Mental Health Care in Pediatric Diabetes: Overcoming Challenges and Barriers
Mary Pat Gallagher, MD
The financial burden of poorly controlled diabetes in childhood and adolescence is not fully evident until complications occur during adulthood. In 2010, researchers estimated that the annual cost of type 1 diabetes (T1D) in the United States was $14.4 billion, including medical costs and lost income.1 Prevention of diabetes-related complications requires that providers who care for children and adolescents with diabetes address barriers to good control soon after diagnosis and at frequent intervals as patients progress developmentally.
As a self-management disease, diabetes requires patients to adjust their insulin regimens based on blood glucose patterns they have recognized (in relation to exercise, illness, type of foods eaten, etc). This requires the synthesis of information from different sources and depends upon cognitive function and attention to detail. Even with the most advanced technology (insulin pumps, continuous glucose monitors, and hybrid closed loop systems), neurodevelopmental and behavioral issues can interfere with a child’s ability to master diabetes self-management skills.2
Prevalence of Mental Health Issues in Pediatrics
The prevalence of mental health issues in the general pediatric population is high, increasing in frequency from childhood through adolescence. Data from the National Health and Nutrition Examination Survey show that the 12-month prevalence of mental health disorders for children aged 8-15 years is 13.1%. The National Institute of Mental Health indicates that the lifetime prevalence of mental health disorders in children aged 13-18 years is 46.2%, with the lifetime prevalence of “severe disorders” being 21.4%.3 In decreasing order of frequency, this grouping of mental health disorders includes:
Prevalence of Mental Health Issues in Pediatric Diabetes
An increased risk for mental health disorders has been well recognized in adults with diabetes.4 Although published data are mixed, larger studies and meta-analyses indicate that the prevalence of mental health disorders in children and adolescents with diabetes is higher than in those without.5-7 In children with mental health disorders, the task of diabetes self-management becomes more complex. Indeed, symptoms of mood disturbance and anxiety are themselves associated with increased glycated hemoglobin (A1C) levels.8
Even in the absence of a recognized mental health disorder, it is common for families to experience a significant amount of conflict as they transition the responsibilities of diabetes management from the parent to the child. Diabetes-related conflict is associated with decreased engagement in disease management, decreased adherence, and increased A1C levels.9-11
American Diabetes Association Recommendations for Psychosocial Care in Practice
The American Diabetes Association (ADA) recognized the important role that behavioral health plays in the successful management of diabetes. In 2016, the ADA released a position statement on psychosocial care of people with diabetes. It states, “Practitioners should identify behavioral/mental health providers, ideally those who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes, with whom they can form alliances and use for referrals in the psychosocial care of people with diabetes (PWD). Ideally, psychosocial care providers should be embedded in diabetes care settings. Shared resources such as electronic health records, management data, and patient-reported information regarding adjustment to illness and life course issues facilitate providers’ capacity to identify and remediate psychosocial issues that impede regimen implementation and improve diabetes management and well-being.”12
The ADA listed recommendations for psychosocial care, along with the level of evidence assigned. Level A evidence comes from randomized controlled trials, level B evidence comes from well-controlled cohort studies, and level E is from expert consensus. From Diabetes Care12:
• Psychosocial care should be integrated with collaborative, patient-centered medical care and provided to all people with diabetes, with the goals of optimizing health outcomes and health-related quality of life. Evidence level: A.
• Providers should consider an assessment of symptoms of diabetes distress, depression, anxiety, disordered eating, and cognitive capacities using patient-appropriate standardized/ validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. Including caregivers and family members in this assessment is recommended. Evidence level: B.
• Consider monitoring patient performance of self-management behaviors as well as psychosocial factors impacting the person’s self-management. Evidence level: E.
• Consider assessment of life circumstances that can affect physical and psychological health outcomes and their incorporation into intervention strategies. Evidence level: E.
• Addressing psychosocial problems upon identification is recommended. If an intervention cannot be initiated during the visit when the problem is identified, a follow-up visit or referral to a qualified behavioral healthcare provider may be scheduled during that visit. Evidence level: E.
It has been shown that behavioral interventions can improve regimen adherence and glycemic control, decreasing A1C levels by at least 0.5%,13-15 which significantly reduces risk for long-term complications.16 Interventions that target modifiable diabetes-related emotional or family processes and those that include training in problem-solving skills14,15 had the largest effect on A1C levels.
Decreasing the A1C level and, in turn, the rate of complications, will reduce the financial burden of T1D over time. It has also been shown that multisystemic treatment can decrease resource utilization in the present.17
Numerous barriers prevent the delivery of behavioral healthcare. When practices refer patients elsewhere for care, only 50% follow through with making an appointment, and fewer remain engaged.18 This may be driven by multiple factors:
• The stigma attached to seeing a mental health professional
• Difficulty identifying a provider who is familiar with diabetes
• Lack of insurance coverage
• Need for prior authorizations for visits when coverage does exist
• Lack of communication between the mental health professional and the referring provider
In a recent report from the Mental Health Issues of Diabetes conference,19 a lack of trained mental health professionals who are knowledgeable about mental health issues as they relate to diabetes was identified as a significant barrier. To that end, another group recommended increased clinical training programs for mental health providers focusing on the mental health needs of young people with diabetes as well as continuing medical education programs for endocrinologists on mental health topics to foster an integration of mental and physical healthcare for patients with T1D.20
The integration of behavioral health into the medical setting is advocated to remove some of the existing barriers to achieving the goals enumerated by the ADA. This model can help reduce the stigma attached to referrals and is associated with an increase in the number of appointments made after referral. Additionally, it strengthens the routine behavioral care that can be offered to patients and families.
However, there are barriers that persist even when practices use the onsite integrated behavioral healthcare model. These barriers are mostly related to the financial feasibility of the model. Billing for services is complex, and rules vary by state and by individual payer contracts. Psychiatric issues considered secondary to medical conditions cannot be billed under psychiatric coverage. Medicare has officially recognized behavioral medicine interventions for the treatment of a variety of medical disorders, outside of mental health disorders. This resulted in the creation of Health and Behavioral Assessment (HBA) codes in January 2002.21
These codes are used to bill for services provided when a patient’s behavioral function is affecting a health problem, as long as the patient’s diagnosis is not a psychiatric one (the patient may have a co-existing psychiatric diagnosis but the visit being billed should address their medical illness). Their use requires a physical health diagnosis using International Classification of Diseases, Tenth Revision, Clinical Modification (not Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Diabetes is among the diagnoses recognized as being responsive to behavioral interventions.
Health and behavior assessments (91650: initial assessment; 96151: repeat assessment) might include evaluation of patient adherence to medical treatment, management of symptoms, adherence to medical treatment, management of symptoms, health-promoting behaviors, health-related risk-taking behaviors, and adjustment to physical illness.
Interventions (96152: individual; 96153: group; 96154: family with patient; 96155: family without patient) might include teaching self-monitoring, cognitive behavioral techniques, relaxation, visualization, coping and social skills, communication and conflict resolution, smoking cessation, relapse prevention, and diet and exercise, as prescribed by a physician.
HBA codes may be used by social workers, psychologists, or other nonphysician providers, but they must be within the scope of practice of the provider. Use of these codes does not require documentation of history, examination, or medical decision-making.
These providers may also render more complex services that are better suited to billing an evaluation and management (E&M) code. HBA codes should not be used when providing an E&M service on the same day. However, these codes may be used if another medical provider has seen the patient prior to the intervention, though this must be clearly noted in the medical record and the Current Procedural Technology code must be amended with an “S” (for “same day”).
The management of diabetes in children and adolescents requires intensive psychosocial surveillance and interventions. While the cost of providing this care has been a barrier in the past, the reduction in resource utilization in the immediate and long term will decrease the economic burden of diabetes. Therefore, clinical practices should work together with their state’s Medicaid programs and private payers to develop contracts for payment that will enable onsite integrated behavioral health programs to exist.