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Routine Mental Health Screening Can Identify Mental Illness Early On

Mental Health Screening

 

 

 Mental illness is a significant problem for today’s adolescents, with major depressive disorder being a particularly disabling condition that is associated with serious long-term morbidity and risk for suicide.[1] The Institute of Medicine (IOM),[2] the US Preventive Services Task Force (USPSTF),[3] and the American Academy of Pediatrics (AAP) recommend a mental health assessment for adolescents as part of routine medical care.[4]

Through regular mental health checkups, teens at risk for suicide and serious disability from mental illness can be identified and offered effective treatment options that can eliminate or curtail lifetime disability.[2,5] Mental health checkups ensure that symptoms of illness are detected early when treatment is most effective.[2,6]

 

John H. Genrich, MD; Leslie C. McGuire, MSW

Posted: 11/02/2009

Introduction

Mental illness is a significant problem for today’s adolescents, with major depressive disorder being a particularly disabling condition that is associated with serious long-term morbidity and risk for suicide.[1] The Institute of Medicine (IOM),[2] the US Preventive Services Task Force (USPSTF),[3] and the American Academy of Pediatrics (AAP) recommend a mental health assessment for adolescents as part of routine medical care.[4]

Through regular mental health checkups, teens at risk for suicide and serious disability from mental illness can be identified and offered effective treatment options that can eliminate or curtail lifetime disability.[2,5] Mental health checkups ensure that symptoms of illness are detected early when treatment is most effective.[2,6]

Adolescent primary care visits offer an ideal opportunity to implement regular mental health screenings. Quick and easy-to-use screening questionnaires that identify teens suffering from underlying mental disorders exist and have proven effective.[2] The use of an evidence-based screen has been shown to be more effective than observation or nonstructured assessment alone.[7] Screening is also adaptable in a range of primary care settings and has been well received in the clinical setting.[8,9]

Despite a growing consensus for mental health screening in primary care, studies have shown that less than one third of primary care providers (PCPs) routinely screen their adolescent patients for mental illness.[10]

Recent Federal Guidelines

Today, there is broad-based support for making mental health screening part of routine medical care for adolescents. In the winter of 2009, the IOM in collaboration with the National Research Council (NRC) identified mental health screening in primary care as an effective step to prevent fully developed mental health disorders.[2] Shortly after, the USPSTF highlighted screening questionnaires as an accurate and effective way to identify adolescent depression.[3]

IOM and NRC

The IOM and NRC found that several initiatives, including evidence-based screening, are effective at preventing more severe mental health problems in youth. The IOM provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to medical professionals, policy makers, leaders in every sector of society, and the public at large. The NRC promotes the acquisition and dissemination of knowledge in matters involving science and health. Their joint 2009 report on adolescent mental health noted the following[2]:

  • Primary care, school, and community settings provide important opportunities for mental health screening;
  • Targeting high-risk youth (foster care, juvenile justice, youth with depressed parents) is good public health practice;
  • Validated screening tools should be used;
  • Identification of risk must be tied to effective intervention;
  • Entities that offer screening must have guidelines in place for referrals; and
  • The federal government should expand prevention and early identification of mental, emotional, and behavioral disorders in young people.

The USPSTF

Also in 2009, the USPSTF recommended that all adolescents between the ages of 12 and 18 years should receive an annual depression screen from their PCPs. The USPSTF is an independent panel of experts in primary care and prevention who systematically reviews the scientific evidence of effectiveness for a broad range of services and develops recommendations for preventive practices. The USPSTF concluded that there is adequate evidence that screening questionnaires accurately identify major depressive disorder in adolescents and that questionnaires developed for primary care can be successfully used with adolescents.[3]

Thomas DeWitt, MD, the USPSTF’s Chair of Methodology, recently stated that, “Identifying (depression) early on in adolescence and treating it…can prevent some of the trauma not only for the child but the families that go through this with their children.”

The AAP

The AAP recommends routine mental health checkups for all adolescents. In 2007, the AAP issued a policy statement highlighting the role that pediatricians can take to help reduce the incidence of adolescent suicide by routinely screening for depression and suicide ideation and behavior. It also stressed the importance of addressing mental health issues among children and adolescents in primary care.[4]

Health Professional Organizations

The American Academy of Family Physicians,[11] the Society for Adolescent Medicine,[12] and the Association of Child and Adolescent Psychiatric Nurses support mental health checkups as part of routine adolescent healthcare.[13] The August 2009 issue of the Journal of Child and Adolescent Psychiatric Nursing outlined the USPSTF recommendations and stated that involving nurses and other practitioners who serve on the front lines of adolescent healthcare in helping to identify mental illness in its earliest stages can help to prevent lifelong negative outcomes.[13]

Undetected Mental Illnesses in Adolescence

According to the US Surgeon General, 11% (4.5 million) of US youth between the ages of 10 and 19 years suffer from a serious mental illness that causes significant impairment in their day-to-day lives at home, in school, and with peers.[14] Recent research revealed that 50% of all lifetime mental disorders start by age 14.[15] The most common mental disorders during the adolescent years are anxiety and depression. When left untreated, mental illness can lead to drug and alcohol abuse, violence, school failure, involvement in the criminal justice system, the loss of critical developmental years, and suicide.[2]

Depression

Among adolescents who were 12-17 years old during 2004-2006, 8.5% suffered an episode of major depression and were about twice as likely to increase their overall risk factors by using alcohol or an illicit drug as youth who had not experienced a major depressive episode during the past year.[1] The rate of those who experience major depression increases as teens get older, with 11.5% of 16- and 17-year-olds suffering an episode in a 1-year span of time[1] (Figure 1). Of those who experienced a major depressive episode, only 38.9% received treatment of any kind.[16]

Figure 1.  Percentages of youth aged 12-17 who experienced a past-year major depressive episode (MDE), by age, 2004-2006.

Anxiety

It is estimated that 13% of 9- to 17-year-olds suffer from an anxiety disorder, an issue that, like other internalizing disorders, often goes undetected in regular adolescent health visits.[14] Anxiety disorders are highly correlated with attempted and completed adolescent suicides, with 27% of adolescents who commit suicide suffering from an anxiety disorder at their time of death.[17]

The most common types of anxiety disorders are phobias, social anxiety, and separation anxiety. Youth who suffer from anxiety are often quiet and compliant, making it even more difficult to detect symptoms. Risk factors for serious anxiety disorders should be monitored so that early interventions can help to prevent dire consequences.[18]

Suicide

Suicide is the third leading cause of death for 11- to 18-year-olds in the United States, and almost as many teens die by suicide each year as those who die from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined.[19] In addition to the thousands of youth who die by suicide, millions more think about and attempt suicide. According to the US Centers for Disease Control and Prevention, 15% of US high school students reported thinking seriously about killing themselves and 7% reported a prior suicide attempt.[20]

Approximately 90% of adolescent suicide victims have a psychiatric disorder, with 63% exhibiting psychiatric symptoms identifiable by screening for at least a year before their death.[17] Rates of mood disorders (Figure 2), such as depression, can be as high as 68% in adolescents who commit suicide, and up to 28% may be suffering from anxiety disorders. Substance abuse is also common, particularly among adolescent male suicide victims.[17]

Figure 2.  Underlying mental disorders contributing to adolescent suicide.

Disability

Mental illness is the second leading cause of disability and premature mortality in the United States.[21] Up to 10% of youth experience serious impairment that leaves them unable to function in school, at home, or with peers.[14] These illnesses are a leading cause of school dropout, substance abuse, unemployment, incarceration, poor physical health, and shortened life expectancy in later life.[2]

Approximately 50% of students age 14 and older who suffer from mental illness drop out of high school; this is the highest dropout rate of any disability group.[22] Junior high and high school students with mental illness fail more courses, earn lower grade point averages, miss more days of school, and are retained at grade level more often than students with other disabilities.[23]

Additionally, it is estimated that up to 50% of the mentally ill population also has a substance abuse problem, with the incidence of abuse greater among adolescent boys and those aged 18-44 years, highlighting the need for early intervention.[24]

Furthermore, mental illness, when undetected, can affect employment status throughout the lifetime. One study showed a 90% unemployment rate among adults with serious mental illness, the highest rate of unemployment of any group of people with disabilities.[25]

Many youth with unidentified and untreated mental illness also end up in jails and prisons. Sixty-five percent of boys and 75% of girls in juvenile detention suffer from mental illness.[26]

When youth go untreated for mental illness, they also experience poorer physical health, use more healthcare services, and incur higher healthcare costs in their adult years than others in the same age group.[27] Youth who are experiencing emotional and behavioral problems, or with higher levels of psychosocial distress, are also likely to be more frequent visitors to their primary care providers.[28,29]

Missed Opportunities

Today only 1 in 5 adolescents between the ages of 12 and 17 years who has a mental health disorder receives treatment.[14] There is also a lengthy gap between onset and treatment. Although symptoms of mental illness are typically present for 2-4 years before the onset of a full-blown disorder, most mental illnesses are not diagnosed for an average of 10 years after the first symptoms appear.[14] Missing early symptoms can result in disorders that create a lifetime of disability or tragically result in suicide.

Adolescent mental illness is especially underidentified in primary care settings. Studies have shown that PCPs identify internalizing disorders, such as depression and anxiety, at rates much lower than the prevalence for mood and anxiety disorders in adolescents; internalizing disorders were identified in less than 1 in 5 cases, and as many as 2 in 3 depressed youth are not identified by their PCPs and do not receive any kind of care.[30]

Early Detection

Routine mental health screening in primary care can detect possible symptoms of depression and other mental illness, much like a blood pressure test can identify possible cardiovascular risk factors. Making mental health checkups routine is key to early identification and critical to prognosis for those who suffer from mental illness.[2,5]

Primary care settings are ideal for implementing mental health checkups, given the regularity with which patients see their PCPs and the existing screening practices already in place there for other health issues. More than 70% of adolescents see a PCP at least once each year, and more than 50% visit a PCP for routine healthcare each year. However, according to one survey of pediatricians and family physicians, only 23% of respondents routinely screen their adolescent patients for mental illness.[31]

Screenings provide prime opportunities for health providers to ask adolescents about their emotional and behavioral health — something that is often not shared otherwise. Studies examining parental awareness of their children’s self-injurious behavior have indicated that fewer than 25% of parents know of their children’s self-harm behavior,[32] and that only a minority of mothers are aware of their children’s suicidal ideation or suicide attempts.[33]

In a recent study that assessed PCPs’ rates of addressing emotional distress with adolescent patients, only 34% of youth reported that their doctors talked to them about their emotional health — with older teens, Latino adolescents, and girls more likely to report that discussion than any other group.[10] Although 1 of 4 teens (27%) reported emotional distress, distress was not a significant predictor for teens talking to their PCPs about their emotional health.[10] In another study, 45% of all suicide victims were shown to visit their PCPs in the month prior to their death, and 77% were shown to have contact with their PCPs in the year before their death.[34] This stresses the importance of systematic screening for mental health problems in the primary care setting.

Screening Questionnaires

Validated screening questionnaires proven to accurately assess potential mental health disorders are widely available at little or no cost. Numerous questionnaires have been evaluated and found to accurately identify symptoms of mental illness and current mental disorders in diverse adolescent populations.[2] According to research, youth are comfortable answering sensitive questions about their mental health on a screening questionnaire.[35] This method of assessment has also been shown to be more effective than observation or nonstructured interview or assessment.[7]

Studies of primary care screening programs have indicated that approximately 12%-14% of those receiving a mental health checkup receive a positive score, and require an interview with a physician or other health professional to determine whether there is evidence of a possible mental illness, and if necessary a referral to a mental health professional.[36,37]

Many evidence-based screening questionnaires are available, including several that detect symptoms of single mental illnesses only and others that are not designed to be used in the primary care setting. Because of its ability to detect a wide range of mental health problems and its thorough validation in primary care settings, the screening tool most widely used in the primary care setting is the Pediatric Symptom Checklist (PSC) (Figure 3).[37] When an individual receives a positive score on the PSC, it is recommended that he/she be further evaluated by a health or mental health professional.[37]

The PSC was developed at Harvard University, Boston, Massachusetts, and is promoted by the AAP as the chosen instrument for its Bright Futures program. The questionnaire is a 35-item youth self-completion screen designed to detect behavioral and psychosocial problems. The PSC’s validity has been examined in a diversity of medical settings and a range of socioeconomic backgrounds. It has been shown that the tool determines impairment and the presence of psychiatric disorders with the same case classifications as the Children’s Behavior Checklist (CBCL) and Clinicians’ Global Assessment Scale (CGAS).[38] The PSC has also exhibited high rates of overall agreement, sensitivity, and specificity (at 79%/92%, 95%/88%, and 68%/100%, respectively) when analyzed against CGAS scores for middle- and lower-income populations, and has been shown to produce an estimated 12% prevalence rate for psychosocial disorders among middle-class patients or when administered in general settings; this is comparable to national estimates of psychosocial impairment.[38]

Clinical Acceptance and Adaptability

A 2007 study published in the Journal of the American Academy of Pediatrics found that depression screening was proven to be feasible in primary care settings and accepted by patients, parents, and providers.[9] In a national survey of randomly selected primary care pediatricians, 90% of pediatricians said that they felt responsible for identifying adolescent depression.[39] This study indicated that a significant proportion of primary care pediatricians would be willing to change how they identified and managed child and adolescent depression.[39]

Mental health checkups can be implemented in regular adolescent health visits at minimal cost and inconvenience. Screening is acceptable to many parents and adolescents in the primary care setting and does not disrupt the flow of patient care.[36,40] They are quick and simple to administer for both the patient and healthcare provider and require no more time than other preventive and wellness screenings.[9] (See the “Personal Commentary: ‘A Pediatrician’s Experience With Mental Health Screening'” accompanying this article.)

Additionally, studies implemented in primary care practices serving adult patients have demonstrated that by identifying and delivering effective treatments to depressed patients, use of inpatient and outpatient medical services can be decreased and cost reductions can be achieved.[41-43]

TeenScreen Primary Care: PCP Materials and Demonstration Projects

TeenScreen Primary Care is an initiative of the TeenScreen National Center for Mental Health Checkups at Columbia University, New York, NY, designed to assist healthcare professionals by integrating mental health checkups into routine adolescent healthcare. TeenScreen provides free evidence-based screening tools to medical providers to help them determine whether their adolescent patients are suffering from depression, anxiety, or other mental health conditions, and to ascertain whether they are at risk for suicide.

TeenScreen’s mental health checkup is designed for 11- to 18-year-olds and involves the administration of the youth self-completion version of the PSC followed by a brief assessment by the PCP (Figure 4). The screening is typically incorporated into well-child exams, sports physicals, and other routine office visits. The PSC can be completed and scored in less than 5 minutes, and can be administered in a private area of the medical office by a nurse, medical technician, or other office staff. Adolescents who score positive on the PSC are evaluated by their PCPs to determine whether the symptoms endorsed on the questionnaire are significant, causing impairment and warranting further attention. If the PCP determines that mental health services are needed, the adolescent’s parents are then notified, and he/she is either referred for mental health services or offered follow-up or treatment by the PCP. Free implementation materials are available at http://www.teenscreen.org/teenscreen-primary-care.

Figure 4.  Mental health checkups in primary care.

TeenScreen is partnered with ValueOptions, Kaiser Permanente, and EmblemHealth — all managed care organizations — and other medical organizations and practices on primary care demonstration projects in 20 states. These programs have shown that mental health checkups for adolescents are adaptable in a wide range of settings, including small medical practices, emergency departments, federally qualified health centers, and children’s wellness centers. They can also be implemented by diverse payers, such as managed care and behavioral health organizations, physicians’ staff plans, fee-for-service plans, and multiparty/payer consortiums. These programs each use the core elements recommended by the USPSTF, including an evidence-based screening questionnaire and a referral system that can link patients requiring additional assessment to qualified health providers.

Future Challenges

Despite available tools and easy implementation guidelines, reimbursement and adequate referral resources remain the 2 most significant challenges to implementing mental health checkups in primary care. PCPs find difficulty in obtaining reimbursement from insurers for mental health services offered in a primary care setting, which can lead to deincentivizing of screening and follow-up. PCPs also report that the shortage of mental health providers, specifically child and adolescent psychiatrists, complicates evaluation and treatment of youth identified with a potential mental illness.

However, TeenScreen demonstration programs have shown that with dedicated behavioral health services and referral hotlines, which are provided by most of the major health plans, necessary referrals can be made quickly and efficiently. These demonstration programs have also highlighted how effective and foresighted leadership in managed care can lead to policy change. All of the health plans participating in TeenScreen’s demonstration projects have assessed their reimbursement policies and now provide proper reimbursement for mental health screening and assessment services offered in primary care settings.

Conclusion

Rates of mental illness in adolescents, including those who commit suicide, are disproportionately high, underscoring the need to identify risk factors early. Adolescents receive a wide range of medical and wellness screenings at healthcare visits. PCPs provide these vital services in order to detect and treat early symptoms of physical ailments. PCPs are beginning to embrace these same practices for the mental health of their patients, with the knowledge that implementation is practical in a range of medical settings. Demonstration programs and studies have indicated that mental health checkups can be incorporated into routine medical care in an array of settings and for medical visits reimbursed by both private and public sector payers. Expert bodies and health professionals also recognize the primary care setting as an effective venue for screening for mental illness in adolescents and endorse the integration of these practices into regular adolescent healthcare visits.

Personal Commentary: “A Pediatrician’s Experience With Mental Health Screening”

John Genrich, MD

In July 2008, I began incorporating a mental health checkup into all routine adolescent office visits. Shortly after, I saw one of my regular patients, who I’ll call Brandon. He is 15 years old and did not exhibit any visible signs of depression or high-risk behavior on his prior annual visits, although no mental health screening effort was in place. Brandon came in for a regular visit and was given a mental health screen in the waiting room as part of his adolescent health exam. He completed the 1-page questionnaire and gave it to my office manager. She quickly scored the questionnaire and put it on the chart. As I walked into the examination room, I saw that he had answered affirmatively that he considered committing suicide in the last 3 months. The subsequent conversation was very emotional, but Brandon was actually relieved that someone asked him these questions. Brandon’s mother was informed and further evaluation was completed. He was referred to and began seeing a mental health specialist.

From this story, it is clear to me that if we have a snapshot into a teenager’s life, once a year or so, why not have a turnkey standard operating procedure to prevent the surprises of a teenager giving up hope, feeling loss of control, or perceiving the inescapable? We urgently need to better understand why, in a national prospective study, 15% of 10th graders are reporting only a 50/50 chance of living to the age of 35.[44] This fatalistic view among adolescents only increases their involvement in risky behaviors.[44] Mental health screening is the right thing to do if you are a physician caring for teenagers.

Nonetheless, PCPs should only do mental health screening when:

  • It is clearly understood that a mental health screening questionnaire, such as the PSC, is only meant to be a preliminary questionnaire, with follow-up by careful evaluation and referral when necessary
  • Mental health clinicians are available by referral for a thorough risk assessment and to make a correct diagnosis
  • Affordable mental health treatment can be immediately forthcoming
  • The PCP’s office has a carefully implemented, systematic tickler system to follow up on teenagers at risk. This can be a telephone call or even a convenient, after-hours meeting
  • When a questionnaire is “scored positive,” the PCP needs to do what he/she goes to work for:
    • (1) Evaluate family history of smoking, substance abuse, sexual activity, family history of depression and suicide, other mental health concerns, and hospitalizations
    • (2) Consider a drug screen
    • (3) Consider family strife and abuse
    • (4) Consider learning difficulties or attention deficits
    • (5) Consider endocrine or hormonal balance
    • (6) Perform a careful physical exam, including blood pressure, ophthalmologic exam, and hearing evaluation.

It is easy to forget or neglect any of these issues, and parents of teenagers rarely consider mental health issues as being part of the routine checkup or even part of the question. As gatekeepers, we need to be checking all of the gates. Also, we need to consider drug and alcohol questions in our mental health screens due to the close correlation with teen behaviors and depression.

The PSC questionnaire is an insightful look at reality in concise terms for most teenagers. It is self-administered and private without parental view or review. It can be administered online or in the office. When given the form, we tell the adolescent that there is no correct answer; it is not graded; and the results will be shared with them in a private, nonjudgmental fashion. In short, a sincere attempt is made to empower the teen to answer the questions honestly. The screen can be scored in nimble fashion by a nurse or an exam-room-entering physician.[37]

Using a mental health screen in my practice actually saves time and affords a springboard to initiate a meaningful interview during the exam process. It has been estimated that such mental health evaluations are “positive” — exhibiting risk factors — 12% of the time.[36] If a potential adolescent suicide risk is identified, then a mental health CPR plan needs to be in place for further expert evaluation, treatment, and follow-up.

Most parents are anxious to be part of the solution. Successful education of parents and office staff can assist the assessment and should include careful instructions as to what behaviors to look for, what not to say, and how to maintain a supportive role.

What will keep us giving the PSC at each office visit is the “surprise factor.” We often see these adolescents visit after visit without reaching into their conflicts and concerns — much less how their turmoil factors into their physical needs. Yes, it is actually time-efficient and has the potential to be cost-efficient. Some foresighted insurance carriers are beginning to realize that early identification of depression, oppositional behaviors, and attention difficulties can, indeed, significantly reduce the bottom line of the future. Enough said.

References

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Authors and Disclosures

Author(s)

John H. Genrich, MD

Hahnemann Medical College of Philadelphia, Philadelphia, Pennsylvania

Disclosure: John H. Genrich, MD, has disclosed the following financial relationships:
Served as an advisor or consultant for: Columbia University
Served as a speaker or a member of a speakers’ bureau for: Columbia University

Leslie C. McGuire, MSW

Deputy Executive Director, Teen Screen National Center for Mental Health Checkups, Columbia University, New York, NY

Disclosure: Leslie C. McGuire, MSW, has disclosed no relevant financial relationships.

Medscape Psychiatry & Mental Health © 2009 Medscape, LLC

 

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