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Integrating Mental Health into Pediatric Primary Care

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>> WEBINAR OPERATOR: Welcome to today's program Integrating Mental Health into Pediatric Primary Care. At this time, all participants are in a listen-only mode. Questions can be submitted anytime during the presentation via the Q&A pod located on the lower right hand corner of your screen. Please note this call is being recorded. It is now my pleasure to turn the call over to Beverly Pringle.

>> DR. BEVERLY PRINGLE: Great, thank you. Good morning everyone, and good afternoon and good evening. I'm Beverly Pringle, of the National Institute of Mental Health, and I'd like to welcome you to today's webinar on integrating mental health into pediatric primary care. This is the second of three webinars in our NIMH 2019 Global Mental Health Webinar Series. The first webinar held last month was on health stigma and discrimination. The third and final webinar will take place in August and will be on treating trauma in refugee and other trauma-affected populations.

We archive all of these webinars so that you can view them later on our web page. You'll see the web page on the screen at the end of the webinar today. Just a couple of logistics before we get started. We will take questions online only, so we ask you to use that Q&A box on your screen. Dr. Sharifi, our speaker, will stop partway through his presentation to answer any questions, and then we'll have additional time at the end for more discussion. Now it gives me great pleasure to introduce our speaker for today, DR. VANDAD SHARIFI. Dr. Sharifi is a psychiatrist and Associate Professor of Psychiatry at Roozbeh Hospital, at the Tehran University of Medical Sciences in Iran.

He's a leader in studying how to embed mental health care into primary care for children and youth. Depression, anxiety and other mental disorders are fast becoming the leading health problems of youth worldwide. While effective interventions exist, such as psycho-social interventions to strengthen problem-solving and social and emotional skills, very few youth receive care, and even fewer receive evidence-based care.
Dr. Sharifi and others have found that primary care is a promising avenue for delivering evidence-based mental health care to youth. He's going to speak with us today about his work integrating and studying the integration of mental health care into primary care for children and adolescents in Iran. Dr. Sharifi, welcome.

>> DR. VANDAD SHARIFI: Hello everyone. Thank you, Dr. Pringle, for inviting me in. It's a pleasure having this presentation on the integration of mental health into pediatric primary care. In this presentation, I will also be talking about our experience in a low-resource setting that is my country Iran. Thank you, Dr. Pringle, for the introduction. As she said, my main interest is in providing community mental health care for people with mental disorders. In recent years, my focus of research has been on providing a collaborative care program and starting it with a special focus on child mental health care.
First of all, some disclosures. I have no financial conflicts of interest to declare and the views in this setup of slides are my own and not necessarily confirmed and approved by Tehran University or the research funding agency. All photos are taken with permissions and have licenses. I would like to start with this picture. This is Arg-e-Bam in central Iran. This is the place that I have taken my profile photo from. Actually, this is the largest Adobe building in the world, that very unfortunately, was almost ruined completely, back 20 years ago. Which in that time, it was ruined by a massive earthquake that killed more than 20,000 people.

Nowadays, people have recovered. They have built their own buildings and houses and also, they have rebuilt this magnificent building. This is a recurring theme in our country and in the history of my country. This is the recurrent theme of destruction and reconstruction. People keep their hope and that's their recurring theme. Let me give you more information about my country. Iran is located in the Middle East. It has a population of around 80 million people. As you can see in this info graph, almost a third of the population are under 18. So, we can say that Iran is still a young country.

Now take a look at the overview of my presentation. As Dr. Pringle said, my presentation is divided into two parts. In the first part, I will talk about some background, for example, the huge unmet need with regard to child mental health, especially in low-resource settings. Then I will tell how primary care can be a promising avenue for improvement of child mental health. Then I will describe a mental health collaborative care model that we have developed and started to work with in primary care networks in my country. Then we will have a question and answer section. After that, I will talk about our NIMH-funded project that's called Collaborative Child Mental Health Care in Low-Resource Settings.

I will talk about the design and methods, and lessons learned. This study has not yet completed, but so far, I can describe what we have found in the midway of the research and what we have learned so far. Finally, I would be very happy, again, to take your questions. Now a little bit about the huge unmet need in child mental health care, especially in less developed settings. We all know that mental health conditions affect 10% to 20% of children and adolescents around the globe. We all know that most of these people, more than 90%, live in the low and middle-income countries. However, we also know that only 10% of child mental health trials come from these countries. Again, another gap.

We know that development of services, especially in low-resource settings, is hindered by lack of government policy or/and inadequate funding and a dearth of trained clinicians. We have good evidence showing that the earlier the intervention and preventive reports, the better our hope to avoid later adult mental health conditions. To speak more about the huge unmet need, I bring about our example in Iran. As I said, Iran has a population of around 80 million people, of which about a third are under 18 (years old). So, the population of children and adolescents is somewhere around 23 million people.

We had done several surveys to estimate the prevalence of mental health problems among children. Even with lowest estimates in our mind, we can say that at least around four million children and adolescents have one or more mental illness and emotional or behavioral problems. From recent studies of utilization of services in my country, we can say that less than 25% of these children who had one or more mental health condition, have received any care. By any care, I mean just one single visit by a GP (General Practitioner), a psychologist, or a psychiatrist. We can say that 3 million children and adolescents have not received any care.

So, we can say that the prevalence of common mental disorders is not that different in children compared to adults. However, we know that most of them go undetected or untreated for decades. With the same study that we have done in recent years, we noticed that the unmet need for receiving care for a mental health problem is highest in age groups under 19. This again shows the importance of attention to child mental health conditions in low-resource settings. What are the reasons for that? We all know that there are some universal barriers:  stigma, poor mental health literacy, high cost of care, and the difficulty of access to care.

We have some special features in my country. Family stigma is the main problem. Family has deep roots in Iranian culture and many families prefer keeping inside the problem in the family rather than asking for help, because receiving care may put family pride in risk. The other issue is the rapidly changing socio-economic situation. We have faced very rapid urbanization. In the last three decades, we have seen movements from rural areas into urban areas and my country now is mostly an urban country. Another issue and another problem is a deteriorating economy due to sanctions. Recent sanctions impose new challenges, especially for the families who have mental health problems, especially children.

Another barrier is that school mental health initiatives and preventive programs are scattered and inadequate like in many other low- and middle-income countries. Specialist mental health professionals are insufficient even in many urban areas. For example, we can see that the number of child psychiatrists in the country is less than 100, and the number of psychiatrists is somewhere around 1,700. The number of pediatricians is less than 4,000, but the number of GPs is more than 40,000. As expected, we can see that almost all the specialists are located in big cities.

That's why primary care can be a promising avenue for improvement of child mental health care, as shown in my previous slide, there are many more GPs and they are more accessible to people around the country. Why is that? Other than accessibility, the other factor that makes primary care a well-placed situation and context to improve child mental health is that it has less stigma. It also has lower costs. Also, it can address both physical and mental health in the same office. With regards to child mental health, we can say that primary care can address both parent and child mental health by the same GP and the same primary care worker.

Now, I will talk a little bit about the primary care network in Iran. It was started in 1970s. It was initiated focused on controlling communicable diseases. Later, the attention shifted towards noncommunicable diseases and in 1988, we witnessed an introduction of mental health into primary care. First, it was focused on severe mental disorders. Now it has shifted from severe mental disorders to more common mental health conditions. However, almost half of GPs practice in the private sector and this could be some difference between my country and some other countries like the US.

>> DR. BEVERLY PRINGLE: I think we may have lost the audio for Dr. Sharifi. Can we get him back? Great. We're working on getting Dr. Sharifi's line back up. In the meantime, I'd encourage everybody if you've got questions that you'd like to put to Dr. Sharifi, please feel free to type those into the Q&A box, so that when he comes back online and reaches the end of this part of his presentation, he can address some of those.

>> WEBINAR OPERATOR: We do have Dr. Sharifi reconnected.

>> DR. BEVERLY PRINGLE: Wonderful. Thank you.

>> DR. VANDAD SHARIFI: Sorry for the interruption. I'm back.

>> DR. BEVERLY PRINGLE: Great. Welcome back. Thank you. You can go ahead.

>> DR. VANDAD SHARIFI: Okay, thanks. I was talking about the unique feature of primary care in Iran in which the medical schools and universities are integrated with the health services. The same organizations both provide the care and also provide education. In recent years we have witnessed developments in primary care networks, one of which is formal screening for adult mental health problems in some health posts, and introduction of some psychological care in urban primary care settings. However, the child mental health services and care are very limited, even in recent years in primary care settings.

More recently, my colleagues and I have developed collaborative care programs across the country and especially in Tehran and some other urban areas, with the aim of linking primary care networks with community mental health centers. Now I will talk about our collaborative care program. The aim was to enhance detection and management of mental conditions in public and private primary care settings, mostly in urban areas. The program links primary care and community mental health centers which are staffed by psychiatrists and psychologists with a master's-level degree.

What are the features of our collaborative care? Previously, our collaborative care was focused on adults and the features were the following. Similar to many other programs, it included training and supervision of GPs by psychiatrists, and GPs we're supposed to treat common mental disorders, and just to refer or use telephone consultations for more severe or more difficult-to-treat cases. Another feature of our model was that we developed a case manager role for our receptionist or health personnel. So, we didn't employ a new behavioral-health care manager.

We had a health information and monitoring system in place, and we used incentives like payment of top-up fees to the GPs, that's like care management fees for US certified medical homes. There are features that may differ from many other collaborative care programs, in which we cover all common mental disorders. For example, anxiety, depression and other common mental health conditions, and not just a single diagnosis like depression. It spans both public and private primary care sectors, and as I said before, we have trained GP receptionists or health personnel to develop case manager skills for follow-up of cases with common mental health conditions.

This is the information system that we have in place, and we have started detecting this, our adult collaborative care (program). And as expected, it led to increased detection and follow-up of common mental disorders among adult clients. It led to enhanced performance of GPs and improved clinical outcomes of patients visiting GPs. Now I will have two slides of the distribution of clients of ten collaborative care programs, I mean, adult collaborative care programs that we have in the country, one of which is our center. As you can see, in a report of six years of collaborative care in ten different centers, most patients are middle-aged. However, you can see a small number of people under the age of 19.

In this adult collaborative care (model), GPs were supposed to just refer and not do anything more if they suspected a child mental health problem. We didn't have comprehensive training for them. We just made a review of common child mental health problems and then asked them to refer the cases to CMHC and to a specialist. Afterwards, in recent years, we decided to include a collaborative care component for children. In the next part of my speech, I will go through the project of integrating the child mental health care component into the existing adult collaborative care program in our setting, that is an NIMH funded research study. I will stop here and get back to you, Dr. Pringle.

>> DR. BEVERLY PRINGLE:  Thank you, Vandad. That was terrific. We've got a question from our audience, and then I have a couple of questions as well. Dr. Holly Campbell-Rosen asks, "What's the breakdown of private versus public health care in Iran? Specifically, in primary care, what percentage of people are seen in private versus public health care, and are there disparities between the two systems?"

>> DR. VANDAD SHARIFI: That's a very good question. Actually, we have the number of GPs-- the number of GPs are even. Half of the GPs are in private sector and the rest in public sector, but we don't know for sure how many people go to public versus private sector. We believe, because of the cost, most of them go to public GPs, especially in rural areas where we don't have any private GP. So, I can say that the number of GPs and primary care workers are equal, but we believe, and my guess is that most people go to GPs in public sector.

>> DR. BEVERLY PRINGLE: That's because of cost?

>> DR. VANDAD SHARIFI: Mostly because of costs, and with regard to rural areas that's because of access.

>> DR. BEVERLY PRINGLE: Yes, that makes sense. You had mentioned that the collaborative care program, one of the outcomes for adult general practitioners was enhanced performance. I wondered if you could say a little bit more about how that collaborative care program enhanced their performance. Do you have any data on what the mechanism was that led to that change?

>> DR. VANDAD SHARIFI: Actually, we used a novel approach to study the performance of GPs. We used that novel approach in our recent NIMH funded project, and we published the report. Our approach was something like this. We trained SPs in-- previously adult SPs to go to GP offices. By SPs I mean standardized patients, and these SPs went to the GP offices and they role-played some scenarios, for example, depression and anxiety.
Then after the GP visit, they filled out some checklists to rate the behavior of the GP – whether they detected a mental health problem or gave anything to (the SP for the problem). We compared the performance of GPs who were in the collaborative care to those who were not. We understood that there is a significant difference between the performance of GPs, using the checklist. However, we did not do a qualitative study to study the mechanism for this difference, so we don't know for sure, but there are some guesses.

>> DR. BEVERLY PRINGLE: Oh yes, that's really helpful. Thank you. Then just one other question is about the receptionists taking on the role of case manager, that's such an interesting innovation, and we often hear with any task sharing model, that a particular -- well, every group in healthcare is so overwhelmed with just their daily responsibilities that they can't possibly take on additional tasks. So how did you manage that?

>> DR. VANDAD SHARIFI: That's a really good question. Actually, we trained the receptionists, and the training was so hard for us because many of them were under-educated, and we trained them to, for example, fill out forms and contact patients and do the follow-up and convince them (patients) to return to the GP offices. Actually, we asked the GPs to pay some incentive to the receptionists for the (extra) job they did. We did not pay anything directly to the receptionists. The GPs had to pay them part of the incentive that we pay to the GPs for their own performance. It's an interesting problem. Some receptionists do not perform well, but it was at least for many of them.

>> DR. BEVERLY PRINGLE: Yes, and do you have any sense that payment for additional tasks can become institutionalized?

>> DR. VANDAD SHARIFI: I believe so and we are testing this in a new study on adult collaborative care to see, if we change the incentivization model and payments of incentive mechanism, if that works and if it makes better the function of the receptionist.

>> DR. BEVERLY PRINGLE: Great. Okay, thank you very much. I think that's all the questions that we have for this segment.

>> DR. VANDAD SHARIFI: Okay, so I can move forward. The idea of providing grants and doing this study goes back to 2012, when I did a postdoc at (Johns Hopkins University). At that time, my supervisor was Ramin Mojtabai, and then I had the opportunity to meet with Dr. Wissow. Dr. Wissow has had a lot of experience on the integration of child mental health into the primary care, so we talked about our experience in adult collaborative care and we decided that we can provide a child component of collaborative care and integrate it into the existing adult collaborative care.

That led to writing the proposal and Professor Wissow did that with the help of some other colleagues, including Dr. Mojtabai, my colleague in Iran, Dr. Shahrivar, and also Dr. Stuart. With the help of some other colleagues from Iran, we started the job almost three years ago. A little bit about the rationale of our study. We all know that the evidence supporting adult collaborative care is very much, but the current knowledge on child collaborative mental healthcare is still inadequate. The number of collaborative care programs for children is much less than for the adults.

The other rationale was that nearly all adults and child models of integration have targeted a narrow range of conditions, and as I said before, many of them focus on a single diagnostic entity like depression or anxiety. We think, given our experience on adults, we can have a broader range and include more common mental health problems. In addition, adult collaborative care models can be expanded to provide direct care for common child and adult mental health problems, so we can use this opportunity and this infrastructure to provide care for child and adolescent people.

We know that task-shifting initiatives through such collaborative care programs may prove an important venue, especially for countries like Iran, to improve youth mental health care. A little bit about the specific aims of this study. We wanted to know if our collaborative care model for children and adolescents that come to the GP offices can result in increased utilization of child mental health care and improved outcomes, both for children and their parents. We wanted to know the mechanisms by why which these outcomes are achieved if any. We wanted also to know if a coordinated program of training and ongoing coaching and support can result in increased uptake of a skill by primary care providers.

Our study that was funded by the NIMH can be divided into two phases. In the formative phase, we wanted to provide guidelines and review literature and train people. In the trial phase, we wanted to test the effectiveness and also study the implementation outcomes. This is a picture of our case managers who are receptionists of GP offices. As I said, we reviewed the body of evidence and also, we looked at the adult collaborative care health information systems. We did some qualitative interviews, both with parents/youth and the GPs to develop our model and develop our training. We then made a guideline and a training package for the GPs.

During the formative phase, we had some findings. For example, we noticed that many parents declined CMHC referrals. The reason was that for many people asking help from a specialist was very stigmatizing, and they had concerns that specialists would propose or prescribe medication for any child mental health condition. The other reason was distance and difficulty to access. In addition, we found that over 75% of patients who were referred to the specialists in our adult care program, had common mental health conditions like anxiety and ADHD, that could potentially have been treated in primary care.

Most parents and youth in the study expressed a preference for mental health care from a GP rather than a specialist. In qualitative interviews, youth commented that we need to restructure the current GP visit to facilitate their participation. They preferred more freedom to talk, and in many GP offices we noted that only parents talk. However, we also noted that GPs have clinical needs and many of them have insufficient time, not only for child mental health visits, but also for adult mental health visits. This is a page from our guideline which covers common categories of conditions not divided on the basis of DSM (Diagnostic and Statistical Manual).

We had some recommendations which were trans-diagnostic, and some were more specific interventions for more specific conditions. We've provided some practical and context-appropriate recommendations, especially for parents. We also have recommendations for GPs, for example, when to refer and how to refer. About the trial, let me first talk about the design of our trial. This is actually a hybrid type two trial in which we study both the outcomes of the (mental health care) effectiveness and implementation (strategies and procedures). This is also a staggered design, a staggered cluster randomized design in which we randomized not the patients, but the GPs.

We randomized GPs in three separate waves. In each wave, again, GPs are randomized either to the intervention group or to the control group. In the intervention group, they received the training to do child collaborative care and follow up with patients, but for the control group, we told the GPs just to continue their previous experience with the adult collaborative care, and only refer the children who have a mental health condition to the specialist, and not to do anymore. As I said, these are in three waves and in each wave, we screened patients, I mean young children and adolescents between five and 15 (years of age), with the SDQ, that's the Strengths and Difficulties Questionnaire.

Each SDQ positive kid is followed for at least six months. As I said, the participants are children and youth between (the ages of) five and 15, along with one of their parents or guardians and also GPs who were already taking part in the collaborative care program. About the intervention: The intervention consisted of training for GPs that included a three-day in-person training with several role-plays and case discussions. Also, we had a follow-up, in-person booster training two months afterwards. The training was based on the guideline and the booster training focused on family engagement, psychoeducation, and troubleshooting problems that GPs had encountered during child visits.

They also used other facilities and other components of the collaborative care that existed for the adults. For example, telephone consultation and referrals. The special features of the interventions are the following. We used the existing adult collaborative care (model) and leveraged it by adding the child component, so we took the opportunity of existing adult collaborative care. Also, in this model, both children and their parents can be managed by the same healthcare provider, I mean the GP, using the same collaborative care model. We also adopted some common elements of treatments, mostly having a trans-diagnostic approach, I will talk about a little bit later.

As I said, our program addresses both public and private sectors using a stepped-care model. Based on our model, we believe that it's feasible and doable for our low-resource settings. This is the list of trainees and, as I said, we train for the categories of mental health problems instead of a specific diagnosis. Especially we focus on some common factors and common factors of treatment, like a relationship, like education, to make sure that's doable in the GP practice. A little bit about the outcomes: The main outcome was the SDQ (score). As I said, we used to train people with the SDQ and to do the follow-up assessment, again, by the SDQ in three and six months.

We also have some other effectiveness outcomes. I don't want to go through them, but among which are some parents' mental health outcomes. There are also some implementation outcomes that we are going to assess by both quantitative and qualitative approaches, for example, GP mental health skill uptake, and there are some potential moderating variables. The other thing is the novel idea of using unannounced visit to GP offices by a young child actor. You can see this young 10-year-old boy. He is a young actor who appears in some movies in Iran.

We asked him and his parents to do some unannounced visit to GP offices and to role-play a scenario of a kid with anxiety features. GPs were not aware of these role-plays and scenarios. Then later, we asked the young kid and his parents to fill out a form and describe their experience of the performance of GP, if the GP has detected a mental health condition or did anything or not. So far, we have recruited 53 GPs and the recruitment is over. We have recruited 1,143 children. As I said, we did not randomize children, we just randomized GP offices. So, we have 26 GP offices in the intervention group, and 27 GP offices were in the control group.

As I said before, we only follow SDQ positive cases. So, in the intervention group, we have 222. In the control group, we have just 191. We have completed recruitment and the follow-up is ongoing. The good news here is that the follow-up (assessment) is well above 90%. Just a quick look at the interim findings. I don't know which group is which, but we did some interim analysis to compare the groups, I mean the intervention and the controlled group, with regard to parent experience after the visit and GP experience after the visit. We noticed that in one group - and I don't know which is which - one group's parents expressed that there was more discussion of child mental health condition compared to the other group.

Again, in the same group, (more) GPs indicated that they have diagnosed children with mental health conditions compared with the other group, 50% compared to 29%. As I said, the follow-up is well above 90% and it will be finished in a few months. There are lessons learned, and noticing the time that I have, I will go through them very quickly. To make it brief, I can say that child mental health care can be more complex than adults because of the two-generational aspects of care, high degrees of comorbidity, there are variations in presentations, GPs have less confidence, and parents more concerns about diagnosis. However, integration is possible.

Task-shifting is useful especially for low-resource settings - using a collaborative care model to improve access and enhance outcomes. There are challenges, one of which is the integration challenge. I use this metaphor of integrating digital receiver into the TV. A decade ago, we had to buy a separate digital receiver for our TV and now it is within the TV. The integration is not the thing that you just put the receiver inside the TV and make connection, you need to change the TV itself. So, this is a challenge. The other challenge is what Dr. Pringle said – and I coin the term, the “saturation of task-shifting.” We may need to shift so many tasks to GPs, that it makes them overburdened.

There are some future directions. We hope it works. All it depends on the results. However, we need to see if collaborative care works for some conditions and not others. We want to see if it can be linked to school mental health initiatives. Also, we need to think if we can scale it up if it works for the children. I hope it works. Finally, I want to conclude with a beautiful picture of a mosque in central Iran. I hope all of you can have time to visit Iran, and we will welcome you to my country. Thank you very much, and I will be happy to take your questions.

>> DR. BEVERLY PRINGLE: Oh, that's wonderful, Vandad. Thank you very much for that presentation. This is such an interesting project. I'd like to invite people to type in some questions for Dr. Sharifi. I have a couple just to get us started. One of them is-- you mentioned two issues that are challenges for integrating mental health care into pediatric primary care, one of them is common to the US and the other one is probably not as big a problem here as it might be in Iran and some other countries. So, the first one is getting that message out to parents, that mental health care does not always mean medication.

We hear that here in the US – I hear that in lots of other countries too – and so I'm curious what your thoughts are about how we can perhaps do that on a broader scale other than waiting for individual families to come into the clinic. The second one, which is really intriguing to me is creating an atmosphere that allows freedom for the children to talk. It seems to me that that's probably a big issue, but in countries where perhaps there's a much stricter sort of authority among parent figures, that that could be difficult.

>> DR. VANDAD SHARIFI: You're right. The first challenge is very common across many countries. In my country, referring to a specialist usually means medications, but we need to tell people, especially parents, that it is not only medication. For example, parents and children who were referred to our CMHC can receive both medications and psychological services, we have psycho-social services for children, and parents may be concerned that it's only medication and we need to convince them.

The second issue can be more common in some countries where fathers and mothers have more authority especially for the youth. They have power over the youth, even above age 18. So, this could be a cross-cultural difference that makes some challenges in my country.

>> DR. BEVERLY PRINGLE: Is there anything in your training that helps the primary care physicians figure out how to change that or open things up a bit within the session, so that the youth or the children are more able to talk?

>> DR. VANDAD SHARIFI: One mechanism that we used, we discussed the issue with the GPs in our training and we told them that if possible, for the GP to ask the parent to come out of the GP office and just talk about the child mental health with the youth and not in the front of parents. That could be difficult for some GP offices because they have busy clinics and have insufficient time.

We also discussed that the youth can be asked directly, even in the absence of the parent of a mental health condition, and they can provide some good information about themselves even in the absence of the parents. During the training and afterwards during the booster training, we noticed that it works at least for some GPs and they feel more comfortable now, interviewing only the youth in the absence of parents and giving more freedom to the youth to talk about their conditions.

>> DR. BEVERLY PRINGLE: That's great, it sounds like you really took a problem-solving approach with the GPs to help them figure out what would work best for them. We have one last question from our audience and the question is, given that you may be getting evidence to support your guidelines for mental health and pediatric primary care, is there a formal mechanism in Iran for disseminating those guidelines throughout the medical community if your study has positive results?

>> DR. VANDAD SHARIFI: Sorry, Dr. Pringle. I didn't hear you well, can you repeat the question?

>> DR. BEVERLY PRINGLE: Yes. If the study is successful and it looks like you're finding a difference even though you don't know which group is which yet, but if your study is very successful, is there a mechanism for disseminating some guidance, your findings or your training program throughout the medical community in Iran?

>> DR. VANDAD SHARIFI: Effectively, we've already started it for the adults. First of all, we talk a lot to the authorities and the Ministry of Health and in the university to convince them that adult collaborative care works well, is effective and could be cost-effective as well. Now we have got their support to scale up adult collaborative care programs. Also, we did some seminars both for specialists and also for GPs to talk about our experience and say how it is effective and it is feasible, and to make more interested, especially among clinicians, specialist clinicians.

Many of them prefer to just see patients by themselves in private units but we need to convince the specialists, especially psychiatrists to join such collaborative care programs, to address the mental health problems of children in the primary care that's more accessible for people. So, one thing is the specialist and then the other is GPs, which we can talk to them more to disseminate our results, and also using other platforms such as websites and journals.

>> DR. BEVERLY PRINGLE: Yes. Very good. I know we're over time, but we do have one more question. Do you have time, Dr. Sharifi, to take one more question?

>> DR. VANDAD SHARIFI: Of course.

>> DR. BEVERLY PRINGLE: Great. The question is, for teams who are used to the collaborative care model for adults, what are the most important recommendations, do you think, for providers who now want to try this with children?

>> DR. VANDAD SHARIFI: That's very important because they may prefer referring to a specialist, especially in our setting in which specialty care in the CMHC by psychologists or psychiatrists are free of charge. We need to convince them that you can receive care from GPs and if needed, just if needed, you can receive care from a specialist. We cannot force them, and I should add that even in the trial group, all the parents can ask for help from a specialist, both from the current CMHC and from outside of our collaborative care.

So, we cannot force them, they can receive specialist care anytime they wish, but we think at least for a proportion of the youth and parents, GP offices are more comfortable to them and more accessible to them. They prefer them over referring to a specialist.

>> DR. BEVERLY PRINGLE: Yes. That makes sense. That brings us to the end of our webinar today. I just want to thank DR. VANDAD SHARIFI very much for this really interesting presentation and for your generosity in taking questions and discussing your work with us. We will make this webinar available with the transcript, including the questions and answers within a few weeks on our website, so those of you who have joined us today, be sure to let your colleagues know that they can still hear this wonderful talk by Dr. Sharifi. I want to, once again, thank you, Vandad, very much for this and thank everybody and have a wonderful rest of your day. Bye now.

>> DR. VANDAD SHARIFI: Thank you very much Dr. Pringle and all the participants, thank you very much, bye bye.