A practical guide to using ratings of depression and anxiety in child psychiatric practice

A Scoping Review of Measures Used in Early Intervention Services for Psychosis

OBJECTIVE

The early intervention service (EIS) model for psychosis has been implemented with increasing frequency; yet, improving outcomes across domains for all patients remains challenging. Measurement-based care can strengthen outcomes by optimizing interventions and promoting alignment with standards, but it is still not widely deployed in EIS. The authors conducted a scoping review by systematically identifying and synthesizing measures used in EIS related to purpose (i.e., to assess patients, families, and programs), domains (e.g., symptoms, quality of life), and reporting perspectives (of patients, families, and clinicians).

METHODS

EMBASE, MEDLINE, PsycINFO, CINAHL, and Cochrane Library databases were searched for pertinent literature published between 2000 and 2020. Two reviewers independently screened titles, abstracts, and full texts and extracted data. Measures were classified as clinician-reported outcome measures (CROMs), patient-reported outcome or experience measures (PROMs/PREMs), or family-reported outcome or experience measures (FROMs/FREMs).

RESULTS

In total, 172 measures of 27 domains were identified from 115 articles. Nineteen measures had been used to assess programs on fidelity, service engagement, and satisfaction; 136 to assess patients on duration of untreated psychosis, symptoms, functioning, quality of life, and others; and 17 to assess families on coping and burden, background, and others. Sixty percent were CROMs, 30% were PROMs/PREMs, and 10% were FROMs/FREMs.

CONCLUSIONS

Greater inclusion of PROMs and FROMs is needed because they align with the EIS philosophy of patient and family engagement and may improve shared decision making and outcomes. A comprehensive, meaningfully synthesized archive of measures can advance measurement-based care, services research, and data harmonization in early psychosis.

Evidence Base for Measurement-Based Care in Child and Adolescent Psychiatry

Measurement-based care (MBC) is the routine collection of data using standardized, validated measures and use of these data to guide treatment. MBC has been implemented throughout medicine to improve patient outcomes, but its use in mental health care remains low. This article summarizes the evidence of MBC's efficacy in adults then reviews the sparser data in youth mental health care. The literature indicates that MBC must be administered immediately before or during every encounter, results must be available to and reviewed by providers immediately, results must be shared with the patient, and results must be used to guide treatment.

The multidisciplinary depression guideline for children and adolescents: an implementation study

It is important that depressed patients receive adequate and safe care as described in clinical guidelines. The aim of this study was to evaluate the implementation of the Dutch depression guideline for children and adolescents, and to identify factors that were associated with the uptake of the guideline recommendations. The study took place in specialised child and adolescent mental healthcare. An implementation project was initiated to enhance the implementation of the guideline. An evaluation study was performed alongside the implementation project, using structured registration forms and interviews with healthcare professionals. Six multidisciplinary teams participated in the implementation study. The records of 655 patients were analysed. After 1 year, 72% of all eligible patients had been screened for depression and 38% were diagnosed with the use of a diagnostic instrument. The severity of the depression was assessed in 77% of the patients during the diagnostic process, and 41% of the patients received the recommended intervention based on the depression severity. Of the patients that received antidepressants, 25% received weekly checks for suicidal thoughts in the first 6 weeks. Monitoring of the patients' response was recorded in 32% of the patients. A wide range of factors were perceived to influence the uptake of guideline recommendations, e.g. the availability of capable professionals, available time, electronic tools and reminders, and the professionals' skills and attitudes. With the involvement of the teams, recommendations were provided for nationwide implementation of the guideline. In conclusion, a systematic implementation programme using stepped care principles for the allocation of depression interventions seems successful, but there remains room for further improvement.

Symptom screening scales for detecting major depressive disorder in children and adolescents: a systematic review and meta-analysis of reliability, validity and diagnostic utility

BACKGROUND

Depression symptom screening scales are often used to determine a clinical diagnosis of major depressive disorder (MDD) in prevention research. The aim of this review is to systematically examine the reliability, validity and diagnostic utility of commonly used screening scales in depression prevention research among children and adolescents.

METHODS

We conducted a systematic review of the electronic databases PsycINFO, PsycEXTRA and Medline examining the reliability, validity and diagnostic utility of four commonly used depression symptom rating scales among children and adolescents: the Children׳s Depression Inventory (CDI), Beck Depression Inventory (BDI), Center for Epidemiologic Studies - Depression Scale (CES-D) and the Reynolds Adolescent Depression Scale (RADS). We used univariate and bivariate random effects models to pool data and conducted metaregression to identify and explain causes of heterogeneity.

RESULTS

We identified 54 studies (66 data points, 34,542 participants). Across the four scales, internal reliability was 'good' (pooled estimate: 0.89, 95% Confidence Interval (CI): 0.86-0.92). Sensitivity and specificity were 'moderate' (sensitivity: 0.80, 95% CI: 0.76-0.84; specificity: 0.78, 95% CI: 0.74-0.83). For studies that used a diagnostic interview to determine a diagnosis of MDD, positive predictive power for identifying true cases was mostly poor. Psychometric properties did not differ on the basis of study quality, sample type (clinical vs. nonclinical) or sample age (child vs. adolescent).

LIMITATIONS

Some analyses may have been underpowered to identify conditions in which test performance may vary, due to low numbers of studies with adequate data.

CONCLUSIONS

Commonly used depression symptom rating scales are reliable measures of depressive symptoms among adolescents; however, using cutoff scores to indicate clinical levels of depression may result in many false positives.

Depression subtypes in pediatric inflammatory bowel disease

OBJECTIVE

The association between inflammatory bowel disease (IBD) and depression provides a unique opportunity to understand the relation between systemic inflammation and depressive symptom profiles.

METHODS

Youth (n = 226) ages 9 to 17 years with comorbid IBD and depression underwent psychiatric assessment and evaluation of IBD activity. Latent profile analysis (LPA) identified depressive subgroups based on similar responses to the Children's Depression Rating Scale-Revised. Demographic factors, depression severity, anxiety, IBD activity, inflammatory markers, IBD-related medications, and illness perception were evaluated as predictors of profile membership.

RESULTS

Mean age was 14.3 years; 75% had Crohn disease; 31% were taking systemic corticosteroids. Mean depressive severity was moderate, whereas IBD activity, which reflects inflammation, was mild. LPA identified 3 subgroups: Profile-1 (mild, 75%) had diverse low-grade depressive symptoms and highest quality of life; Profile-2 (somatic, 19%) had severe fatigue, appetite change, anhedonia, decreased motor activity, and depressed mood with concurrent high-dose steroid therapy and the highest IBD activity; and Profile-3 (cognitive, 6%) had the highest rates of self-reported depressive symptoms, ostomy placements, and anxiety with IBD symptoms in the relative absence of inflammation.

CONCLUSIONS

Evidence was found for 3 depression profiles in youth with IBD and depression. Our analyses determined that patients with predominantly somatic or cognitive symptoms of depression comprised 25% of our cohort. These findings may be used to design subgroup-specific interventions for depression in adolescents with IBD and other physical illnesses associated with systemic inflammation.

Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Brazilian children and adolescents

The aim of this study was to evaluate the psychometric properties of the Brazilian-Portuguese version of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in a large community sample of Brazilian children and adolescents. A total of 2410 students completed the 41-item Brazilian-Portuguese version of the SCARED. The one-factor and the five-factor structure of the SCARED fit this sample well. However, the five-factor model had a significantly better fit than the one-factor model and an adequate fit for age and gender subgroups. Anxiety symptoms in Brazilian youth were reported at a moderate-high level as compared to other studies. Females were found to score significantly higher on the total score and on all of the subscales as compared to the males. The total score and each of the five factors for both children and adolescents showed good internal consistency, test-retest and construct validity. According to our findings the Brazilian-Portuguese version of the SCARED is a reliable and valid instrument to assess anxiety in Brazilian children and adolescents.

A systematic overview of measurement-based care in the treatment of childhood and adolescent depression

Major depressive disorder (MDD) is one of the most prevalent psychiatric disorders affecting children and adolescents. The significant psychiatric, social, and functional impairments associated with this disorder coupled with the high incidence of relapse indicate a need for continued efforts to enhance treatment. Current empirically supported treatments for childhood and adolescent MDD include psychotropic medications, psychotherapy, and a combination of both treatments, with selection of the most appropriate strategy depending on symptom severity. One strategy to enhance treatment outcome is the use of measurement-based care. This article provides a systematic review of measurement-based care in the treatment of childhood and adolescent MDD. It also presents a comprehensive analysis of widely used depression rating scales and discusses their utility in clinical practice. This review found evidence supporting the utility and benefit of depression rating scales to document depression severity in children and adolescents. We also found evidence suggesting that many of these scales are time efficient, and that both clinician-rated and self-rated scales provide accurate assessment of depressive symptomatology. Future research is warranted to examine the utility of measurement-based care in clinical practice with child and adolescent populations.

Reliability and validity of the screen for child anxiety related emotional disorders (SCARED) in Chinese children

The present study examined the psychometric properties of the screen for child anxiety related emotional disorders (SCARED) in a large community sample of Chinese children. The 41-item version of the SCARED was administered to 1559 primary and junior high school students (774 boys and 785 girls, mean age 11.8+/-2.11) in 12 Chinese cities. The SCARED demonstrated moderate to high internal consistency (alpha=0.43-0.89) and test-retest reliability (intraclass correlation coefficients=0.46-0.77 over 2 weeks and 0.24-0.67 over 12 weeks), moderate parent-child correlation (r=0.49-0.59) and good discriminant validity (between anxiety and non-anxiety disorders). The SCARED total score was significantly correlated with the internalizing factor of the child behavior checklist (0.41). Factor analyses revealed the same five-factor structure as the original SCARED. These findings support that the SCARED is a reliable and valid anxiety screening instrument in Chinese children.

Use of a psychosocial screen to detect children with symptoms of posttraumatic stress disorder: an exploratory study

OBJECTIVE

The aim of this study was to evaluate the sensitivity and specificity of the parent and youth versions of the 17-item Pediatric Symptom Checklist (PSC-17) for identifying children with symptoms of posttraumatic stress disorder (PTSD).

METHODS

Cross-sectional convenience samples of children aged 8 to 10 years treated at a primary care pediatrics practice in New York City were recruited. The PSC-17 and its 5-item internalizing subscale were used in both parent- and youth-completed formats. Posttraumatic stress disorder symptoms were identified with the University of California, Los Angeles posttraumatic stress reaction index (UCLA RI), used as a structured interview with the child.

RESULTS

One hundred fifty-six children enrolled in the study. Twenty-two percent of children met the UCLA RI cutoff for likely PTSD. The youth version of the PSC-17 and its 5-item internalizing subscale identified these children with sensitivities of 78% and 75% and specificities of 77% and 77%, respectively, relative to the UCLA RI. The parent version of the PSC-17 and the internalizing subscale had poorer sensitivities of 44% and 25% and similar specificities of 79% and 92%, respectively.

CONCLUSIONS

Symptoms of PTSD can be identified using the youth self-report version of the PSC-17. A 5-item subscale of the PSC-17 also performed well and can readily be used in primary care settings.