Settings and Levels of Mental Health Care
Mental health care takes place in a variety of settings. Understanding the mental health care landscape can help the pediatric clinician interact with colleagues and guide patients and families.
Mental Health Care Settings
Mental health care is provided in a continuum of settings that address the acuity and severity of an individual's symptoms at the time of care.
Mental health care must be provided in the least restrictive environment in which patient safety can be reasonably assured.
Outpatient care
Outpatient therapy: regular visits with a therapist or counselor, usually weekly or more frequently if needed. Outpatient therapy can be individual, family-focused, or may take place in groups. More information on types of therapy may be found here.
Medication management: After an assessment visit or visits, the prescriber, patient and caregivers settle on a medication treatment plan. Follow-up visits are usually monthly while medication adjustments are made, then may be less frequent. Medication management visits may include therapy as well.
How to access outpatient care: Identifying high-quality, evidence-based outpatient therapy which is geographically accessible, has timely intake appointments and accepts your patients' insurance type can be challenging in any locality. Any referral list shared with patients and families should be regularly updated to ensure that practices or individuals are still in business, accepting new patients, and with working phone numbers.
Intensive outpatient care (IOP)
Intensive outpatient program is often a step-down level of care from PHP (see below). Intensive outpatient treatment is individual, group and family therapy provided 4-5 days a week for 3-4 hours/day. IOP is an appropriate level of care for children and adolescents who are able to attend school but who can benefit from a concentrated period of therapy to address impairing mental health symptoms. Examples include recurrent non-suicidal self-injurious behaviors, severe anxiety or depression, obsessive-compulsive disorder, and ongoing stabilization for eating disorders. IOPs are staffed by psychologists, clinical social workers, and milieu therapists. They do not generally provide medication management.
How to access Intensive Outpatient Programs: Most IOPs allow for self-referral, meaning that families can call the program, describe their child's needs, and find out if the IOP is likely a good treatment option. If so, an intake appointment is offered. Many IOPs are co-located with Partial Hospitalization Programs (see below), and the intake assessment includes a determination of the appropriate level of care.
Partial Hospitalization (PHP)
Sometimes called "day hospital", PHPs provide intensive individual, group, milieu and family therapy 5 days a week, similar to a school day. Pediatric PHPs include daily time for school work, and a teacher with mental health training liaises with participants' regular schools to facilitate post-discharge support and plans for transitioning back to school. The PHP level of care is for individuals whose mental or behavioral health symptoms preclude them from functioning in the school and/or home environments but which do not constitute an imminent risk of harm. PHP programs are staffed by multidisciplinary teams including psychologists, psychiatrists, clinical social workers, teachers, and milieu therapists.
How to access Partial Hospitalization Programs: Most PHPs allow for self-referral, meaning that families can call the program, describe their child's needs, and find out if the PHP is likely a good treatment option. If so, an intake appointment is offered. Many PHPs are co-located with Intensive Outpatient Programs, and the intake assessment includes a determination of the appropriate level of care.
Your local academic child psychiatry program or pediatric emergency department may be able to provide you with a list of PHP and IOP options in your community. If you maintain a referral list of PHPs and IOPs, you will want to note the age range of patients they accept, the types of insurance plans they work with, and any restrictions on presenting symptoms or disorders. For example, some programs will not accept children or adolescents with a history of overt aggression because they do not have staffing or environmental elements that allow them to safely manage aggressive behavior.
Inpatient psychiatry
Inpatient psychiatry takes place in closed part of a hospital or facility. Inpatient care provides mental and physical stabilization during an acute episode of psychiatric distress. Criteria for inpatient care are that the individual poses an imminent danger to themselves or others, or that their mental health has deteriorated such that they are unable to care for themselves or be cared for in an outpatient setting. Children and adolescents on inpatient pschiatry units spend much of the day in group therapeutic activities and will have a period of time set aside for school work.
Inpatient programs are staffed by multidisciplinary teams including psychologists, psychiatrists, clinical social workers, teachers, and milieu therapists. Caregivers cannot stay with patients on most pediatric inpatient psychiatry units but can visit and are expected to participate in family therapy sessions and discharge planning.
How to access inpatient psychiatric care: The vast majority of patients enter inpatient psychiatry units through an emergency department or after medical stabilization on an inpatient medical unit. Medical clearance, including screening for active substance intoxication and for infectious diseases such COVID-19, is required prior to admission to an inpatient psychiatry unit where patients interact with each other in therapeutic settings. If you feel that your pediatric outpatient needs inpatient psychiatric care, the patient should be directed to the nearest emergency department.
Other settings:
- School-based mental health clinics
- Residential treatment facilities
- Dual-diagnosis programs for mental health and substance use disorders