Promoting Treatment Access Following Pediatric Primary Care Depression Screening: Randomized Trial of Web-Based, Single-Session Interventions for Parents and Youths

Emerging Risk of Adolescent Depression and Suicide Detected Through Pediatric Primary Care Screening

OBJECTIVE

The goal of the current study was to document patterns of stability and change in adolescent depression and suicide risk detected via universal depression screening in pediatric primary care and to determine who may go on to experience emerging risk.

METHODS

Retrospective electronic health record information (sociodemographic data and depression screening results for 2 timepoints) was extracted for adolescents aged 12-17 who attended well-visits between November 15, 2017, and February 1, 2020, in a large pediatric primary care network. A total of 27,335 adolescents with 2 completed depression screeners were included in the current study.

RESULTS

While most adolescents remained at low risk for depression and suicide across the 2 timepoints, others experienced emerging risk (i.e., low risk at time 1 but elevated risk at time 2), decreasing risk (i.e., high risk at time 1 but low risk at time 2) or stable high risk for depression or suicide. Odds of experiencing emerging depression and suicide risk were higher among adolescents who were female (compared to males), Black (compared to White), and had Medicaid insurance (compared to private insurance). Odds of experiencing emerging depression risk were also higher among older adolescents (compared to younger adolescents) as well as adolescents who identified as Hispanic/Latino (compared to non-Hispanic/Latino).

CONCLUSIONS

Findings can inform symptom monitoring and opportunities for prevention in primary care.

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

BACKGROUND

Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap.

OBJECTIVE

We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department.

METHODS

Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time.

RESULTS

The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023.

CONCLUSIONS

SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45666.

Examination of Web-Based Single-Session Growth Mindset Interventions for Reducing Adolescent Anxiety: Study Protocol of a 3-Arm Cluster Randomized Controlled Trial

BACKGROUND

Anxiety disorders are the most common mental disorders worldwide. In Hong Kong, 7% of adolescents are diagnosed with anxiety disorders, and 1 in every 4 secondary school students reports clinical-level anxiety symptoms. However, 65% of them do not access services. Long waitlists in public services, the high cost of private services, or the fear of being stigmatized can hinder service access. The high prevalence of anxiety and low intervention uptake indicate a pressing need to develop timely, scalable, and potent interventions suitable for adolescents. Single-session interventions (SSIs) have the potential to be scalable interventions for diagnosable or subclinical psychopathology in adolescents. Providing precise and context-adapted intervention is the key to achieving intervention efficacy.

OBJECTIVE

This study aims to compare the effectiveness of three SSIs: single-session intervention of growth mindset on negative emotions (SIGMA), SSI of growth mindset of personality (SSI-GP), and active control, in reducing adolescent anxiety.

METHODS

Adolescents (N=549, ages 12-16 years) from secondary schools will be randomized to 1 of 3 intervention conditions: the SIGMA, SSI-GP, or active control. The implementation of each intervention is approximately 45 minutes in length. Adolescent participants will report anxiety symptoms (primary outcome), perceived control, hopelessness, attitude toward help-seeking, and psychological well-being at preintervention, the 2-week follow-up, and the 8-week follow-up. A pilot test has confirmed the feasibility and acceptability of SIGMA among adolescents. We hypothesized that SIGMA and SSI-GP will result in a larger reduction in anxiety symptoms than the control intervention during the posttest and 8-week follow-up period. We also predict that SIGMA will have a more significant effect than SSI-GP. We will use the intention-to-treat principle and linear regression-based maximum likelihood multilevel models for data analysis.

RESULTS

This study will be conducted from December 2022 to December 2023, with results expected to be available in January 2024.

CONCLUSIONS

This protocol introduces the implementation content and strategies of growth mindset SSIs (consists of 2 forms: SIGMA and SSI-GP) among school students. The study will provide evidence on the efficacy of different growth mindset SSIs for adolescent anxiety. It will also establish implementation strategies for self-administrative SSIs among school students, which can serve as a pioneer implementation of a scalable and self-accessible brief intervention to improve the well-being of young people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05027880; https://clinicaltrials.gov/ct2/show/NCT05027880.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41758.

Adolescent depression screening in primary care: Who is screened and who is at risk?

BACKGROUND

Limited research has simultaneously focused on sociodemographic differences in who receives recommended adolescent depression screening in primary care and who endorses elevated depression and suicide risk on these screeners. We describe screening and risk rates in a large pediatric primary care network in the United States after the network expanded its universal depression screening guideline to cover all well-visits (i.e., annual medical checkups) for adolescents ages 12 and older.

METHODS

Between November 15, 2017 and February 1, 2020, there were 122,682 well-visits for adolescents ages 12-17 (82,531 unique patients). The Patient Health Questionnaire - Modified for Teens (PHQ-9-M) was administered to screen for depression.

RESULTS

A total of 99,961 PHQ-9-Ms were administered (screening rate=81.48%). The likelihood of screening was higher among adolescents who were female, 12-14 years of age at their first well-visit during the study, White, Hispanic/Latino, or publicly-insured (i.e., Medicaid-insured). Additionally, 5.92% of adolescents scored in the threshold range for depression symptoms and 7.19% endorsed suicidality. Heightened depression and suicide risk were observed among adolescents who were female, 15-17 years of age at their first well-visit during the study, Black, Hispanic/Latino, attending urban primary care practices, or Medicaid-insured. Odds of endorsing suicidality were also higher among teens who identified as other races.

LIMITATIONS

Limitations related to data available in the electronic health record and reliance on data from a single hospital system are noted.

CONCLUSIONS

Findings highlight misalignments in screening and risk status that are important to address to ensure more equitable screening implementation and health outcomes.

Combining selective serotonin reuptake inhibitors and cognitive behavioral therapy in youth with depression and anxiety

BACKGROUND

Treatment studies of children and adolescents with internalizing disorders suggest that the combination of a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone. We sought to determine how response to combined treatment varies across disorders (anxiety versus depression), and by specific patient characteristics.

METHODS

Three large National Institutes of Health-funded trials of children and adolescents with major depression (n = 2) and anxiety disorders (n = 1) were evaluated, each comparing CBT + SSRI to SSRI only, Bayesian Hierarchical Models (BHMs) were used, for endpoint response, time course of response and predictors of response in participants who received SSRI or SSRI+CBT.

RESULTS

SSRI+CBT significantly decreased symptoms by week 4 (p<0.001) across disorders. This improvement continued at week 8 and 12 (p<0.001); however, the additive benefit of CBT over SSRI monotherapy was not statistically significant until week 12 (p<0.001). The fastest response to SSRI+CBT was for patients who were younger, with milder baseline anxiety/depression symptoms and depressive disorders. The slowest response for SSRI+CBT was for boys, adolescents, minoritized children, those with severe symptoms and externalizing disorders.

LIMITATIONS

Limitations included inconsistent moderators, variation in the number of observations over time and a lack of genetic or pharmacokinetic variables related to SSRI exposure across studies.

CONCLUSIONS

The superiority of SSRI+CBT for youth with depression and anxiety is further supported. For purposes of rapid and greater relief, combination treatment is the superior approach across anxiety and depression and is robust to a range of participant characteristics. However, the added value of CBT (with an SSRI) occurs late in treatment. These findings represent a step towards understanding heterogeneity of treatment response and raise the possibility that interventions could be better tailored or adapted based on patient characteristics.

The Parents Are Not Alright: A Call for Caregiver Mental Health Screening During the COVID-19 Pandemic

Nearly a year into the COVID-19 pandemic, conversations about the impact of COVID-19 on children and families have shifted. Initial advice for parents stressed topics such as how to talk about the pandemic with children or cope with illness-related distress. They now focus on youth adjustment to a heavily disrupted school year and on strategies for building long-term resilience. Although these conversations often center on youth adjustment, they have-at last-started to consider the well-being of parents (and other caregivers) as well. This shift in focus is crucial given the enormous challenges that parents face right now and the direct links between their well-being and that of their children. What continues to lag, even well into the pandemic, however, is the provision of workable solutions for addressing parents' mental health. While we applaud the renewed focus on parenting stress and well-being, we remain deeply concerned by the absence of a plan for intervening.

The Biobehavioral Family Model: An Evidence-Based Approach to Biopsychosocial Research, Residency Training, and Patient Care

Engel's biopsychosocial model, based in systems theory, assumes the reciprocal influence of biological, psychological, and social factors on one another and on mental and physical health. However, the model's application to scientific study is limited by its lack of specificity, thus constraining its implementation in training and healthcare environments. The Biobehavioral Family Model (BBFM) is one model that can facilitate specification and integration of biopsychosocial conceptualization and treatment of illness. The model identifies specific pathways by which family relationships (i.e., family emotional climate) impact disease activity, through psychobiological mechanisms (i.e., biobehavioral reactivity). Furthermore, it is capable of identifying positive and negative effects of family process in the same model, and can be applied across cultural contexts. The BBFM has been applied to the study of child health outcomes, including pediatric asthma, and adult health, including for underserved primary care patients, minoritized samples, and persons with chronic pain, for example. The BBFM also serves as a guide for training and clinical practice; two such applications are presented, including the use of the BBFM in family medicine residency and child and adolescent psychiatry fellowship programs. Specific teaching and clinical approaches derived from the BBFM are described in both contexts, including the use of didactic lecture, patient interview guides, assessment protocol, and family-oriented care. Future directions for the application of the BBFM include incorporating temporal dynamics and developmental trajectories in the model, extending testable theory of family and individual resilience, examining causes of health disparities, and developing family-based prevention and intervention efforts to ameliorate contributing factors to disease. Ultimately, research and successful applications of the BBFM could inform policy to improve the lives of families, and provide additional support for the value of a biopsychosocial approach to medicine.

Acceptability and Utility of an Open-Access, Online Single-Session Intervention Platform for Adolescent Mental Health

BACKGROUND

Many youths with mental health needs are unable to access care. Single-session interventions (SSIs) have helped reduce youth psychopathology across multiple trials, promising to broaden access to effective, low-intensity supports. Online, self-guided SSIs may be uniquely scalable, particularly if they are freely available for as-needed use. However, the acceptability of online SSI and their efficacy have remained unexamined outside of controlled trials, and their practical utility is poorly understood.

OBJECTIVE

We evaluated the perceived acceptability and proximal effects of Project YES (Youth Empowerment & Support), an open-access platform offering three online SSIs for youth internalizing distress.

METHODS

After selecting one of three SSIs to complete, participants (ages 11-17 years) reported pre- and post-SSI levels of clinically relevant outcomes that SSIs may target (eg, hopelessness, self-hate) and perceived SSI acceptability. User-pattern variables, demographics, and depressive symptoms were collected to characterize youths engaging with YES.

RESULTS

From September 2019 through March 2020, 694 youths accessed YES, 539 began, and 187 completed a 30-minute, self-guided SSI. SSI completers reported clinically elevated depressive symptoms, on average, and were diverse on several dimensions (53.75% non-white; 78.10% female; 43.23% sexual minorities). Regardless of SSI selection, completers reported pre- to post-program reductions in hopelessness (dav=0.53; dz=0.71), self-hate (dav=0.32; dz=0.61), perceived control (dav=0.60; dz=0.72) and agency (dav=0.39; dz=0.50). Youths rated all SSIs as acceptable (eg, enjoyable, likely to help peers).

CONCLUSIONS

Results support the perceived acceptability and utility of open-access, free-of-charge SSIs for youth experiencing internalizing distress.

TRIAL REGISTRATION

Open Science Framework; osf.io/e52p3.