Impact of Experiential Training With Standardized Patients on Screening and Diagnosis of Adolescent Depression in Primary Care

Journal of Adolescent Health 65 (2019) 57e62

www.jahonline.org Original article

Impact of Experiential Training With Standardized Patients on Screening and Diagnosis of Adolescent Depression in Primary Care Elise M. Fallucco, M.D. a, *, Lauren James, M.A. a, Carmen Smotherman, M.S. b, and Peggy Greco, Ph.D. c a

Department of Psychiatry, University of Florida College of Medicine e Jacksonville, Jacksonville, Florida Center for Health Equity and Quality Research, University of Florida College of Medicine e Jacksonville, Jacksonville, Florida c Division of Psychology, Department of Pediatrics, Nemours Children’s Healthcare System, Jacksonville, Florida b

Article history: Received October 18, 2018; Accepted December 26, 2018 Keywords: Adolescent depression; Screening; Provider training; Standardized patients; Primary care

See Related Editorial on p.7 A B S T R A C T

Purpose: Primary care providers (PCPs) report inadequate training in depression care. The objective of this study was to examine the long-term impact of PCP training with standardized patients on screening and diagnosis of adolescent depression in primary care. Methods: A retrospective review of electronic medical and billing records for adolescent (aged 12 e18 years) well-visits assessed the frequency of screening and new diagnoses of depression. Twenty-five PCPs participated in training. The study included all adolescent well-visits in the 12 months before and after PCP training. Adolescents with a previous diagnosis of depression were excluded from the sample. Univariate and multivariable analyses were used to assess associations with screening. Odds ratios were used to describe the magnitude of associations. Results: The analysis included 7,108 well-visits for adolescents (mean age 14.5 years, standard deviation 1.7 years; gender: 52% male; race: 65% white, 13% black, 22% other races; ethnicity: 25% Hispanic; insurance: 67% commercial). Depression screening rate increased significantly after training from 51% to 80% of adolescents seen at well-visits (adjusted odds ratio 40.8, 95% confidence interval 32.6e51.0, p < .0001). Although the likelihood of being screened for depression increased post-training, there was variation based on patient’s insurance. A significantly greater percentage of adolescents were newly diagnosed with depression after training (2.22% vs. .89%, p < .0001). Conclusions: PCPs who participated in experiential training using standardized patients were more likely to screen for and diagnose adolescent depression in the 12 months after training. Future studies are needed to examine the effects of PCP training on patient outcomes. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.

Conflicts of interest: The authors report no conflict of interest. * Address correspondence to: Elise M. Fallucco, M.D., Department of Psychiatry, University of Florida College of Medicine e Jacksonville, 580 West 8th Street; Tower II, 6th Floor Suite 6005; Jacksonville, FL 32209. E-mail address: [email protected]fl.edu (E.M. Fallucco). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2018.12.022

IMPLICATIONS AND CONTRIBUTION

Despite guidelines that recommend screening at well-visits, adolescent depression remains underrecognized and undertreated. A multifaceted educational intervention that incorporates active learning can facilitate an increase in the frequency of adolescent depression screening, identification, and treatment.

Adolescent depression affects approximately 1 of 10 youth, and evidence suggests depression has become even more prevalent among U.S. adolescents aged 12e17 years, increasing from 8.7% to 11.3% between 2005 and 2014 [1e3]. Only a minority (38%) of the 2 million U.S. adolescents diagnosed annually with depression receive treatment [4]. Left untreated, adolescent depression is associated with substance use, academic failure,

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juvenile justice involvement, increased health expenditures, and suicide [5e8]. In light of the critical public health problem of untreated depression, the American Academy of Pediatrics [9] and the United States Preventive Services Task Force [10,11] have urged primary care providers (PCPs) to screen for major depressive disorder in adolescents aged 12e18 years. However, providers rarely screen for adolescent depression [12e15] due, in part, to inadequate PCP training in adolescent depression recognition and treatment [16e19]. Brief education programs for PCPs have shown promise in improving rates of primary care screening for adolescent depression [20,21]. Kramer et al. [20] found that general practitioners who participated in a training intervention were more likely to screen adolescents for depression after training. Yet, post-training depression screening rates in that study remained far from universal. In a previous study by our team, a selfselected sample of adolescent patients was found to be greater than three times more likely to be screened for depression after their PCPs participated in an experiential training workshop using standardized patients (SPs) [21]. Results indicated nearuniversal post-training screening with this self-selected sample, as indicated by adolescent report. Rates of depression diagnoses were also significantly higher, and treatment options were discussed more frequently compared with baseline, according to patient self-report [21]. This previous study was conducted with a self-selected sample of adolescent patients who reported on their PCPs practices at three specific points in time. In contrast, the present study was designed to obtain outcome data continuously over a 12-month period before and a 12-month period after intervention rather than at several discrete points in time. Furthermore, outcome indices were measured objectively through medical record and billing record review, rather than by adolescent self-report. These improvements to the study design allowed for a more objective and longitudinal estimate of the impact of this experiential workshop with SPs on PCP practices. The goals of the present study were (1) to provide experiential training using SPs to a large, new sample of community PCPs; (2) to measure the frequency of adolescent depression screening at well-visits for 12 months before and after training; and (3) to measure the percentage of adolescents newly diagnosed with depression for 12 months before and after training. As an exploratory aim, we sought to assess antidepressant medication prescription patterns in this sample. Methods Research design PCPs in a Central Florida children’s health care system participated in an experiential workshop with SPs in early April 2015. All of these PCPs belonged to a unified primary care network. To determine the impact of training, a retrospective electronic medical record (EMR) chart review assessed adolescent depression screening during pediatric well-visits for 1 year before training (April 2014 to March 2015), as well as for 1 year after training (late April 2015 to March 2016). All data from the retrospective chart review were deidentified and specifically did not contain any Health Insurance Portability and Accountability Act (HIPAA) identifiers. The study received expedited approval from the Nemours Institutional Review Board, who waived the

requirement for obtaining informed consent/parental permission and authorization for use and disclosure of deidentified protected health information. Participants and recruitment All PCPs (n ¼ 25) who were affiliated with a children’s primary care network in Central Florida were invited by their Medical Director to attend the experiential training that was held on the evening of April 8, 2015. Their Medical Director encouraged participation in the training as part of a concerted effort to standardize care through the use of recommended screening tools. As training was held after hours, the Medical Director offered compensation for attending training in the form of “points” that were used to determine each PCP’s annual bonus. As an additional incentive, PCPs received Continuing Medical Education credit for their participation. The network had historically used a Relative Value Unit (RVU)-based compensation system before and after training, which incentivized providers to perform billable services (including depression screening). Experiential workshop with SPs The development and content of the experiential training have been previously described. [21] In brief, training consisted of a 60-minute seminar plus a 60-minute session during which PCPs practiced clinical skills in assessment and treatment of adolescent depression with SPs. Training was led by a boardcertified child and adolescent psychiatrist and was followed by a 30-minute debriefing and question-and-answer period. The case-based seminar reviewed (1) depression screening using a standardized tool, the Patient Health Questionnaired9 Item Modified for Teens, [22] (2) suicide risk assessment, (3) depression diagnosis and treatment with antidepressant medication, and (4) long-term management. The training was based on the American Academy of Pediatrics’ guidelines for depression assessment and management in primary care [23,24]. As the goal of the training was to promote universal office-based depression screening at well-visits, the training focused on practical ways to implement depression screening in primary care. PCPs received a sample office protocol detailing how to distribute, score, and review the Patient Health Questionnaired9 Item Modified for Teens, document screening, and bill and code for services. PCPs received an educational packet including copies of the screening tool, treatment algorithms, and antidepressant medication dosing guidelines. The gold standard of referring patients for cognitive behavioral therapy along with initiating antidepressant medication was emphasized for patients with moderate or severe depression. During the SP session, all PCPs practiced clinical skills learned during the seminar twice, during two separate 10-minute mock interviews with an SP. In one of the mock interviews, the PCP interviewed an SP portraying the role of a 16-year-old with low mood, poor grades, and a positive depression screening score. In the other mock interview, the PCP interviewed an SP who portrayed a 17-year-old with irritability, drug use, and a negative depression screening score. After each PCP-SP mock interview, the SP gave verbal feedback to the PCP for 5e10 minutes regarding the PCP’s communication skills. Finally, the training leader met with the PCPs for 30 minutes to debrief and discuss

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ways to implement adolescent depression screening into their practices. Data collection The EMR was queried for information about each well-visit for adolescents (aged 12e18 years; Current Procedural Terminology [CPT] codes 99384-5, 99394-5) during the study period. All adolescents with a previous diagnosis of depression (i.e., before the date of the well-visit) were excluded from the sample. Patients and PCPs were given unique identifiers, and all data were completely deidentified (without HIPAA identifiers) by the EMR data extraction team before review by the study team. The primary outcome for the study was the frequency of adolescent patients who were screened for depression at annual well-visits by their PCP. To determine whether or not each adolescent was screened for depression at their annual well-visit, the EMR was queried for specific procedural codes for depression screening (i.e., CPT codes 96110, 96127; or Healthcare Procedure Coding System codes G0444, G8431, or S2005). Typically, adolescent patients have only one well-visit per 12-month period. For those adolescents who scheduled more than one well-visit per 12-month period, the second well-visit was excluded from the data set. To determine whether an adolescent was diagnosed with depression, the EMR was queried for any adolescent well-visit with a new diagnosis of major depressive disorder (either single episode or recurrent) or of depressive disorder not otherwise classified (ICD-9 diagnosis codes 311, 296.2, 296.3; ICD-10 diagnosis codes F32.0-9 and/or F33.0-9). General demographic information (i.e., age in years at the time of the visit, gender, race/ethnicity, private vs. public insurance) for all adolescent patients was collected. Race was categorized into black, white, Asian, and Other, and ethnicity was dichotomized into Hispanic/Latino and noneHispanic/Latino. Insurance was categorized as private/commercial, Medicaid, or “Other” (uninsured, underinsured). Analysis Descriptive summaries of frequencies and percentages for categorical variables and medians and quartiles for numeric variables were completed. To compare the percentage of providers who were screening universally for adolescent depression (defined as screening at least 75% of adolescent patients at well-

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visits), before versus after the intervention, McNemar’s test for paired data was used. Univariate analyses using hierarchical models (e.g., GLIMMIX procedure in SAS) were used to evaluate the effects of individual covariates (patient age, gender, race, ethnicity, and insurance) on screening pre- and post-training. Multivariable models were used to examine the associations of training, and other variables found to be significantly associated with screening in the univariate model. Effects of training on the proportion of adolescents who were newly diagnosed with depression and/or treated with antidepressant medications at well-visits were also investigated. Odds ratios (ORs) along with their 95% confidence intervals (CIs) were used to describe the magnitude of associations. The significance level for statistical tests was set at .5. All analyses were performed using SAS for Windows Version 9.4 (SAS for Windows Version 9.4, SAS Institute Inc., Cary, NC). Results Screening for adolescent depression All 25 of the PCPs who were invited attended the experiential training. During the study period, there were 7,326 well-visits, but 218 were excluded as they were patients who had been diagnosed with depression at a previous visit (n ¼ 68 pretraining and n ¼ 150 post-training). Thus, there were 7,108 eligible adolescent well-visits that occurred at 14 different practices in the 2-year study period. The demographics of the PCP practice samples are shown in Table 1. Patient demographics associated with screening The univariate analysis revealed that before training, patients with private or commercial insurance were more likely to be screened compared with patients with “Other” insurance (OR ¼ 2.63; 95% CI ¼ 1.07e6.49, p ¼ .037). There was no pre-training difference in screening rates between patients with private or commercial insurance and those patients with Medicaid (OR ¼ 1.34; 95% CI ¼ .89e2.02, p ¼ .162). Patient insurance was not significantly associated with depression screening after training; patients with private/commercial insurance, Medicaid, or “Other” insurance were equally likely to be screened. Patient ethnicity, race, gender, and age at visits were not significantly associated with depression screening either before or after training.

Table 1 Demographics of PCP practice samples: pre- and post-training Variable

Category

Pre-training (n ¼ 3,150, 44%)

Post-training (n ¼ 3,958, 56%)

Gender

Female Male Black White Asian Other Hispanic Non-Hispanic or Latino Private/commercial Medicaid Other

1,527 (48) 1,623 (52) 354 (13) 1,647 (63) 32 (1) 601 (23) 716 (27) 1,912 (73) 2,043 (65) 1,008 (32) 99 (3) 14.3 (13.1; 15.9)

1,906 (48) 2,052 (52) 423 (13) 2,259 (67) 37 (1) 641 (20) 793 (23) 2,592 (77) 2,736 (69) 1,143 (29) 79 (2) 14.3 (13.0; 15.8)

Race

Ethnicity Insurance

Age at visita PCP ¼ primary care providers. a Median (first quartile; third quartile).

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Figure 1. Adolescents (percentage) screened for depression at well-visits: before versus after training.

Increase in depression screening following training

Medication treatment for adolescent depression

The proportion of adolescents who were screened for depression at well-visits in the 12 months before and after training, respectively, is illustrated in Figure 1. Overall, depression screening rate at well-visits increased significantly after SP training from 51% to 80% (adjusted OR ¼ 40.8, 95% CI ¼ 32.6e51.0, p < .0001). After training, significantly more PCPs practiced universal screening, defined as screening >75% of adolescents (22 of the 24 providers, 91.6%) compared with before training (12 of the 24 providers, 50%, p ¼ .004). This increase in screening rate above 75% was maintained throughout the 1-year post-training period, ranging from 75% to 91% during this period of time. The multivariable model revealed significant higher odds of being screened post-training in all insurance categories. The magnitude of these associations was different across the insurance categories. Patients with Medicaid seen for a well-visit had 60 times higher odds of being screened for depression post-training compared with pre-training (OR ¼ 60.7; 95% CI ¼ 43.6e84.7). Adolescents whose insurance was categorized as “Other” were also nearly 60 times more likely to be screened at well-visits posttraining compared with pre-training (OR ¼ 57.8, 95% CI ¼ 20.2e 165.8). The odds of screening for depression post- versus pre-training for patients with private/commercial insurance were 31.2 (95% CI ¼ 23.8e40.9).

Results of the exploratory analysis showed that PCPs prescribed antidepressant medication to a significantly greater percentage of adolescents seen at well-visits after the training (2.22%) compared with before the training (.86%, p < .0001). The odds of being prescribed antidepressant medication were significantly higher posttraining (OR ¼ 2.5; 95% CI ¼ 1.7e3.9, p < .0001). There was no significant difference between the percentage of adolescents newly diagnosed with depression who were prescribed medication before training (n ¼ 5; 18%) compared with after training (n ¼ 14; 16%, p ¼ .808). In other words, although training resulted in higher screening rates and higher diagnosis rates, it did not result in higher medication rates for the subset of patients diagnosed with depression. The most commonly prescribed antidepressant medications in the entire sample (n ¼ 82 patients) were fluoxetine at 43.9%, sertraline at 28.1%, and citalopram at 7.3%.

Diagnosis of adolescent depression In addition to a significant increase in screening rates, experiential training also resulted in a significant increase in the proportion of adolescents at well-visits who were newly diagnosed with depression. In the year before the training intervention, 28 of 3,150 (.89%) adolescents were diagnosed with depression compared with 88 of 3,958 (2.22%) adolescents seen after training. The odds of receiving a new diagnosis of depression were almost three times higher after training (OR ¼ 2.7; 95% CI ¼ 1.8e4.2, p < .0001).

Discussion This longitudinal study examined the impact of a brief, experiential workshop on PCP practices in screening, diagnosis, and treatment for adolescent depression at well-visits in a large children’s health care system. To our knowledge, this is one of the few studies to demonstrate a significant, immediate, and pervasive impact on clinical care of adolescent depression after a timelimited intervention. Experiential training for PCPs resulted in a significant increase in PCP practices of adolescent depression screening and depression diagnosis; as measured by OR, adolescents were more than 40 times more likely to be screened and almost three times more likely to be diagnosed with depression after training. Screening for adolescent depression remained near universal (i.e., >75% of adolescents screened) in the year after training. Our finding of a significantly increased screening rate is consistent with our past study that showed a screening rate

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increase from 49% pretraining to 68% at 2e8 months posttraining by adolescent patient self-report [21]. These earlier findings are bolstered by the present study, which used objective billing records rather than self-report and lengthier pre- and post-intervention periods. This widespread adoption of universal screening after training is remarkable when compared with findings from other studies of educational interventions designed to promote screening in adolescents. Kramer et al. [20] found a less robust increase in depression screening (from .7% to 20% of adolescents aged 13e17 years) in the 16 weeks after an educational intervention for general practitioners in Britain as documented in the EMR. Although both our training and the intervention by Kramer et al. allowed providers to apply their knowledge of depression assessment by discussing clinical cases, only our team’s training used SPs to help providers practice the application of clinical skills. The combination of seminar-based case discussion with clinical practice using SPs has been shown to be superior to seminar alone without SPs in increasing provider confidence and knowledge [25]. Mock interviews with SPs coupled with individual feedback from SPs likely helped providers refine their approach and increased their comfort discussing sensitive topics such as depression and suicide. In sum, the improvements in PCP practices in this study support the findings from multiple studies that multifaceted, interactive educational interventions are needed to create a major impact on provider practices [26,27]. Another factor that may have facilitated implementation of depression screening was the method of screening. Specifically, our study used a standardized self-report that could be completed by the adolescent before the visit, thus limiting the provider time spent during the interview to ascertain whether or not the adolescent had the nine key symptoms of depression. This use of an adolescent self-report screening tool was considered more time efficient compared with screening via a lengthier clinical interview as used by Kramer et al. [20]. During our training, PCPs were also reminded to bill and code for screening using a CPT code, which generated RVUs for the providers and possible reimbursement for privately insured patients. The additional RVUs together with the possibility of financial reimbursement may have helped to decrease provider reluctance to screen and spend additional time with patients with positive screens. The use of a time-efficient screening method that could be reimbursed may have lowered time-related and financial barriers to screening. In addition to recommending screening adolescents for depression, the United States Preventive Services Task Force has called for research showing that screening results in improved identification and ultimately treatment [28]. The present study answers this call by showing that screening resulted in improved identification of depression, with adolescents being almost three times more likely to receive a new diagnosis of depression in the year after training compared with the year before training. PCPs were taught to use evidence-based algorithms and guidelines to evaluate adolescents with positive screens to determine whether their symptoms were consistent with a diagnosis of depression as opposed to other problems that present with depressed mood and low energy. The significant increase in new diagnoses of depression resulted in a post-training rate comparable to national epidemiologic estimates of depression in adolescence [29]. While training resulted in higher screening rates and higher diagnosis rates, it did not result in higher medication rates for the subset of patients diagnosed with depression. Although providers were not more likely to treat with antidepressant medication,

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they may have used nonpharmacologic resources (i.e., referring for CBT) on a more frequent basis. Although the training emphasized the efficacy of CBT, the present study was not designed to objectively measure rates of referrals for therapy. One major limitation of the present study is that the preepost study design limits the ability to draw causal conclusions. Future studies in this area should be designed as randomized controlled trials with providers randomly assigned to usual care or experiential training. Second, PCP diagnoses of depression were not independently verified or validated. Although PCPs have been shown to have few false positives [30], diagnoses of depression should be independently corroborated, perhaps with a subsample undergoing a semistructured psychiatric interview to validate PCP diagnoses. Third, this study measured only one treatment option, prescription rates of antidepressant medication. Ideally, provider recommendations after depression diagnoses should be comprehensively tracked to include referral for CBT and other treatment options, as well as prescription of medications. Ultimately, it would be advisable to track subsequent patient adherence with recommendations and related outcomes (i.e., depressive symptoms). A final limitation is the use of billing codes to measure depression screening. Although providers were reminded to use proper billing codes for standardized depression screening, it is possible that the increase in billing for screening simply reflected an enhanced awareness of coding after training. This seems less likely to account for the majority of the posttraining increase, especially given that these billing codes were used at approximately 50% of the well-visits in the year before training. In addition, the post-training increase in billing for depression screening was accompanied by a post-training increase in new diagnoses of depression (from .89% to 2.22), suggesting that the increased billing for depression screening was more likely to reflect increases in actual screening practices. This study’s significant and pervasive impact on clinical care of adolescent depression after experiential training for PCPs indicates the importance of developing and implementing multifaceted educational interventions to facilitate early identification of adolescent depression. Training can result in near-universal screening and increased diagnoses, proving to be a successful step on the route toward addressing the critical public health problem of underdiagnosed and undertreated depression. Acknowledgments The sponsors had no involvement in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The authors would like to thank Dr. Thomas Lacy, M.D., who championed depression screening in primary care in his role as Medical Director, and all of the providers and standardized patients who participated in the training seminar. Funding Sources Funding for this study comes from a Substance Abuse and Mental Health Services Administration Grant # 5U79SM05993904 to the Partnership for Child Health and from the HallHalliburton Foundation. References [1] Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey

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