On any given day, Alexandra Bannach, a pediatrician in Newport, will have three or four patients scheduled to see her for a check-in about ongoing mental health treatment, most commonly for depression or anxiety. That’s true of her three colleagues as well.
Meanwhile, about half of the annual visits with teens and pre-teens throughout the rest of her work day reveal symptoms that might result in a mental health diagnosis. The number of those cases and their severity has increased dramatically in the past half decade, she said. That led her practice team to decide last year to extend the amount of time they take with each adolescent patient.
“We just needed more time in those rooms,” said Bannach, who has worked at North Country Pediatrics for 18 years. “It’s not just doing a physical (exam) anymore and saying, ‘you’re cleared for sports.’ You have to address mental health issues and with those, obviously, there’s no blood tests. It’s really sitting down and talking.”
Until last summer, Bannach and her colleagues were largely on their own to try to meet the growing need — a daunting task, for which, until very recently, primary care residency programs provided little to no preparation.
She educated herself and treated what she felt she could. In some cases, she would refer patients to a child psychiatrist. But those referrals frustrated her, as well as her patients, as waitlists for those appointments can range from six months to a year.
Now she calls VT CPAP.
Short for the Vermont Child Psychiatry Access Program, VT CPAP is the brainchild of Greta Spottswood, a child psychiatrist at Community Health Centers of Burlington and director for the grant-funded program.
The free service is a high-quality telephone hotline for primary care providers who see children and youth. It offers professional feedback on diagnosing, treating and finding resources for their patients with mild to moderate mental health challenges. A social worker answers the phone every weekday from 9 a.m. to 3 p.m. and coordinates the support, which range from scheduling conversations with a child psychiatrist to sharing up-to-date information about mental health resources in the provider’s community.
The need for the hotline became clear to Spottswood soon after she started her practice in Vermont in 2017 after a residency and fellowship in Boston. Within a matter of months, her own waitlist to see patients grew to more than half a year. It was impossible for her to keep up.
Full-time equivalent pediatricians and general family practitioners outnumbered board-certified child psychiatrists in Vermont by 12 to 1 in 2018, the latest year a physician census was undertaken in those fields by the state Department of Health. The ratio may have improved since then due to a new residency program at the University of Vermont’s Larner College of Medicine, but the basic math has not.
“You can have a lot more psychiatrists and still not meet the need as we are providing care currently,” she said. “We have to change the system rather than just trying to see more patients.”
This is not a new idea. Similar kinds of support hotlines are offered across the country. But it is new for Vermont.
The additional resources are badly needed, Haley McGowan, a child psychiatrist at the medical center and the medical director of the Child, Adolescent and Family Unit at the state Department of Mental Health, told the House Committee on Health Care last month.
Nearly half of all youth in the U.S. will meet criteria for a mental health disorder, either in childhood or adolescence, McGowan said. Around a quarter will develop a mental health disorder that will result in severe impairment or distress.
On Monday, the Centers for Disease Control and Prevention released results from its annual national survey of high school students. In 2021, almost 60% of female students reported feelings of sadness or hopelessness every day for at least two weeks that disrupted their normal activities.
“As you might guess, limited access to mental health resources here in Vermont means that primary care providers — pediatricians, family medicine doctors — end up providing that care often in ways that feel far out of the range of their expertise and training,” said McGowan, praising Spottswood’s new program.
Since it started in June, 79 clinics with 387 providers have enrolled in the service, McGowan said. “This really does help to save a lot of that child psychiatry workforce for those more acute cases,” she added.
It also helps primary care providers feel more equipped to provide ongoing mental health care. Bannach estimates that among the four providers in her practice, one of them calls the hotline at least once a week, where every work day they can reach a dedicated social worker and board certified child psychiatrist. The interactions and the ongoing support and training provided have made a huge difference, she said.
“I don’t know if I can communicate … how much having the program has helped us in feeling comfortable and more confident that the care we provide is actually appropriate,” Bannach said. “It’s really been an absolute game-changer.”
She and her colleagues are not the only ones using the service. Since it started in June, the hotline received 217 calls from providers, an average of two a day. Use is growing as more practitioners become aware of what the service can provide, Spottswood said. In late January, the program had its busiest day, fielding 10 calls.
Because of the dedicated staff, “it’s not just a 30-second phone conversation,” said Bannach. “They can really explore that case with us.” She can also call back and speak to the same psychiatrist a month later about the same patient. (Information sharing between providers both bound by federal medical privacy laws is allowed.)
In total, over the first seven months, 55 providers called at least once, with an additional 42 support staff calling, according to data being collected to evaluate the program.
The calls were most often about specific cases, though some were more general and medication-related, or seeking help for a therapist referral. The majority of the changes in care recommended after a discussion with the psychiatrist were related to medication management, but also involved diagnoses or sharing vetted screening tools.
In between taking calls, the social worker on staff spends time responding to requests for general educational resources, and compiles and updates lists of classes and support groups available in different parts of the state. A lot of the person’s time is also spent checking in with therapists about their availability to take on a new patient, either in person or virtually.
“Keeping tabs on local resources and tracking down therapists is a Herculean effort,” said Ellen Arrowsmith, one of three who work part time. She estimates she usually calls between 15 and 20 therapists in order to find two or three options for a family to consider for their child. But that groundwork is essential.
“The fewer barriers there are, the more likely that the family is going to actually engage in treatment,” Arrowsmith said. “So many people get so discouraged by having to wade through so much of ‘no’ and no response.”
The program currently costs just under $500,000 annually to operate, Spottswood said. It is funded through several multi-year grants, including two through the Vermont Department of Mental Health and private matching funds through the Vermont Community Foundation. She and staff at the department are seeking a source of sustainable funding to maintain the service and keep it free.
Other states with similar programs have been able to expand the focus to nurses and therapists practicing in schools. Spottswood said VT CPAP would like to consider that once the primary care support is established and ongoing funding is secured.
Bannach does not want to imagine losing access to the support. With a therapist based in her practice and VT CPAP, she now feels capable of managing cases that she previously would have referred out.
Providing the full range of mental health care in primary care settings has a wide range of benefits. For Bannach, she sees that it increases access, and reduces the sense of stigma some still feel in seeking professional help. Also, it benefits other aspects of her practice.
“It can be incredibly rewarding care to provide,” Bannach said. “It strengthens your bond with the family and the patient and it always feels amazing if you can help.”
Correction: An earlier version of this story mischaracterized a precursor program to VT CPAP and incorrectly stated that Haley McGowan led that program.
