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Outcomes of Depression Screening Among Adolescents Accessing School-based Pediatric Primary Care Clinic Services
Journal of Pediatric Nursing 38 (2018) 8–14
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Outcomes of Depression Screening Among Adolescents Accessing School-based Pediatric Primary Care Clinic Services Sarmila Bhatta, DNP, FNP-C a, Jane Dimmitt Champion, PhD, DNP, FNP, FAAN, FAANP b,⁎, Cara Young, PhD, RN, FNP-C c, Elizabeth Loika, DNP, PNP-C, FNP-C d a
Family Nurse Practitioner, School of Nursing, The University of Texas at Austin, United States Lee and Joseph D. Jamail Endowed Professorship in Nursing, School of Nursing, The University of Texas at Austin, 1710 Red River St, Austin, TX 78701, United States School of Nursing, The University of Texas at Austin, 1710 Red River St, Austin, TX 78701, United States d Clinical Associate Professor, School of Nursing, The University of Texas at Austin, 1710 Red River St, Austin, TX 78701, United States b c
a r t i c l e
i n f o
Article history: Received 27 August 2017 Revised 28 September 2017 Accepted 1 October 2017 Available online xxxx Keywords: Adolescent Depression Primary care Screening
a b s t r a c t Purpose: Implementation of routine Patient Health Questionnaires (PHQ-9) screening among adolescents aged 12–18 year, accessing school-based pediatric primary care clinic services for identification of adolescents at potential risk for Major Depressive disorder (MDD). Design and Methods: Retrospective chart review (N = 256 cases) documented PHQ-9 depression screening outcomes among adolescents accessing school-based pediatric primary care clinic services for episodic illness and wellness visits. Data analyses included descriptive statistical methods. Results: Chart review included 137 (53.5%) females and 119 (46.5%) males. PHQ-9 depression screening was identified for 56.3% (n = 144) of charts with scores ≥10 for 12.5% (n = 18) among those screened. Mental health referrals were made for 83.3% (n = 15) with PHQ-9 scores ≥10. Dysthymia related concerns were reported among 20.1% (n = 29) of which 55.2% (n = 16) received mental health referrals. Female adolescents reported more sleep problems (χ2 = 9.174, p = 0.002) and tiredness (χ2 = 6.165, p = 0.013) than males. The 15–18 year age group (χ2 = 5.443, p = 0.020) was more likely to experience sleep problem and low selfesteem than 12–14 year age group (χ2 = 5.143, p = 0.023). Conclusion: Implementation of PHQ-9 depression screening protocol identified MDD among adolescent accessing pediatric school-based primary care clinic services facilitating referrals to mental health providers, potentially improving morbidity and mortality among adolescents. Practice Implications: MDD is common among adolescents and associated with functional impairments and increased morbidity and mortality. Due to its high prevalence, it is imperative to improve screening and treatment access in this population via school-based clinics. © 2017 Elsevier Inc. All rights reserved.
Background Major Depressive Disorder (MDD) is common in children and adolescents and linked to functional impairment and suicide. Prevalence of major depressive episode among adolescents in the United States was 12.5% in 2015 (National Institute of Mental Health [NIMH], 2015). MDD is higher among adolescent (12–17 years) females (36.1%) than males (13.6%) (Breslau et al., 2017). Suicide is the second leading cause of death among adolescents (Center for Disease Control and Prevention [CDC], 2014).
⁎ Corresponding author. E-mail addresses: [email protected] (S. Bhatta), [email protected] (J.D. Champion), [email protected] (C. Young), [email protected] (E. Loika).
https://doi.org/10.1016/j.pedn.2017.10.001 0882-5963/© 2017 Elsevier Inc. All rights reserved.
Depression increases significantly in the presence of chronic diseases. One of five adolescents in the United States has a chronic disease requiring continuous treatment and management (Corathers et al., 2013). Unrecognized and untreated MDD increases risk for obesity, suicidal thoughts, attempts, and completion. It also affects academic performance and relationships with parents, siblings, and peers (Thapar, Collishaw, Pine, & Thapar, 2012). Adolescents with MDD are likely to have somatic symptoms such as headaches, abdominal pain, and musculoskeletal pain (Forman-Hoffman et al., 2016). They are also more likely to use health care services, particularly those with other chronic illnesses (Wright et al., 2016). Depression in adolescents is under-recognized and undetected (Fallucco, Seago, Cuffe, Kraemer, & Wysocki, 2015). The USPSTF recommends screening for MDD in adolescents 12–18 years old. These recommendations include screening to ensure accurate diagnosis, treatment, and follow-up of MDD if adequate systems are in place (USPSTF,
S. Bhatta et al. / Journal of Pediatric Nursing 38 (2018) 8–14
2016). Screening for MDD promotes early initiation of treatment and referral. Early detection of depressive symptoms makes the referral for formal evaluation possible. Hence, early intervention for mental disorders during adolescence can have an important impact on adult mental health outcomes. Despite these guidelines, limited screening by primary care providers suggests the opportunity to identify depression is missed (Taliaferro et al., 2013). Primary care providers report they lack sufficient training in depression assessment and management (Fallucco et al., 2015). These findings indicate the need for utilization of quality improvement processes for implementation of screening within primary care settings. The purpose of this project was to implement routine mental health screening among adolescent ages 12–18 years who were accessing school-based pediatric primary care clinic services for identification of those at risk for depression. Literature Review Depressive disorder is experienced by 15–20% of adolescents by 18 years of age (Meredith et al., 2009). Adolescents with depressive symptoms are at risk for development of depression in later life (Tsai et al., 2014). Thapar et al. (2012) found 60–90% of depressive episodes in adolescents remit within a year, however approximately 50–70% of those who remit experience recurrence of depressive symptoms within 5 years. The prevalence of depression among adolescents in primary care settings ranges from 9%–20%; however, 70% of depressed youth reportedly have not discussed their mood with their providers (Taliaferro et al., 2013). Primary care providers can play a significant role in identifying depression among adolescents. These providers, the first point of contact, have the opportunity to establish trusting relationships with adolescents. Primary care providers frequently rely on presenting symptoms or parental concerns to identify depressed mood among adolescents. Many adolescents may manifest their depressive symptoms as somatic problems rather than presenting with the concern of mood problems (Taliaferro et al., 2013). They frequently present with irritability rather than depressed mood, which can contribute to lack of identification of MDD among adolescent patients (Thapar et al., 2012). These findings suggest routine, systematic depression screening by primary care providers can improve identification of MDD in adolescents and address unmet mental health needs (Taliaferro et al., 2013; Williams, O'Connor, Eder, & Whitlock, 2009). Primary care providers report acceptability of screening processes with minimal resistance from parents and adolescents concerning depression screening (Zuckerbrot et al., 2007). Primary care providers may not perform depression screening or address mental health issues due to lack of (a) time, (b) training and/or confidence in treating mental health problems, and (3) availability of referral resources (Taliaferro et al., 2013). Gaps in the literature still exist regarding best practices for depression screening, barriers to implementation, and management practices. The USPSTF (2016) continues, however, to recommend routine screening of all adolescents between the ages of 12–18 years when adequate systems are in place for appropriate referral and management. Taliaferro et al. (2013) found nurse practitioners were less likely to feel responsible to manage depression in adolescents (26%), compared with physicians (46%). Nurse practitioners felt less sure that they could effectively manage depression in adolescents in their practice setting. Pediatric clinicians were more likely than family providers to report familiarity with USPSTF recommendations (54% vs 43%) but were still less likely to routinely administer a standardized depression screening instruments (44% vs 53%). Primary care providers more frequently utilized their clinical observation and overall impression to identify adolescents experiencing depression rather than using a standardized instrument. These findings indicate the need for utilization of quality improvement processes for implementation of depression screening
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for adolescents within primary care settings. This study utilized the Patient Health Questionnaire-9 Adolescent Version (PHQ-9) screen for implementation of depression screening in a pediatric school-based primary care-based clinic. Conceptual Framework The Donabedian model provided the framework for development of the screening intervention and assessment of mental health screening outcomes following implementation of the PHQ-9. The model assesses outcomes via three factors: structure, process, and outcome. Structure includes resources in the organization such as finances, staff, equipment; process describes implementation of a structure such as mental health screening; outcome refers to the results of the process such as timely identification and management of mental health problems (Kunkel, Rosenqvist, & Westerling, 2007). The Donabedian model integrates the Plan-Do-Study-Act (PDSA) cycle to tests changes on small scale (U.S. Department of Health and Human Services, Health Resources and Services Administration [U.S. DHHS, HRSA], 2011). This model focuses on three questions to set the improvement aim, establish measures, and select changes. The following questions were answered in order to guide depression screening protocol implementation: 1) What are we trying to accomplish? 2) How will we know that a change is an improvement? 3) What changes can we make that will result in improvement? A comprehensive literature review supported the problem identification, intervention and assessment of outcomes. Methods Planning the Intervention Institutional Review Board approval was obtained for conduct of this quality improvement project. Implementation of the project occurred at a pediatric school-based primary care clinic located in the southwestern US. This clinic provides primary care services to adolescents within the local independent school district. The school district services an area including a population of approximately 17,000. Ethnic composition is majority Hispanic (66%), non-Hispanic White (19%), Black (10%) and other (5%). School district enrollment is 11,300 students including predominately Hispanic (82%) ethnicity (Black 10%, non-Hispanic White, other 2%). Health care is provided by five nurse practitioners (three full-time, two part-time), two registered nurses and two medical assistants with two administrative support staff members. Approximately 25 clients access care via the clinic on a daily basis. A retrospective chart review was conducted in December 2016, prior to implementation of screening, to assess baseline clinic population demographics, payer source, type of visits, previous mental health screening methods, mental health diagnoses, and previous mental health referrals. The retrospective review (02/01/2016–05/31/2016) included 258 charts (adolescents aged 12–18 years) to represent the period one year prior to projected screening implementation (02/01/2017–05/31/ 2017). Review of these charts identified approximately equal distribution of females (n = 128, 49.6%) and males (n = 130, 50.4%). Adolescents aged 12–14 years (n = 133, 51.6%) and 15–18 years (n = 125, 48.4%) were primarily of Hispanic (n = 227, 88%) ethnicity. A standardized depression screening protocol was not available at the clinic prior to implementation of this project (i.e., screening adolescents for depression with PHQ-9). The baseline chart review found adolescent mental health addressed by clinic personnel (nurse or medical assistant) during well visits. Medical assistant or nursing personnel questioned parents or adolescents about psychosocial or behavioral health concerns during intake. The nurse practitioner would then reassess intake findings and document overall psychosocial well-being. Documentation of mental health concerns included situations prompted by patients, parents or providers. Baseline chart review
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found 55% (n = 143) were screened for psychosocial health by any method within the previous 1–3 year time-period most often during well visits. The most frequently documented mental health concerns were anxiety, history of depression, depression concerns, behavioral problems, history of ADHD, autism, substance abuse, sexual abuse, history of suicidal attempt, and non-suicidal self-injury. Of the 143 (55.4%) adolescents that screened positive for potential mental health concerns, 22% (n = 31) were referred for additional mental health services. Prior to implementation of the project, community mental health organizations were contacted to obtain information concerning the availability of services, referral procedures, willingness to accept referrals, potential appointment wait listing, and eligibility requirements. A resource list of local area service providers was also developed.
room. Assessment of PHQ-9 screening protocol outcomes included a retrospective chart review following protocol implementation. PDSA Cycle The Plan in this project was to screen all adolescents 12–18 years old during well or episodic illness visits. The Do involved implementing the PHQ-9 screening protocol. During the Act phase, modification to the screening process and clinic personnel feedback improved the outcome. A PDSA cycle occurred every 2–4 weeks. Projected outcomes included identification and referral of adolescents at high risk for depression via PHQ-9 screening protocol. The post-implementation retrospective chart review identified documentation for 256 eligible adolescent visits during the study period. Measures
Protocol Development An evidence-based PHQ-9 screening protocol was developed through extensive literature review and inter-professional collaboration with clinic, school district, and academic key stakeholders. This protocol provided an algorithm for the implementation of the PHQ-9 screening including adolescent and parent education for mild depressive symptoms and mental health provider referrals (Fig. 2). The selfadministered version of PHQ-9 modified for adolescents uses the DSM-IV criteria to assess for mental health problems in primary care. The PHQ-9 provides diagnoses of probable depression and assesses severity of symptom as a continuous score (Richardson et al., 2010). According to protocol, clinic staff who initiate contact with the adolescents provide the PHQ-9 to the adolescent for selfadministration in a clinic exam room. After the screening, clinic staff review the PHQ-9 screening and calculate the score. After reviewing the PHQ-9 responses and scores, providers initiate symptom related conversation and recommend referral as indicated. Those who have elevated depressive symptoms scores yet do not meet the criteria for mental health referrals (i.e., score b 10), receive a handout regarding mental health promotion. Per protocol, adolescents with positive depression screens and scores equal to or N 10 require mental health referrals. Likewise, those who respond ‘yes’ to dysthymia related question and report concerning symptoms on clinical discussion are indicated for referral. Protocol Implementation Nursing and administrative staff and nurse practitioners involved in the care of adolescents at the clinic underwent formal educational training. An informational handout was provided to those who could not attend the formal educational training and follow-up included ascertainment of understanding of the protocol. Email communication and face-to-face meetings were utilized to facilitate the project implementation phase. Protocol training included handouts describing epidemiology of depression among adolescents, risk factors, symptoms, recommendation for routine screening from multiple organizations (e.g., Bright Futures, American Academy of Pediatrics, and USPSTF), recommended screening protocol, and instructions for implementation of screening instrument. Education concerning mental health interviewing and intervention was offered to providers should positive symptoms be identified. Following completion of the educational session, clinic staff shared the opportunity to practice PHQ-9 screening and scoring. Implementation of the project occurred between January 31, 2017 and May 31, 2017. All adolescents aged 12–18 years, accessing the clinic for health care services during this time, received the PHQ-9 for completion. No screening occurred for those who accessed the clinic solely for the purpose of vaccination or sports physical. Those who met the inclusion criteria completed the PHQ-9 questionnaire in a private clinic exam
Data extracted for the post-implementation retrospective chart review included the following variables. Socio-demographic variables and chronic diseases correlate with mental health problems (Merikangas et al., 2010). Therefore, data extracted for the postimplementation retrospective chart review were: (1) age, (2) gender, (3) ethnicity (4) payer source, (5), reason of clinic visit, (6), whether depression screening was obtained, (7) MDD screening result, (8) mental health related treatment plan, (9) referral, (10) referral source, (11) mental health history, (12), symptoms of depression, and (13) chronic medical problems. Data were de-identified using study ID. The PHQ-9 has high sensitivity 89.5% and good specificity of 78.8% for detecting MDD among adolescents (Richardson et al., 2010). Each item of the PHQ-9 asks the adolescent to rate the severity of depression symptoms they have experienced during the past 2 weeks. Each item on the measure is rated on a 4-point scale (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day) with the total score ranging from 0 to 27. A higher score represents a greater severity of depression. The score will be summed to obtain a total raw score and will be interpreted as 0–4 = no or minimal depression, 5–9 = mild depression, 10–14 moderate depression, 15–19 = moderately severe depression, and 20–27 = severe depression. Analysis The data were analyzed using SPSS 24.0 software. The study was combination of descriptive and non-parametric statistics. Data analyses included descriptive statistics and frequency tables to describe sociodemographics, depression screening status, referral status, and depressive symptoms. Pearson's chi-squared analysis tested associations between socio-demographics and screening status, depressive symptoms and gender, depressive symptoms by age group, demographic and referral status, severity of depressive symptoms and referral status. Age categories included two groups (12–14 years vs. 15–18 years). Ethnicity categories included two groups, Hispanic and other. Results Socio-demographics The post-intervention retrospective chart review (n = 256) identified adolescents (n = 144, 56.3%) with PHQ-9 screening. The majority (n = 238, 93.0%) of adolescents was of Hispanic ethnicity. Insurance status included public (n = 177, 69.1%) and private (n = 12, 4.7%); 26.2% (n = 67) were uninsured. The majority of visits was for episodic illness (n = 180, 70.3%) versus wellness (n = 76, 29.7%) visits. Age distribution of the adolescents included: 46.1% (n = 118) 12–14 years old and 53.9% (n = 138) 15–18 years old. Few had documentation of a personal history of depression (3.9%, n = 10) of which 80% (n = 8) were female and 20% (n = 2) were male. There was no documentation of
S. Bhatta et al. / Journal of Pediatric Nursing 38 (2018) 8–14
depression history in 96% (n = 246) of charts; 2.0% (n = 5) had documentation of past or current use of antidepressants. Examination of associations between screening status and gender, age, ethnicity, payer source, and visit purpose was conducted. A significant association between payer source and screening status was found (χ2 = 7.45, p = 0.024). Similarly, there was a statistically significant relationship between visit purpose and screening status (χ2 = 3.997, p = 0.046); 66% (n = 50) were screened during wellness visits while 52.2% (n = 94) were screened during episodic illness visits (Table 1). Frequency Distribution of Outcome of Depression Screening Protocol Of screened adolescents (n = 144), 41.7% (n = 60) were between 12 and 14 years old and 58.3% (n = 84) were between 15 and 18 years old; 58.3% (n = 84) were female and 41.7% (n = 60) were male (Table 1). Results of PHQ-9 screening identified 87.5% (n = 126) of adolescents with a score b10 and 12.5% of adolescents with a score ≥ 10. A PHQ-9 score of ≥ 10 was indicated for referral per protocol, of which 83.3% (n = 15) were referred to mental health providers for further evaluation and management while 16. 7% (n = 3) refused referral (Table 4). Furthermore, 18. 8% (n = 27) reported the presence of mild depression, 9.0% (n = 13) moderate depression and 3.5% (n = 5) moderately severe depression (Table 4). Of the 144 screened adolescents, 8% (n = 12) of adolescents reported symptoms of suicidal thought or history of previous suicide attempt of which 75% (n = 9) were referred to mental health providers (Table 3). Symptoms of dysthymia were assessed by asking depressed mood in most days in past year. Referral per protocol was indicated if the symptoms were present for ≥2 years. A total of 20.1% (n = 29), reported those symptoms of which 55.2% (n = 16) were referred to mental health providers (Table 4). Data indicated 11.1% (n = 14) with a PHQ-score b10 and reporting depressive symptoms suggesting dysthymia were referred to mental health providers. Of those who were not screened with the PHQ-9, 1.8% (n = 2) were referred to mental health providers.
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indicated positive responses. To the question, “Feeling that you would be better dead or hurting yourself in some way”, 6.0% (n = 5) of females and none of the males indicated positive responses. Likewise, 25% (n = 21) of females reported sad or depressed mood most days in the past year whereas 13.3% (n = 8) male these symptoms. Responses to the question “How difficult did these problems make it for you to do your work”, 12% (n = 10) of females and 6.7% (n = 4) of males reported some level of difficulties. Thought of ending your life in the past month were reported by 4.8% (n = 4) of females and 3.3% of males (n = 2); 2.4% (n = 2) of females and 6.7% (n = 4) of males attempted suicide in the past (Table 2). Statistically significant relationships existed between gender and sleep disturbance and gender and tiredness. Female adolescents were more likely to report sleep problems (χ2 = 9.147, p = 0.002) and tiredness (56%, n = 47 vs. 35%, n = 21) (χ2 = 6.165, p = 0.013) than male adolescents (Table 2). Significant associations between age and sleep problems and low self-esteem were also identified. The 15–18 year age group was more likely to experience sleep problems (47.6% n = 40 vs. 28.3% n = 17) (χ2 = 5.443, p = 0.020) and low self-esteem (22.6%, n = 19 vs. 8.3%, n = 5) (χ2 = 5.143, p = 0.023) than the 12–14 year age group. Significant relationships between depressed mood in most days in the past year and referral status (χ2 = 27.711, p b 0.001) were found (Table 3). Among those reporting these symptoms (n = 29), 55.2% (n = 16) received referral to mental health providers as compared to 44.8% (n = 13) not referred (Table 4). No significant relationships between gender and severity of depression existed.
Table 2 Comparison of depressive symptoms by gender (N = 144). Gender Female Male (n = 84) (n = 60)
Total (N = 144)
n
%
n
%
N
%
No Yes No Yes No Yes
65 19 51 33 42 42
77.4 22.6 60.7 39.3 50.0 50.0
46 14 39 21 45 15
76.7 23.3 65.0 35.0 75.0 25.0
111 33 90 54 87 57
77.1 0.010 0.920 22.9 62.5 0.274 0.600 37.5 60.4 9.174 0.002⁎ 39.6
No Yes No Yes No Yes
62 22 37 47 66 18
73.8 26.2 44.0 56.0 78.6 21.4
48 12 39 21 54 6
80.0 20.0 65.0 35.0 90.0 10.0
110 34 76 68 120 24
76.4 0.744 0.388 23.6 52.8 6.165 0.013⁎ 47.2 83.3 3.291 0.070 16.7
No Yes No Yes
53 31 67 17
63.0 37.0 79.8 20.2
44 16 48 12
73.3 26.7 80.0 20.0
97 47 115 29
67.4 1.669 0.196 32.6 79.9 0.001 0.972 20.1
Characteristic
Comparison of Depressive Symptoms by Gender and Age Comparisons of depressive symptoms by gender and age were made. Sleep disturbance was reported by 50% (n = 42) of females and 25% (n = 15) males. Concerning feeling bad about yourself or feeling that you are a failure, 21.4% (n = 18) females and 10% (n = 6) males
Table 1 Demographic characteristics of participants (N = 256). Screening status Yes
Total
Characteristic
No n = 112
%
% n = 144
% N = 256
χ2
P
Gender
53 59 58 54 104 8 34
47.3 52.7 51.8 48.2 92.9 7.1 30.4
84 60 60 84 134 10 33
137 119 118 138 238 18 67
3.07
0.08
2.59
0.107
77
68.8 100 69.4 177 69.1
1
0.9
11
7.6
12
4.7
86 26 110 2
76.8 23.2 98.2 1.8
94 50 115 29
65.3 34.7 79.9 20.1
180 76 225 31
70.3 3.99 29.7 87.9 19.9 12.1
Female Male Age group 12–14 15–18 Ethnicity Hispanic Other Payer source No insurance Public insurance Private insurance Reason of visits Sick Wellness Was patient No referred? Yes
58.3 41.7 41.7 58.3 93.1 6.9 22.9
⁎ The Chi-square statistic is significant at the 0.05 level.
53.5 46.5 46.1 53.9 93 7 26.2
0.004 0.951 7.45
0.024⁎
0.046⁎ NA
Depressed mood, irritable, hopeless Little interest or pleasure in doing things Trouble falling asleep, staying asleep, or sleeping too much Poor appetite, weight loss, or overeating Feeling tired, having little energy Feeling bad yourself, feeling that you are a failure Trouble concentrating on things Moving or speaking too slowly that other people could have noticed Thought that you would be better dead, or hurting yourself in some way Depressed mood in most days in past year How difficult these problems made it for you to do your work? Serious thought of ending your life in the past month Have you ever in your whole life tried to kill yourself?
χ2
P
No 79 94.0 60 100.0 139 96.5 3.700 NA Yes 5 6.0 0 0.0 5 3.5
No Yes No Yes
63 21 74 10
75.0 25.0 88.0 12.0
52 8 56 4
86.7 13.3 93.3 6.7
115 29 130 14
79.9 2.962 0.085 20.1 90.3 9.7
No 80 95.2 58 96.7 Yes 4 4.8 2 3.3
138 95.8 0.179 NA 6 4.2
No 82 97.6 56 93.3 Yes 2 2.4 4 6.7
138 95.8 1.610 NA 6 4.2
⁎ The Chi-square statistic is significant at the 0.05 level.
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S. Bhatta et al. / Journal of Pediatric Nursing 38 (2018) 8–14
Table 3 Comparison of depressive symptoms by age. Age group 12–14 years (n = 60)
15–18 years (n = 84)
Total (N = 144)
n
%
n
%
N
%
No Yes No Yes No Yes
46 14 37 23 43 17
76.7 23.3 61.7 38.3 71.7 28.3
65 19 53 31 44 40
77.4 22.6 63.0 37.0 52.4 47.6
111 33 90 54 87 57
77.1 0.010 0.920 22.9 62.5 0.030 0.861 37.5 60.4 5.443 0.020⁎ 39.6
No Yes No Yes No Yes
45 15 32 28 55 5
75.0 25.0 53.3 46.7 91.7 8.3
65 19 44 40 65 19
77.4 22.6 52.4 47.6 77.4 22.6
110 34 76 68 120 24
76.4 0.110 0.740 23.6 52.8 0.013 0.910 47.2 83.3 5.143 0.023⁎ 16.7
No Yes No Yes
39 21 47 13
65.0 35.0 78.3 21.7
58 26 68 16
69.0 31.0 81.0 19.0
97 47 115 29
67.4 0.261 0.610 32.6 79.9 0.149 0.699 20.1
Symptoms Depressed mood, irritable, hopeless Little interest or pleasure in doing things Trouble falling asleep, staying asleep, or sleeping too much Poor appetite, weight loss, or overeating Feeling tired, having little energy Feeling bad yourself, feeling that you are a failure Trouble concentrating on things Moving or speaking too slowly that other people could have noticed Thought that you would be better dead, or hurting yourself in some way Depressed mood in most days in past year How difficult these problems made it for you to do your work? Serious thought of ending your life in the past month Have you ever in your whole life tried to kill yourself?
χ2
P
No 57 95.0 82 97.6 139 96.5 0.716 NA Yes 3 5.0 2 2.4 5 3.5
No Yes No Yes
50 10 54 6
83.3 16.7 90.0 10.0
65 19 76 8
77.4 22.6 90.5 9.5
115 29 130 14
79.9 0.771 0.380 20.1 90.3 0.009 0.924 9.7
No 56 93.3 82 97.6 138 95.8 1.610 NA Yes 4 6.7 2 2.4 6 4.2 No 56 93.3 82 97.6 138 95.8 1.610 NA Yes 4 6.7 2 2.4 6 4.2
Qualitative Data Although, not screened for depression, the common behavior problems documented in the chart were: suicide attempts in the past, substance abuse, history of depression, autism, mood problems, and high
Table 4 Comparison of demographic and severity of symptoms by referral status. Referral status (N = 256) Yes
No
Total
Demographic and symptoms
n % = 31
% n = 225
% N = 256
χ2
Gender
Female Male 12–14 15–18 Hispanics Other No Yes
20 11 18 13 28 3 13 16
7.8 4.3 7.0 5.1 10.9 1.2 9.0 11.1
117 108 100 125 210 15 102 13
45.7 42.2 39.1 48.8 82.0 5.9 70.8 9.0
137 119 118 138 238 18 115 29
1.716 0.19
No or minimal Mild Moderate Moderately severe
3
2.1
97
66.9 100 69.0 NA
11 7.6 10 6.9 5 3.4
16 3 0
11.0 27 2.1 13 0.0 5
Ethnicity Depressed mood in most days in past year Severity of depressive symptoms
⁎ The Chi-square statistic is significant at the 0.05 level.
PDSA Cycle Documentation of staff compliance with the screening protocol occurred on a weekly basis (Fig. 1). Staff compliance was 100% on week 7 and week 14 however during the other weeks screening intermittently fluctuated. Email reminders occurred via work email or text messages every 2–3 weeks. A second PDSA cycle occurred in week 6 with feedback to staff. Barriers to successful screening identified by staff were busy schedule, short staff, and remembering to screen. In order to improve recall of new protocol, screening signs were placed in different areas as reminders. After the second PDSA cycle, the screening rate improved to 100% in week 7. The third cycle was implemented in week 10. The screening rate was shared with clinic staff and frequently reminded for screening via face-to-face communication, text-messages, or emails. The identified reasons for a low screening rate reviewed with clinic staff and nurse practitioners in week 10 led to a gradual increase in the screening rate in week 10. During week 16, the number of adolescent visits and screening number decreased as did screening compliance. During this week, all clinic staff was involved in conducting sports physicals within a number of middle schools and high schools rather than seeing patients in the clinic. Discussion
⁎ The Chi-square statistic is significant at the 0.05 level.
Age group
risk sexual behaviors. Even though, adolescents' responses to PHQ-9 questionnaires did not indicate the need for referral to mental health providers, they were referred because of several reasons. Some of the information noted frequently in the charts included: running away from home, substance abuses, concern of ADHD or depression, stress due to obesity, stress in family, anxiety, hallucination, chronic medically unexplained physical complaints, and suicidal thoughts. Two adolescents not screened with the PHQ-9 received referrals to mental health providers due to concern of depression. Three adolescents refused referral to mental health providers although their PHQ-score indicated referral. They reported the symptoms they were experiencing were due to current illnesses and symptoms improved during the follow-up.
53.5 46.5 46.1 53.9 93.0 7.0 79.9 20.1
P
The purpose of this project was to implement a depression screening protocol in a school-based pediatric primary care clinic to improve early detection and referral of adolescents aged 12–18 years. Results of the retrospective chart review indicate use of standardized depression screening protocol assisted in the identification of adolescents at risk for depression. During the 4 months of project implementation, approximately 31.3% of adolescents screened positive for elevated depressive symptoms; 12.5% scored at or above the recommended screening cutoff of 10 for mental health referral (Table 4). This prevalence is consistent with NIMH 2015 data, which was 12.5% (NIMH, 2015). Prevalence rates of depression among Hispanic adolescents were also consistent with NIMH 2015 data. The prevalence of MDD found in Hispanic adolescents is 12.6% and this project found a 12.7% prevalence of MDD among Hispanic adolescents.
2.034 0.15 NA
NA
27.71 0.00⁎
NA
18.6 9.0 3.4 Fig. 1. Depression screening.
S. Bhatta et al. / Journal of Pediatric Nursing 38 (2018) 8–14
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Fig. 2. Adolescents depression screening protocol flow diagram. Abbreviation: SXS, symptoms; PHQ, patient health questionnaires; MHP, Mental Health Provider; F/U, follow-up.
During the project implementation, over 56.0% of adolescents who received healthcare through the clinic were screened for depression. It is possible that if all adolescents had been screened the prevalence may have been higher. The implementation of PHQ-9 screening tool created the opportunity to initiate a discussion of mental health. Adolescents with suicide related responses and history of previous suicidal attempts in this study had a high likelihood of referral to mental health providers following screening (75%). Similarly, adolescents who reported dysthymia symptoms (55.2%) were likely to get referral to mental health providers. Most (83.3%) of adolescents who were indicated for referral based on PHQ-9 score were referred to mental health providers. Receipt of these mental health referrals by providers was confirmed and status of the referral was discussed. These findings represent a positive outcome as adolescents who were screened were provided self-care handouts and referred. The screening protocol algorithm provided convenient reference for consistency in referral processes. Very little has been written about implementation of the PHQ-9 in school-based clinics. Integration of PHQ-9 screening in school-based clinics however may improve awareness of MDD among adolescents. This project included distribution of handouts for mental health promotion for those who had elevated depressive symptoms. The standardized PHQ-9 screen also provided a vehicle for engaging the adolescents in discussion regarding their mental health status. This also suggests that by implementing depression screening, the awareness of MDD among adolescents is improved. In this study 70.3%
participants presented to the clinic for sick visits and screening rate for sick visits was 52.2% (Table 1). A previous study has reported that those who presents with more physical illnesses or use more mental health services are more likely to score high on the PHQ-9 which suggests the importance of screening for those who have more physical illnesses (Tsai et al., 2014). Other study found that even when the symptoms are mild, depression in adolescents is associated with increased healthcare utilization and cost (Wright et al., 2016). Therefore, utilization of depression screening and timely referral when indicated may promote cost-effectiveness of healthcare. The cost of implementing depression screening is minimal. The implementation of screening can be time consuming for a busy clinic, but the opportunity to decrease costs related to identifying and treating depression early outweigh initial implementation challenges.
Challenges to Implementation Despite perceived determination, clinic patient volume and human memory failure among clinic staff played a role in missed screening. Electronic health record prompts, periodic training, and email reminders could potentially improve screening rates. Some adolescents who screened positive reported that symptoms were related to current illnesses. This is a consideration when screening during an episodic illness visit. Further assessment of potential barriers to compliance with mental health referrals is also indicated.
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Clinical Implications This project provided a protocol for implementation of the depression screening tool, PHQ-9, within a school-based pediatric primary health clinic setting. This study resulted in improved screening and referral for depression among adolescents. It also increased opportunity for further mental health discussion and education for selfmanagement of depressive symptoms. Advanced practice nurses can act as change agents to implement screening protocols, provide education, and refer adolescents for further management of depression. This project provided opportunities for advanced practice nurses to collaborate with mental health providers concerning adolescent mental health. Cano et al. (2015) found Hispanic adolescents have higher rates of depressive symptoms than non-Hispanic White. One in five adolescents in the United States is Hispanic with an increase to one in three adolescents anticipated by 2040 (Cano et al., 2015). Our findings identified significant depressive symptoms among predominately Hispanic adolescents in a primary care-based clinic. Implications of these findings include further assessment of the accumulation of cultural stressors that may increase the risk of poor mental health outcomes among this group. Limitations Limitations include generalizability to adolescents of other ethnic and cultural backgrounds. Likewise, although the plan for follow-up was discussed with adolescents per protocol, the majority did not follow-up with primary care providers, and follow-up was not assessed in this project. Screening for the majority of adolescents occurred during visits for episodic illness which may have been a confounding source of depressive symptoms. Conclusion Implementation of a depression screening protocol improved screening rates in a school-based pediatric primary care clinic and facilitated formal referrals to mental health providers. The protocol promoted systematic evidenced-based depression screening among adolescents 12–18 years old which can serve to improve the early diagnosis and treatment of MDD in adolescents to improve short-and longterm adolescent health outcomes. This protocol is an exemplar for application in other real world settings. References Breslau, J., Gilman, S. E., Stein, B. D., Ruder, T., Gmelin, T., & Miller, E. (2017). Sex differences in recent first-onset depression in an epidemiological sample of adolescents. Translational Psychiatry, 7(5), e1139. https://doi.org/10.1038/tp.2017.105. Cano, M.Á., Schwartz, S. J., Castillo, L. G., Romero, A. J., Huang, S., Lorenzo-Blanco, E. I., ... Szapocznik, J. (2015). Depressive symptoms and externalizing behaviors among
Hispanic immigrant adolescents: Examining longitudinal effects of cultural stress. Journal of Adolescence, 42, 31–39. https://doi.org/10.1016/j.adolescence.2015.03.017. Center for Disease Control and Prevention (CDC) (2014). 10 leading causes of death by age group, United States, 2014. Retrieved July 13, 2017 from https://www.cdc.gov/ injury/images/lc-charts/leading_causes_of_death_age_group_2014_1050w760h.gif. Corathers, S. D., Kichler, J., Jones, N. -H. Y., Houchen, A., Jolly, M., Morwessel, N., ... Hood, K. K. (2013). Improving depression screening for adolescents with type 1 diabetes. Pediatrics, 132(5), e1395–e1402. https://doi.org/10.1542/peds.2013-0681. Fallucco, E. M., Seago, R. D., Cuffe, S. P., Kraemer, D. F., & Wysocki, T. (2015). Primary care provider training in screening, assessment, and treatment of adolescent depression. Academic Pediatrics, 15(3), 326–332. https://doi.org/10.1016/j.acap.2014.12.004. Forman-Hoffman, V., McClure, E., McKeeman, J., Wood, C. T., Middleton, J. C., Skinner, A. C., ... Viswanathan, M. (2016). Screening for major depressive disorder in children and adolescents: A systematic review for the U.S. preventive services task force. Annals of Internal Medicine, 164(5), 342. https://doi.org/10.7326/M15-2259. Kunkel, S., Rosenqvist, U., & Westerling, R. (2007). The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden. BMC Health Services Research, 7(1). https://doi.org/10.1186/1472-6963-7104. Meredith, L. S., Stein, B. D., Paddock, S. M., Jaycox, L. H., Quinn, V. P., Chandra, A., & Burnam, A. (2009). Perceived barriers to treatment for adolescent depression. Medical Care, 47(6), 677–685. https://doi.org/10.1097/MLR.0b013e318190d46b. Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., ... Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity survey replication–adolescent supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989. https://doi. org/10.1016/j.jaac.2010.05.017. National Institute of Mental Health (NIMH) (2015). Major depression among adolescents. Retrieved July 13, 2017 from https://www.nimh.nih.gov/health/statistics/prevalence/ major-depression-among-adolescents.shtml. US Preventative Services Task Force (2016). Depression in children and adolescents: screening. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/ Document/UpdateSummaryFinal/depression-in-children-and-adolescentsscreening1. Richardson, L. P., McCauley, E., Grossman, D. C., McCarty, C. A., Richards, J., Russo, J. E., ... Katon, W. (2010). Evaluation of the patient health questionnaire-9 Item for detecting major depression among adolescents. Pediatrics, 126(6), 1117–1123. https://doi.org/ 10.1542/peds.2010-0852. Taliaferro, L. A., Hetler, J., Edwall, G., Wright, C., Edwards, A. R., & Borowsky, I. W. (2013). Depression screening and management among adolescents in primary care: Factors associated with best practice. Clinical Pediatrics, 52(6), 557–567. Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. The Lancet, 379(9820), 1056–1067. https://doi.org/10.1016/S0140-6736(11)60871-4. Tsai, F. -J., Huang, Y. -H., Liu, H. -C., Huang, K. -Y., Huang, Y. -H., & Liu, S. -I. (2014). Patient health questionnaire for school-based depression screening among Chinese adolescents. Pediatrics, 133(2), e402–e409. https://doi.org/10.1542/peds.2013-0204. U.S. DHHS, HRSA (2011). Quality improvement. Retrieved July 10, 2017 from https:// www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf. Williams, S. B., O'Connor, E. A., Eder, M., & Whitlock, E. P. (2009). Screening for child and adolescent depression in primary care settings: A systematic evidence review for the US preventive services task force. Pediatrics, 123(4), e716–e735. https://doi.org/10. 1542/peds.2008-2415. Wright, D. R., Katon, W. J., Ludman, E., McCauley, E., Oliver, M., Lindenbaum, J., & Richardson, L. P. (2016). Association of adolescent depressive symptoms with health care utilization and payer-incurred expenditures. Academic Pediatrics, 16(1), 82–89. https://doi.org/10.1016/j.acap.2015.08.013. Zuckerbrot, R. A., Maxon, L., Pagar, D., Davies, M., Fisher, P. W., & Shaffer, D. (2007). Adolescent depression screening in primary care: Feasibility and acceptability. Pediatrics, 119(1), 101–108. https://doi.org/10.1542/peds.2005-2965.
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Outcomes of Depression Screening Among Adolescents Accessing School-based Pediatric Primary Care Clinic Services Sarmila Bhatta, DNP, FNP-C a, Jane Dimmitt Champion, PhD, DNP, FNP, FAAN, FAANP b,⁎, Cara Young, PhD, RN, FNP-C c, Elizabeth Loika, DNP, PNP-C, FNP-C d a
Family Nurse Practitioner, School of Nursing, The University of Texas at Austin, United States Lee and Joseph D. Jamail Endowed Professorship in Nursing, School of Nursing, The University of Texas at Austin, 1710 Red River St, Austin, TX 78701, United States School of Nursing, The University of Texas at Austin, 1710 Red River St, Austin, TX 78701, United States d Clinical Associate Professor, School of Nursing, The University of Texas at Austin, 1710 Red River St, Austin, TX 78701, United States b c
a r t i c l e
i n f o
Article history: Received 27 August 2017 Revised 28 September 2017 Accepted 1 October 2017 Available online xxxx Keywords: Adolescent Depression Primary care Screening
a b s t r a c t Purpose: Implementation of routine Patient Health Questionnaires (PHQ-9) screening among adolescents aged 12–18 year, accessing school-based pediatric primary care clinic services for identification of adolescents at potential risk for Major Depressive disorder (MDD). Design and Methods: Retrospective chart review (N = 256 cases) documented PHQ-9 depression screening outcomes among adolescents accessing school-based pediatric primary care clinic services for episodic illness and wellness visits. Data analyses included descriptive statistical methods. Results: Chart review included 137 (53.5%) females and 119 (46.5%) males. PHQ-9 depression screening was identified for 56.3% (n = 144) of charts with scores ≥10 for 12.5% (n = 18) among those screened. Mental health referrals were made for 83.3% (n = 15) with PHQ-9 scores ≥10. Dysthymia related concerns were reported among 20.1% (n = 29) of which 55.2% (n = 16) received mental health referrals. Female adolescents reported more sleep problems (χ2 = 9.174, p = 0.002) and tiredness (χ2 = 6.165, p = 0.013) than males. The 15–18 year age group (χ2 = 5.443, p = 0.020) was more likely to experience sleep problem and low selfesteem than 12–14 year age group (χ2 = 5.143, p = 0.023). Conclusion: Implementation of PHQ-9 depression screening protocol identified MDD among adolescent accessing pediatric school-based primary care clinic services facilitating referrals to mental health providers, potentially improving morbidity and mortality among adolescents. Practice Implications: MDD is common among adolescents and associated with functional impairments and increased morbidity and mortality. Due to its high prevalence, it is imperative to improve screening and treatment access in this population via school-based clinics. © 2017 Elsevier Inc. All rights reserved.
Background Major Depressive Disorder (MDD) is common in children and adolescents and linked to functional impairment and suicide. Prevalence of major depressive episode among adolescents in the United States was 12.5% in 2015 (National Institute of Mental Health [NIMH], 2015). MDD is higher among adolescent (12–17 years) females (36.1%) than males (13.6%) (Breslau et al., 2017). Suicide is the second leading cause of death among adolescents (Center for Disease Control and Prevention [CDC], 2014).
⁎ Corresponding author. E-mail addresses: [email protected] (S. Bhatta), [email protected] (J.D. Champion), [email protected] (C. Young), [email protected] (E. Loika).
https://doi.org/10.1016/j.pedn.2017.10.001 0882-5963/© 2017 Elsevier Inc. All rights reserved.
Depression increases significantly in the presence of chronic diseases. One of five adolescents in the United States has a chronic disease requiring continuous treatment and management (Corathers et al., 2013). Unrecognized and untreated MDD increases risk for obesity, suicidal thoughts, attempts, and completion. It also affects academic performance and relationships with parents, siblings, and peers (Thapar, Collishaw, Pine, & Thapar, 2012). Adolescents with MDD are likely to have somatic symptoms such as headaches, abdominal pain, and musculoskeletal pain (Forman-Hoffman et al., 2016). They are also more likely to use health care services, particularly those with other chronic illnesses (Wright et al., 2016). Depression in adolescents is under-recognized and undetected (Fallucco, Seago, Cuffe, Kraemer, & Wysocki, 2015). The USPSTF recommends screening for MDD in adolescents 12–18 years old. These recommendations include screening to ensure accurate diagnosis, treatment, and follow-up of MDD if adequate systems are in place (USPSTF,
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2016). Screening for MDD promotes early initiation of treatment and referral. Early detection of depressive symptoms makes the referral for formal evaluation possible. Hence, early intervention for mental disorders during adolescence can have an important impact on adult mental health outcomes. Despite these guidelines, limited screening by primary care providers suggests the opportunity to identify depression is missed (Taliaferro et al., 2013). Primary care providers report they lack sufficient training in depression assessment and management (Fallucco et al., 2015). These findings indicate the need for utilization of quality improvement processes for implementation of screening within primary care settings. The purpose of this project was to implement routine mental health screening among adolescent ages 12–18 years who were accessing school-based pediatric primary care clinic services for identification of those at risk for depression. Literature Review Depressive disorder is experienced by 15–20% of adolescents by 18 years of age (Meredith et al., 2009). Adolescents with depressive symptoms are at risk for development of depression in later life (Tsai et al., 2014). Thapar et al. (2012) found 60–90% of depressive episodes in adolescents remit within a year, however approximately 50–70% of those who remit experience recurrence of depressive symptoms within 5 years. The prevalence of depression among adolescents in primary care settings ranges from 9%–20%; however, 70% of depressed youth reportedly have not discussed their mood with their providers (Taliaferro et al., 2013). Primary care providers can play a significant role in identifying depression among adolescents. These providers, the first point of contact, have the opportunity to establish trusting relationships with adolescents. Primary care providers frequently rely on presenting symptoms or parental concerns to identify depressed mood among adolescents. Many adolescents may manifest their depressive symptoms as somatic problems rather than presenting with the concern of mood problems (Taliaferro et al., 2013). They frequently present with irritability rather than depressed mood, which can contribute to lack of identification of MDD among adolescent patients (Thapar et al., 2012). These findings suggest routine, systematic depression screening by primary care providers can improve identification of MDD in adolescents and address unmet mental health needs (Taliaferro et al., 2013; Williams, O'Connor, Eder, & Whitlock, 2009). Primary care providers report acceptability of screening processes with minimal resistance from parents and adolescents concerning depression screening (Zuckerbrot et al., 2007). Primary care providers may not perform depression screening or address mental health issues due to lack of (a) time, (b) training and/or confidence in treating mental health problems, and (3) availability of referral resources (Taliaferro et al., 2013). Gaps in the literature still exist regarding best practices for depression screening, barriers to implementation, and management practices. The USPSTF (2016) continues, however, to recommend routine screening of all adolescents between the ages of 12–18 years when adequate systems are in place for appropriate referral and management. Taliaferro et al. (2013) found nurse practitioners were less likely to feel responsible to manage depression in adolescents (26%), compared with physicians (46%). Nurse practitioners felt less sure that they could effectively manage depression in adolescents in their practice setting. Pediatric clinicians were more likely than family providers to report familiarity with USPSTF recommendations (54% vs 43%) but were still less likely to routinely administer a standardized depression screening instruments (44% vs 53%). Primary care providers more frequently utilized their clinical observation and overall impression to identify adolescents experiencing depression rather than using a standardized instrument. These findings indicate the need for utilization of quality improvement processes for implementation of depression screening
9
for adolescents within primary care settings. This study utilized the Patient Health Questionnaire-9 Adolescent Version (PHQ-9) screen for implementation of depression screening in a pediatric school-based primary care-based clinic. Conceptual Framework The Donabedian model provided the framework for development of the screening intervention and assessment of mental health screening outcomes following implementation of the PHQ-9. The model assesses outcomes via three factors: structure, process, and outcome. Structure includes resources in the organization such as finances, staff, equipment; process describes implementation of a structure such as mental health screening; outcome refers to the results of the process such as timely identification and management of mental health problems (Kunkel, Rosenqvist, & Westerling, 2007). The Donabedian model integrates the Plan-Do-Study-Act (PDSA) cycle to tests changes on small scale (U.S. Department of Health and Human Services, Health Resources and Services Administration [U.S. DHHS, HRSA], 2011). This model focuses on three questions to set the improvement aim, establish measures, and select changes. The following questions were answered in order to guide depression screening protocol implementation: 1) What are we trying to accomplish? 2) How will we know that a change is an improvement? 3) What changes can we make that will result in improvement? A comprehensive literature review supported the problem identification, intervention and assessment of outcomes. Methods Planning the Intervention Institutional Review Board approval was obtained for conduct of this quality improvement project. Implementation of the project occurred at a pediatric school-based primary care clinic located in the southwestern US. This clinic provides primary care services to adolescents within the local independent school district. The school district services an area including a population of approximately 17,000. Ethnic composition is majority Hispanic (66%), non-Hispanic White (19%), Black (10%) and other (5%). School district enrollment is 11,300 students including predominately Hispanic (82%) ethnicity (Black 10%, non-Hispanic White, other 2%). Health care is provided by five nurse practitioners (three full-time, two part-time), two registered nurses and two medical assistants with two administrative support staff members. Approximately 25 clients access care via the clinic on a daily basis. A retrospective chart review was conducted in December 2016, prior to implementation of screening, to assess baseline clinic population demographics, payer source, type of visits, previous mental health screening methods, mental health diagnoses, and previous mental health referrals. The retrospective review (02/01/2016–05/31/2016) included 258 charts (adolescents aged 12–18 years) to represent the period one year prior to projected screening implementation (02/01/2017–05/31/ 2017). Review of these charts identified approximately equal distribution of females (n = 128, 49.6%) and males (n = 130, 50.4%). Adolescents aged 12–14 years (n = 133, 51.6%) and 15–18 years (n = 125, 48.4%) were primarily of Hispanic (n = 227, 88%) ethnicity. A standardized depression screening protocol was not available at the clinic prior to implementation of this project (i.e., screening adolescents for depression with PHQ-9). The baseline chart review found adolescent mental health addressed by clinic personnel (nurse or medical assistant) during well visits. Medical assistant or nursing personnel questioned parents or adolescents about psychosocial or behavioral health concerns during intake. The nurse practitioner would then reassess intake findings and document overall psychosocial well-being. Documentation of mental health concerns included situations prompted by patients, parents or providers. Baseline chart review
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found 55% (n = 143) were screened for psychosocial health by any method within the previous 1–3 year time-period most often during well visits. The most frequently documented mental health concerns were anxiety, history of depression, depression concerns, behavioral problems, history of ADHD, autism, substance abuse, sexual abuse, history of suicidal attempt, and non-suicidal self-injury. Of the 143 (55.4%) adolescents that screened positive for potential mental health concerns, 22% (n = 31) were referred for additional mental health services. Prior to implementation of the project, community mental health organizations were contacted to obtain information concerning the availability of services, referral procedures, willingness to accept referrals, potential appointment wait listing, and eligibility requirements. A resource list of local area service providers was also developed.
room. Assessment of PHQ-9 screening protocol outcomes included a retrospective chart review following protocol implementation. PDSA Cycle The Plan in this project was to screen all adolescents 12–18 years old during well or episodic illness visits. The Do involved implementing the PHQ-9 screening protocol. During the Act phase, modification to the screening process and clinic personnel feedback improved the outcome. A PDSA cycle occurred every 2–4 weeks. Projected outcomes included identification and referral of adolescents at high risk for depression via PHQ-9 screening protocol. The post-implementation retrospective chart review identified documentation for 256 eligible adolescent visits during the study period. Measures
Protocol Development An evidence-based PHQ-9 screening protocol was developed through extensive literature review and inter-professional collaboration with clinic, school district, and academic key stakeholders. This protocol provided an algorithm for the implementation of the PHQ-9 screening including adolescent and parent education for mild depressive symptoms and mental health provider referrals (Fig. 2). The selfadministered version of PHQ-9 modified for adolescents uses the DSM-IV criteria to assess for mental health problems in primary care. The PHQ-9 provides diagnoses of probable depression and assesses severity of symptom as a continuous score (Richardson et al., 2010). According to protocol, clinic staff who initiate contact with the adolescents provide the PHQ-9 to the adolescent for selfadministration in a clinic exam room. After the screening, clinic staff review the PHQ-9 screening and calculate the score. After reviewing the PHQ-9 responses and scores, providers initiate symptom related conversation and recommend referral as indicated. Those who have elevated depressive symptoms scores yet do not meet the criteria for mental health referrals (i.e., score b 10), receive a handout regarding mental health promotion. Per protocol, adolescents with positive depression screens and scores equal to or N 10 require mental health referrals. Likewise, those who respond ‘yes’ to dysthymia related question and report concerning symptoms on clinical discussion are indicated for referral. Protocol Implementation Nursing and administrative staff and nurse practitioners involved in the care of adolescents at the clinic underwent formal educational training. An informational handout was provided to those who could not attend the formal educational training and follow-up included ascertainment of understanding of the protocol. Email communication and face-to-face meetings were utilized to facilitate the project implementation phase. Protocol training included handouts describing epidemiology of depression among adolescents, risk factors, symptoms, recommendation for routine screening from multiple organizations (e.g., Bright Futures, American Academy of Pediatrics, and USPSTF), recommended screening protocol, and instructions for implementation of screening instrument. Education concerning mental health interviewing and intervention was offered to providers should positive symptoms be identified. Following completion of the educational session, clinic staff shared the opportunity to practice PHQ-9 screening and scoring. Implementation of the project occurred between January 31, 2017 and May 31, 2017. All adolescents aged 12–18 years, accessing the clinic for health care services during this time, received the PHQ-9 for completion. No screening occurred for those who accessed the clinic solely for the purpose of vaccination or sports physical. Those who met the inclusion criteria completed the PHQ-9 questionnaire in a private clinic exam
Data extracted for the post-implementation retrospective chart review included the following variables. Socio-demographic variables and chronic diseases correlate with mental health problems (Merikangas et al., 2010). Therefore, data extracted for the postimplementation retrospective chart review were: (1) age, (2) gender, (3) ethnicity (4) payer source, (5), reason of clinic visit, (6), whether depression screening was obtained, (7) MDD screening result, (8) mental health related treatment plan, (9) referral, (10) referral source, (11) mental health history, (12), symptoms of depression, and (13) chronic medical problems. Data were de-identified using study ID. The PHQ-9 has high sensitivity 89.5% and good specificity of 78.8% for detecting MDD among adolescents (Richardson et al., 2010). Each item of the PHQ-9 asks the adolescent to rate the severity of depression symptoms they have experienced during the past 2 weeks. Each item on the measure is rated on a 4-point scale (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day) with the total score ranging from 0 to 27. A higher score represents a greater severity of depression. The score will be summed to obtain a total raw score and will be interpreted as 0–4 = no or minimal depression, 5–9 = mild depression, 10–14 moderate depression, 15–19 = moderately severe depression, and 20–27 = severe depression. Analysis The data were analyzed using SPSS 24.0 software. The study was combination of descriptive and non-parametric statistics. Data analyses included descriptive statistics and frequency tables to describe sociodemographics, depression screening status, referral status, and depressive symptoms. Pearson's chi-squared analysis tested associations between socio-demographics and screening status, depressive symptoms and gender, depressive symptoms by age group, demographic and referral status, severity of depressive symptoms and referral status. Age categories included two groups (12–14 years vs. 15–18 years). Ethnicity categories included two groups, Hispanic and other. Results Socio-demographics The post-intervention retrospective chart review (n = 256) identified adolescents (n = 144, 56.3%) with PHQ-9 screening. The majority (n = 238, 93.0%) of adolescents was of Hispanic ethnicity. Insurance status included public (n = 177, 69.1%) and private (n = 12, 4.7%); 26.2% (n = 67) were uninsured. The majority of visits was for episodic illness (n = 180, 70.3%) versus wellness (n = 76, 29.7%) visits. Age distribution of the adolescents included: 46.1% (n = 118) 12–14 years old and 53.9% (n = 138) 15–18 years old. Few had documentation of a personal history of depression (3.9%, n = 10) of which 80% (n = 8) were female and 20% (n = 2) were male. There was no documentation of
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depression history in 96% (n = 246) of charts; 2.0% (n = 5) had documentation of past or current use of antidepressants. Examination of associations between screening status and gender, age, ethnicity, payer source, and visit purpose was conducted. A significant association between payer source and screening status was found (χ2 = 7.45, p = 0.024). Similarly, there was a statistically significant relationship between visit purpose and screening status (χ2 = 3.997, p = 0.046); 66% (n = 50) were screened during wellness visits while 52.2% (n = 94) were screened during episodic illness visits (Table 1). Frequency Distribution of Outcome of Depression Screening Protocol Of screened adolescents (n = 144), 41.7% (n = 60) were between 12 and 14 years old and 58.3% (n = 84) were between 15 and 18 years old; 58.3% (n = 84) were female and 41.7% (n = 60) were male (Table 1). Results of PHQ-9 screening identified 87.5% (n = 126) of adolescents with a score b10 and 12.5% of adolescents with a score ≥ 10. A PHQ-9 score of ≥ 10 was indicated for referral per protocol, of which 83.3% (n = 15) were referred to mental health providers for further evaluation and management while 16. 7% (n = 3) refused referral (Table 4). Furthermore, 18. 8% (n = 27) reported the presence of mild depression, 9.0% (n = 13) moderate depression and 3.5% (n = 5) moderately severe depression (Table 4). Of the 144 screened adolescents, 8% (n = 12) of adolescents reported symptoms of suicidal thought or history of previous suicide attempt of which 75% (n = 9) were referred to mental health providers (Table 3). Symptoms of dysthymia were assessed by asking depressed mood in most days in past year. Referral per protocol was indicated if the symptoms were present for ≥2 years. A total of 20.1% (n = 29), reported those symptoms of which 55.2% (n = 16) were referred to mental health providers (Table 4). Data indicated 11.1% (n = 14) with a PHQ-score b10 and reporting depressive symptoms suggesting dysthymia were referred to mental health providers. Of those who were not screened with the PHQ-9, 1.8% (n = 2) were referred to mental health providers.
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indicated positive responses. To the question, “Feeling that you would be better dead or hurting yourself in some way”, 6.0% (n = 5) of females and none of the males indicated positive responses. Likewise, 25% (n = 21) of females reported sad or depressed mood most days in the past year whereas 13.3% (n = 8) male these symptoms. Responses to the question “How difficult did these problems make it for you to do your work”, 12% (n = 10) of females and 6.7% (n = 4) of males reported some level of difficulties. Thought of ending your life in the past month were reported by 4.8% (n = 4) of females and 3.3% of males (n = 2); 2.4% (n = 2) of females and 6.7% (n = 4) of males attempted suicide in the past (Table 2). Statistically significant relationships existed between gender and sleep disturbance and gender and tiredness. Female adolescents were more likely to report sleep problems (χ2 = 9.147, p = 0.002) and tiredness (56%, n = 47 vs. 35%, n = 21) (χ2 = 6.165, p = 0.013) than male adolescents (Table 2). Significant associations between age and sleep problems and low self-esteem were also identified. The 15–18 year age group was more likely to experience sleep problems (47.6% n = 40 vs. 28.3% n = 17) (χ2 = 5.443, p = 0.020) and low self-esteem (22.6%, n = 19 vs. 8.3%, n = 5) (χ2 = 5.143, p = 0.023) than the 12–14 year age group. Significant relationships between depressed mood in most days in the past year and referral status (χ2 = 27.711, p b 0.001) were found (Table 3). Among those reporting these symptoms (n = 29), 55.2% (n = 16) received referral to mental health providers as compared to 44.8% (n = 13) not referred (Table 4). No significant relationships between gender and severity of depression existed.
Table 2 Comparison of depressive symptoms by gender (N = 144). Gender Female Male (n = 84) (n = 60)
Total (N = 144)
n
%
n
%
N
%
No Yes No Yes No Yes
65 19 51 33 42 42
77.4 22.6 60.7 39.3 50.0 50.0
46 14 39 21 45 15
76.7 23.3 65.0 35.0 75.0 25.0
111 33 90 54 87 57
77.1 0.010 0.920 22.9 62.5 0.274 0.600 37.5 60.4 9.174 0.002⁎ 39.6
No Yes No Yes No Yes
62 22 37 47 66 18
73.8 26.2 44.0 56.0 78.6 21.4
48 12 39 21 54 6
80.0 20.0 65.0 35.0 90.0 10.0
110 34 76 68 120 24
76.4 0.744 0.388 23.6 52.8 6.165 0.013⁎ 47.2 83.3 3.291 0.070 16.7
No Yes No Yes
53 31 67 17
63.0 37.0 79.8 20.2
44 16 48 12
73.3 26.7 80.0 20.0
97 47 115 29
67.4 1.669 0.196 32.6 79.9 0.001 0.972 20.1
Characteristic
Comparison of Depressive Symptoms by Gender and Age Comparisons of depressive symptoms by gender and age were made. Sleep disturbance was reported by 50% (n = 42) of females and 25% (n = 15) males. Concerning feeling bad about yourself or feeling that you are a failure, 21.4% (n = 18) females and 10% (n = 6) males
Table 1 Demographic characteristics of participants (N = 256). Screening status Yes
Total
Characteristic
No n = 112
%
% n = 144
% N = 256
χ2
P
Gender
53 59 58 54 104 8 34
47.3 52.7 51.8 48.2 92.9 7.1 30.4
84 60 60 84 134 10 33
137 119 118 138 238 18 67
3.07
0.08
2.59
0.107
77
68.8 100 69.4 177 69.1
1
0.9
11
7.6
12
4.7
86 26 110 2
76.8 23.2 98.2 1.8
94 50 115 29
65.3 34.7 79.9 20.1
180 76 225 31
70.3 3.99 29.7 87.9 19.9 12.1
Female Male Age group 12–14 15–18 Ethnicity Hispanic Other Payer source No insurance Public insurance Private insurance Reason of visits Sick Wellness Was patient No referred? Yes
58.3 41.7 41.7 58.3 93.1 6.9 22.9
⁎ The Chi-square statistic is significant at the 0.05 level.
53.5 46.5 46.1 53.9 93 7 26.2
0.004 0.951 7.45
0.024⁎
0.046⁎ NA
Depressed mood, irritable, hopeless Little interest or pleasure in doing things Trouble falling asleep, staying asleep, or sleeping too much Poor appetite, weight loss, or overeating Feeling tired, having little energy Feeling bad yourself, feeling that you are a failure Trouble concentrating on things Moving or speaking too slowly that other people could have noticed Thought that you would be better dead, or hurting yourself in some way Depressed mood in most days in past year How difficult these problems made it for you to do your work? Serious thought of ending your life in the past month Have you ever in your whole life tried to kill yourself?
χ2
P
No 79 94.0 60 100.0 139 96.5 3.700 NA Yes 5 6.0 0 0.0 5 3.5
No Yes No Yes
63 21 74 10
75.0 25.0 88.0 12.0
52 8 56 4
86.7 13.3 93.3 6.7
115 29 130 14
79.9 2.962 0.085 20.1 90.3 9.7
No 80 95.2 58 96.7 Yes 4 4.8 2 3.3
138 95.8 0.179 NA 6 4.2
No 82 97.6 56 93.3 Yes 2 2.4 4 6.7
138 95.8 1.610 NA 6 4.2
⁎ The Chi-square statistic is significant at the 0.05 level.
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S. Bhatta et al. / Journal of Pediatric Nursing 38 (2018) 8–14
Table 3 Comparison of depressive symptoms by age. Age group 12–14 years (n = 60)
15–18 years (n = 84)
Total (N = 144)
n
%
n
%
N
%
No Yes No Yes No Yes
46 14 37 23 43 17
76.7 23.3 61.7 38.3 71.7 28.3
65 19 53 31 44 40
77.4 22.6 63.0 37.0 52.4 47.6
111 33 90 54 87 57
77.1 0.010 0.920 22.9 62.5 0.030 0.861 37.5 60.4 5.443 0.020⁎ 39.6
No Yes No Yes No Yes
45 15 32 28 55 5
75.0 25.0 53.3 46.7 91.7 8.3
65 19 44 40 65 19
77.4 22.6 52.4 47.6 77.4 22.6
110 34 76 68 120 24
76.4 0.110 0.740 23.6 52.8 0.013 0.910 47.2 83.3 5.143 0.023⁎ 16.7
No Yes No Yes
39 21 47 13
65.0 35.0 78.3 21.7
58 26 68 16
69.0 31.0 81.0 19.0
97 47 115 29
67.4 0.261 0.610 32.6 79.9 0.149 0.699 20.1
Symptoms Depressed mood, irritable, hopeless Little interest or pleasure in doing things Trouble falling asleep, staying asleep, or sleeping too much Poor appetite, weight loss, or overeating Feeling tired, having little energy Feeling bad yourself, feeling that you are a failure Trouble concentrating on things Moving or speaking too slowly that other people could have noticed Thought that you would be better dead, or hurting yourself in some way Depressed mood in most days in past year How difficult these problems made it for you to do your work? Serious thought of ending your life in the past month Have you ever in your whole life tried to kill yourself?
χ2
P
No 57 95.0 82 97.6 139 96.5 0.716 NA Yes 3 5.0 2 2.4 5 3.5
No Yes No Yes
50 10 54 6
83.3 16.7 90.0 10.0
65 19 76 8
77.4 22.6 90.5 9.5
115 29 130 14
79.9 0.771 0.380 20.1 90.3 0.009 0.924 9.7
No 56 93.3 82 97.6 138 95.8 1.610 NA Yes 4 6.7 2 2.4 6 4.2 No 56 93.3 82 97.6 138 95.8 1.610 NA Yes 4 6.7 2 2.4 6 4.2
Qualitative Data Although, not screened for depression, the common behavior problems documented in the chart were: suicide attempts in the past, substance abuse, history of depression, autism, mood problems, and high
Table 4 Comparison of demographic and severity of symptoms by referral status. Referral status (N = 256) Yes
No
Total
Demographic and symptoms
n % = 31
% n = 225
% N = 256
χ2
Gender
Female Male 12–14 15–18 Hispanics Other No Yes
20 11 18 13 28 3 13 16
7.8 4.3 7.0 5.1 10.9 1.2 9.0 11.1
117 108 100 125 210 15 102 13
45.7 42.2 39.1 48.8 82.0 5.9 70.8 9.0
137 119 118 138 238 18 115 29
1.716 0.19
No or minimal Mild Moderate Moderately severe
3
2.1
97
66.9 100 69.0 NA
11 7.6 10 6.9 5 3.4
16 3 0
11.0 27 2.1 13 0.0 5
Ethnicity Depressed mood in most days in past year Severity of depressive symptoms
⁎ The Chi-square statistic is significant at the 0.05 level.
PDSA Cycle Documentation of staff compliance with the screening protocol occurred on a weekly basis (Fig. 1). Staff compliance was 100% on week 7 and week 14 however during the other weeks screening intermittently fluctuated. Email reminders occurred via work email or text messages every 2–3 weeks. A second PDSA cycle occurred in week 6 with feedback to staff. Barriers to successful screening identified by staff were busy schedule, short staff, and remembering to screen. In order to improve recall of new protocol, screening signs were placed in different areas as reminders. After the second PDSA cycle, the screening rate improved to 100% in week 7. The third cycle was implemented in week 10. The screening rate was shared with clinic staff and frequently reminded for screening via face-to-face communication, text-messages, or emails. The identified reasons for a low screening rate reviewed with clinic staff and nurse practitioners in week 10 led to a gradual increase in the screening rate in week 10. During week 16, the number of adolescent visits and screening number decreased as did screening compliance. During this week, all clinic staff was involved in conducting sports physicals within a number of middle schools and high schools rather than seeing patients in the clinic. Discussion
⁎ The Chi-square statistic is significant at the 0.05 level.
Age group
risk sexual behaviors. Even though, adolescents' responses to PHQ-9 questionnaires did not indicate the need for referral to mental health providers, they were referred because of several reasons. Some of the information noted frequently in the charts included: running away from home, substance abuses, concern of ADHD or depression, stress due to obesity, stress in family, anxiety, hallucination, chronic medically unexplained physical complaints, and suicidal thoughts. Two adolescents not screened with the PHQ-9 received referrals to mental health providers due to concern of depression. Three adolescents refused referral to mental health providers although their PHQ-score indicated referral. They reported the symptoms they were experiencing were due to current illnesses and symptoms improved during the follow-up.
53.5 46.5 46.1 53.9 93.0 7.0 79.9 20.1
P
The purpose of this project was to implement a depression screening protocol in a school-based pediatric primary care clinic to improve early detection and referral of adolescents aged 12–18 years. Results of the retrospective chart review indicate use of standardized depression screening protocol assisted in the identification of adolescents at risk for depression. During the 4 months of project implementation, approximately 31.3% of adolescents screened positive for elevated depressive symptoms; 12.5% scored at or above the recommended screening cutoff of 10 for mental health referral (Table 4). This prevalence is consistent with NIMH 2015 data, which was 12.5% (NIMH, 2015). Prevalence rates of depression among Hispanic adolescents were also consistent with NIMH 2015 data. The prevalence of MDD found in Hispanic adolescents is 12.6% and this project found a 12.7% prevalence of MDD among Hispanic adolescents.
2.034 0.15 NA
NA
27.71 0.00⁎
NA
18.6 9.0 3.4 Fig. 1. Depression screening.
S. Bhatta et al. / Journal of Pediatric Nursing 38 (2018) 8–14
13
Fig. 2. Adolescents depression screening protocol flow diagram. Abbreviation: SXS, symptoms; PHQ, patient health questionnaires; MHP, Mental Health Provider; F/U, follow-up.
During the project implementation, over 56.0% of adolescents who received healthcare through the clinic were screened for depression. It is possible that if all adolescents had been screened the prevalence may have been higher. The implementation of PHQ-9 screening tool created the opportunity to initiate a discussion of mental health. Adolescents with suicide related responses and history of previous suicidal attempts in this study had a high likelihood of referral to mental health providers following screening (75%). Similarly, adolescents who reported dysthymia symptoms (55.2%) were likely to get referral to mental health providers. Most (83.3%) of adolescents who were indicated for referral based on PHQ-9 score were referred to mental health providers. Receipt of these mental health referrals by providers was confirmed and status of the referral was discussed. These findings represent a positive outcome as adolescents who were screened were provided self-care handouts and referred. The screening protocol algorithm provided convenient reference for consistency in referral processes. Very little has been written about implementation of the PHQ-9 in school-based clinics. Integration of PHQ-9 screening in school-based clinics however may improve awareness of MDD among adolescents. This project included distribution of handouts for mental health promotion for those who had elevated depressive symptoms. The standardized PHQ-9 screen also provided a vehicle for engaging the adolescents in discussion regarding their mental health status. This also suggests that by implementing depression screening, the awareness of MDD among adolescents is improved. In this study 70.3%
participants presented to the clinic for sick visits and screening rate for sick visits was 52.2% (Table 1). A previous study has reported that those who presents with more physical illnesses or use more mental health services are more likely to score high on the PHQ-9 which suggests the importance of screening for those who have more physical illnesses (Tsai et al., 2014). Other study found that even when the symptoms are mild, depression in adolescents is associated with increased healthcare utilization and cost (Wright et al., 2016). Therefore, utilization of depression screening and timely referral when indicated may promote cost-effectiveness of healthcare. The cost of implementing depression screening is minimal. The implementation of screening can be time consuming for a busy clinic, but the opportunity to decrease costs related to identifying and treating depression early outweigh initial implementation challenges.
Challenges to Implementation Despite perceived determination, clinic patient volume and human memory failure among clinic staff played a role in missed screening. Electronic health record prompts, periodic training, and email reminders could potentially improve screening rates. Some adolescents who screened positive reported that symptoms were related to current illnesses. This is a consideration when screening during an episodic illness visit. Further assessment of potential barriers to compliance with mental health referrals is also indicated.
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Clinical Implications This project provided a protocol for implementation of the depression screening tool, PHQ-9, within a school-based pediatric primary health clinic setting. This study resulted in improved screening and referral for depression among adolescents. It also increased opportunity for further mental health discussion and education for selfmanagement of depressive symptoms. Advanced practice nurses can act as change agents to implement screening protocols, provide education, and refer adolescents for further management of depression. This project provided opportunities for advanced practice nurses to collaborate with mental health providers concerning adolescent mental health. Cano et al. (2015) found Hispanic adolescents have higher rates of depressive symptoms than non-Hispanic White. One in five adolescents in the United States is Hispanic with an increase to one in three adolescents anticipated by 2040 (Cano et al., 2015). Our findings identified significant depressive symptoms among predominately Hispanic adolescents in a primary care-based clinic. Implications of these findings include further assessment of the accumulation of cultural stressors that may increase the risk of poor mental health outcomes among this group. Limitations Limitations include generalizability to adolescents of other ethnic and cultural backgrounds. Likewise, although the plan for follow-up was discussed with adolescents per protocol, the majority did not follow-up with primary care providers, and follow-up was not assessed in this project. Screening for the majority of adolescents occurred during visits for episodic illness which may have been a confounding source of depressive symptoms. Conclusion Implementation of a depression screening protocol improved screening rates in a school-based pediatric primary care clinic and facilitated formal referrals to mental health providers. The protocol promoted systematic evidenced-based depression screening among adolescents 12–18 years old which can serve to improve the early diagnosis and treatment of MDD in adolescents to improve short-and longterm adolescent health outcomes. This protocol is an exemplar for application in other real world settings. References Breslau, J., Gilman, S. E., Stein, B. D., Ruder, T., Gmelin, T., & Miller, E. (2017). Sex differences in recent first-onset depression in an epidemiological sample of adolescents. Translational Psychiatry, 7(5), e1139. https://doi.org/10.1038/tp.2017.105. Cano, M.Á., Schwartz, S. J., Castillo, L. G., Romero, A. J., Huang, S., Lorenzo-Blanco, E. I., ... Szapocznik, J. (2015). Depressive symptoms and externalizing behaviors among
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