me several times about different patients and everything that it's basically just seeking reassurance from me. She always has the plan, right? And she knows what she's going to do, but she just wants to run it by me and make sure it's okay. And I think it's one of the most rewarding aspects to just tell someone you're doing the right thing, you're doing everything that I would do, and just hear the reassurance that they experience in that as well, so I find that to be one of the most rewarding aspects of the work.

Host 1: I was just going to resonate with that, that it feels so much better to feel like you have a lifeline and a connection if you get in over your head, that it makes you more comfortable in the water.

Host 2: Exactly.

Host 1: Very cool.

Host 2: And in a specialty that you don't have training in, when you were talking, I was thinking of my experience with complicated pediatric situations. When I lean on the pediatrician to say, I know this is the next step, but basically I need your blessing. And it feels good to collaborate and lean on each other for the specialties we're not trained in or don't keep up on a daily basis.

Dr. Alison Manning: As psychiatrists, part of our training is receiving supervision and talking through some of these challenging cases, in a supportive way, and pediatric providers don't have that. So, they're almost operating in isolation with some of these really tough cases and dealing with vicarious trauma. And so, it's also helpful to be able to have that listening ear to just talk through some of these challenging situations.

Host 2: This must be particularly true. You know, when you talk about isolating settings, if you're working on your own or have a small practice or a private practice. Because in academic settings, you can still find supervision opportunities, but it's harder when you're doing work in like areas that really have that need.

This has been a very illuminating and rewarding conversation for us as well. I will say, if you're a PCP looking to provide care and improve your ability to manage mental health conditions in your practice, and you are located in Rhode Island, please consider reaching out to the PediPRN Program at PediPRN.org when you need it. And for our listeners, if you are a parent, or somebody who lives in Rhode Island and you need mental health care in the moment, don't have resources, or would like to get connected, you can always talk to your PCP about the PediPRN Program to get connected to further resources, or at least, like we've discussed, a lifeline when it's needed.

For our listeners, if you have any questions or topics you'd like us to cover, please do get in touch with us. Follow us on Facebook at Bradley Hospital and our podcast at www.bradleyhospital.org/podcast. Thank you for joining us.