Publication Date


Document Type

Doctoral Dissertation

Academic Program

Clinical and Population Health Research, MD/PhD


Population and Quantitative Health Sciences

First Thesis Advisor

Kate L. Lapane


mental health services, adolescent health, transition age youth, integrated care



Youth and young adults represent a critical time for early detection and intervention of serious mental health conditions (SMHCs); however, of all age groups, health care use is lowest in young adults. Continued access to health services such as outpatient primary care and specialized mental health care, especially during the transition from pediatric to adult care, is important to improving outcomes in those with serious mental health conditions.


Stakeholder engagement and a mixed-method design were used. Quantitative Aims 1 and 2 used the IBM MarketScanCommercial Database. Qualitative Aim 3 used semi-structured interviews with a purposive sample of pediatricians and child/adolescent psychiatrists. Stakeholders were engaged throughout all Aims to ensure relevance of goals, real-world interpretation of results, and dissemination of key findings. Aim 1 described patterns of outpatient (e.g., primary, reproductive, mental health care) and acute (e.g., emergency room use, inpatient hospitalization) health care use by age, and serious mental health condition for youth and young adults. Aim 2 used logistic models with generalized estimating equations to identify factors associated with mental health follow-up after hospitalization and emergency room use for a serious mental health condition. Aim 3 explored pediatrician and child/adolescent psychiatrist perspectives on coordinated care for youth and young adults with serious mental health conditions, particularly as they transition to adult care.

Main Results

The prevalence of outpatient mental health care and primary care decreased with age, with a larger drop in primary care utilization. While 74.0-78.4% of those aged 12-17 years used both outpatient mental health care and primary care, 53.1-59.7% of those aged 18-27 years did. Differences were observed by mental health condition; those with schizophrenia and other psychotic disorders had the lowest rates of outpatient primary care use and the highest rates of acute care use.

Of those hospitalized, 42.7% received follow-up within 7 days and 64.7% within 30 days. Of those with emergency room use not resulting in a hospitalization, 28.6% received follow-up within 7 days and 46.4% within 30 days. Having established mental health care strongly predicted follow-up, and more so than having established primary care.

Providers described poor communication systems, no organized process for the transition from pediatric to adult care, a lack of time and reimbursement, and inadequate connection to community supports as key barriers to continuous, coordinated care for youth with serious mental health conditions.


Findings provide foundational knowledge to inform efforts to provide a comprehensive continuum of care for people with serious mental health conditions, potentially through increased access to primary care and specialized mental health care via enhanced care coordination of providers.



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Available for download on Friday, April 26, 2024