Youth with rheumatic disease are at increased risk for mental health disorders, though availability of mental health care remains limited in this population. We found that youth with rheumatic disease received increased access to mental health treatment when psychological services were integrated and embedded within their routine rheumatology care. Referrals to psychology also increased significantly over the intervention period, suggesting that psychology integration within a medical clinic can increase identification of psychosocial and behavioral needs among patients and families. Additionally, the majority of youth with jSLE demonstrated reduced or stable depression scores over time when receiving psychological treatment as a component of their medical care. Results of this project suggest that psychology integration into rheumatology care remains feasible, and increases access to mental health treatment and identification of psychological needs in this at-risk population. Of note, there were no established models to follow for integration of psychological services into pediatric rheumatology care at the time of this project’s implementation. This integrated model represents the first of its kind to include psychology service embedment throughout all aspects of pediatric rheumatology care.

Extant literature supports the merging medical and psychology specialties into an integrated plan of care to improve mental and physical health outcomes in youth with chronic illness [15]. In line with a biopsychosocial approach to care, we have found substantial value added by integration of psychological services into routine rheumatology care. Psychology integration into medical care has been shown to reduce mental health stigma and barriers to care [15]. This was observed within our population where access to psychological services proved invaluable in normalizing discussion of mental health concerns, and promoting patient and family’s buy-in and follow through with mental health evaluation and treatment. It remains important to note that our patient population represented a large catchment area, including a significant percentage of patients from rural areas and two neighboring states with poor access to mental health services. As such, embedment of psychological treatment into medical care allowed for increased access to behavioral health care. Patient satisfaction data revealed an overwhelmingly positive response to our integrated model, with patients and their families expressing satisfaction and appreciation of psychology’s integration into rheumatology clinic, and reflecting upon their increased access to mental health treatment and improved disease management.

This project was completed over the course of 4 years, in which psychology was gradually integrated into pediatric rheumatology care. Our QI team has learned the value of approaching integration with a stepwise progression to ensure that team members are aware of mental health needs among youth with rheumatic disease, as well as the contribution that psychological services lend to a patient’s plan of care. Psychological services were first provided to youth with rheumatic disease within a separate behavioral health clinic and targeted common reasons for referral, such as anxiety/needle fears, pain management, and depression. Clinical screening was later introduced to identify patients with mental health or behavioral needs who were then seen by psychology across behavioral health clinic or multidisciplinary clinic settings. Psychological services were strategically integrated into multidisciplinary clinics within rheumatology, particularly among populations with high needs (e.g., those with jSLE or joint hypermobility), and eventually, expanded to patients with wide-ranging diagnoses within the rheumatology clinic setting. Primary interventions within this quality improvement initiative included implementation of mental health-focused education among providers and staff, mental health screening, and multidisciplinary medical clinics with psychology involvement. Psychological services were made available on a preventative basis for those with a new diagnosis or within certain high-risk groups, as well as when patients were presenting with acute problems that were in need of treatment.

There are barriers to psychology integration into rheumatology care, including limited access to or funding for a psychologist or mental health professional. Should resources be available to obtain a psychologist, other barriers may include team cohesion and awareness of mental health impact on physical functioning and psychology’s role, as well as the psychologist’s ability to remain productive with a sufficient referral base. There were also time demands associated with psychology integration into rheumatology care. Integrating psychological services into rheumatology care increased visit duration by approximately 30 to 60 min, though patients and families consented to extend their visit, and clinical flow and templates were adjusted accordingly. Patients were scheduled within a lengthier time slot when behavioral needs were anticipated to ensure sufficient time for evaluation and treatment of rheumatic disease, as well as provision of psychological services. Alternatively, when behavioral needs were discovered spontaneously during the visit, psychological intervention directly followed medical management to limit disruptions to the clinic flow and the physician’s schedule. Based on qualitative feedback, psychology’s involvement allowed providers to spend reduced time focusing on the behavioral factors that impact disease management and thereby, increased provider efficiency.

Future steps within our program include broadening of our mental health screening to include assessment of anxiety and suicide risk, ensuring access to screening across rheumatic diseases, as well as increasing the scope of psychology integration into rheumatology clinic and outcome measurement in the form of provider satisfaction with integrated services. Additionally, future studies of interest include exploration of the impact of psychology referral and involvement on rheumatic disease scales, such as patient global score.

Psychology integration into pediatric rheumatology care allowed for exponential growth in access to mental health support, at a time where children and adolescents are experiencing heightened levels of emotional distress, especially those facing additional risk factors of chronic physical illness and pain. Through integration of psychological services into rheumatology care, receipt of mental health treatment was normalized and de-stigmatized within our patient population. Psychosocial and geographical barriers for patients were also minimized by embedding psychological services into established medical care. Physicians also gained an appreciation for the contribution of psychological services in their practice upon observing improved outcomes for their patients when psychology was involved, as well as the reduction in the demands on rheumatologists when behavioral targets were instead addressed by a psychologist. This study suggests the feasibility of psychology integration into pediatric rheumatology care, and highlights the capacity for psychology integration to increase access to mental health and behavioral support among patients and families affected by pediatric rheumatic disease.