The risk of depression and anxiety is alarmingly high among adolescents with chronic medical conditions (CMCs), and comorbid psychiatric illnesses in this population are associated with worsened disease status.1 Adequate mental health treatment for children and adolescents, especially those with CMCs, is often suboptimal, with two-thirds of youth with psychiatric disorders never receiving services.2 COVID-19 and associated lockdown measures have only exacerbated the mental health challenges for youth over the course of the pandemic.3 Finding ways to improve the uptake of these services is paramount.
The study by Reinauer and colleagues4 aimed to fill the gap in mental health service utilization using motivational interviewing (MI), a counseling style to elicit positive behavior choices and increase one’s intrinsic motivation.5 The authors conducted a cluster randomized trial studying the efficacy of MI training for pediatricians in increasing mental health service utilization, defined as making at least 1 appointment by the 6-month follow-up, compared with treatment as usual, for youth with CMCs experiencing symptoms of anxiety or depression. Although the findings by Reinauer et al4 did not reach statistical significance regarding the primary outcome for usage of mental health care services in patients who were seen by the MI-trained pediatricians, MI training was associated with (1) longer conversations between the pediatricians and the patients and (2) lower anxiety scores at the 1-year follow-up visit. The study addressed an important topic with a potentially high clinical impact: the lack of follow-through for needed mental health assessments in youth.2
MI was a sensible choice of intervention. It has been shown to improve symptoms of mood disorders and increase treatment attendance among individuals with psychiatric dysfunction.5 Given the previous success of MI, it was reasonable to assume that it would increase the uptake of mental health services for youth with CMCs and at least mild depression and/or anxiety. Despite the results being potentially clinically important, it is somewhat surprising that MI training was not associated with a statistically significant increase in mental health services use.
It is possible that the choice of patient population diluted the true effect of MI. First, the study mostly involved teenagers, who tend not to respond as well to single-session interventions compared with children.6 Second, the study participants had mostly mild to moderate mental health symptoms, as illustrated by the low mean Generalized Anxiety Disorder 7-item scale (GAD-7) and Patient Health Questionnaire 9 (PHQ-9) scores. Individuals with milder psychiatric symptoms could potentially be less responsive to MI, as the propensity to seek care is higher in more severe psychiatric disorders.2 In addition, the MI intervention itself could have alleviated a patient’s milder symptoms (as illustrated with lower anxiety scores at the 1-year follow-up in the MI group), consequently decreasing the need to seek additional mental health services.
Fidelity to the MI training and skill acquisitions were not objectively assessed in this study, but relied on physician self-report. Other studies have used observer-rated assessment tools to report clinicians’ skill acquisition and adherence following MI training. Self-report by therapists have been associated with overestimation of MI proficiency.7 It is possible that the lack of statistical significance regarding mental health services use was because of variation in MI skills between clinicians, especially given the small number of physicians in the intervention group (n = 18).
Although MI represents a potentially efficacious intervention strategy to increase mental health utilization, there are some limitations in the study. These limitations should be considered by clinicians before incorporating this technique into routine clinical care.
Reinauer et al4 reported that MI training was associated with longer conversations between patients and physicians. They also found that conversation length was significantly associated with mental health access. However, the study did not control for conversation length when analyzing the effect of MI training on mental health services uptake, rendering it difficult to determine whether the observed higher numbers for mental health care services use in the MI group is the effect of longer conversation length rather than MI itself. Although this may limit the importance of MI training, it nevertheless highlights the importance for specialized pediatricians to take the time to counsel their patients on mental health topics, a behavior that seemed to have been more prominent in the MI-trained group. Finally, the time required by the specialized pediatricians to both complete MI training (2 days plus an additional 1 day per year for maintenance) and use MI with the patients (average of 30 minutes per session, not counting regular disease-specific assessments) appears be the biggest roadblock to implementing this technique.
The study by Reinauer et al4 does not robustly demonstrate the benefit of MI training for specialized pediatricians in increasing mental health service utilization among youths with CMCs. This leads to the question of which patients might benefit most from such an intervention, and which health care clinicians should use it. Nonetheless, the results make MI a potential strategy to improve mental health services uptake and offer new perspectives for the treatment of affected youth.
With the increasing prevalence of psychiatric disorders in children and teenagers in recent years, it might not be feasible to refer all youths with mild symptoms to specialized mental health care because of the limited availability of psychiatric resources. Future studies could assess the efficacy of different types of MI interventions based on the severity of psychiatric symptoms among youth with CMCs. For example, a study could investigate the effect of an MI intervention specifically targeting anxiety and depression symptoms for youth with mild psychiatric symptoms, and another could evaluate the effect of MI intervention geared towards mental health services uptake for youth with more severe symptoms.
Although it appears intuitive that spending more time with patients could improve certain behaviors, the work by Reinauer and colleagues4 is particularly informative on this point, as it demonstrated that the conversation length between the pediatrician and the youth is associated with increased uptake of mental health services. This suggests that pediatricians could spend more time counseling their patients, at least the ones with moderate to severe psychiatric disorders, who clearly need referral to adequate psychiatric services.
Sustained and vigorous efforts continue to be required to expand the capacity and uptake of mental health services for youth with CMCs and mental health needs. All specialized pediatricians have a role to play in ensuring that at-risk youth with CMCs receive the psychiatric support they need.
Investigator, CHEO Research Institute