Opportunities for Early Identification: Implementing Universal Depression Screening with a Pathway to Suicide Risk Screening in a Pediatric Health Care System

Cluster randomized trial of a team communication training implementation strategy for depression screening in a pediatric healthcare system: a study protocol

BACKGROUND

Pediatric depression is a global concern that has fueled efforts for enhanced detection and treatment engagement. As one example, the US Preventive Services Task Force recommends depression screening for adolescents ages 12-18 years. While many health systems have implemented components of depression screening protocols, there is limited evidence of effective follow-up for pediatric depression. A key barrier is timely team communication and coordination across clinicians and staff within and across service areas for prompt service linkage. However, team effectiveness interventions have been shown to improve team processes and outcomes and can be applied in healthcare settings.

METHODS

This project aims to refine and test a team communication training implementation strategy to improve implementation of an existing pediatric depression screening protocol in a large pediatric healthcare system. The team will be defined as part of the study but is expected to include medical assistants, nurses, physicians, and behavioral health clinicians within and across departments. The implementation strategy will target team mechanisms at the team-level (i.e., intra-organizational alignment and implementation climate) and team member-level (i.e., communication, coordination, psychological safety, and shared cognition). First, the project will use mixed methods to refine the team training strategy to fit the organizational context and workflows. Next, a hybrid type 3 implementation-effectiveness pilot trial will assess the initial effectiveness of the team communication training (implementation strategy) paired with the current universal depression screening protocol (clinical intervention) on implementation outcomes (i.e., feasibility, acceptability, appropriateness, workflow efficiency) and clinical/services outcomes (increased frequency of needed screening and reduced time to service linkage). Finally, the study will assess mechanisms at the team and team member levels that may affect implementation outcomes.

DISCUSSION

Team communication training is hypothesized to lead to improved, efficient, and effective decision-making to increase the compliance with depression screening and timely service linkage. Findings are expected to yield better understanding and examples of how to optimize team communication to improve efficiency and effectiveness in the pediatric depression screening-to-treatment cascade. This should also culminate in improved implementation outcomes including patient engagement critical to address the youth mental health crisis.

TRIAL REGISTRATION

NCT06527196. Trial Sponsor: University of California San Diego.

Columbia-Suicide Severity Rating Scale (C-SSRS) Reveals High Rates of Suicidality in 602 Patients With Cleft and Craniofacial Conditions

INTRODUCTION

Little is known about rates of suicidal ideation and behavior among youth with cleft lip and/or palate (CLP) and other craniofacial conditions.

METHODS

Records of patients ages 6 and older who were administered the Columbia-Suicide Severity Rating Scale (C-SSRS) Lifetime Version during routine multidisciplinary cleft or craniofacial team visits between 2019 and 2023 were examined. Demographics information, C-SSRS data, and diagnoses were assessed with statistics including t tests, the Fisher exact test, and odds ratios.

RESULTS

A total of 1140 C-SSRS questionnaires across 602 (433 CLP and 169 craniofacial) patients with an average age of 11.2±3.7 years were included. Eighty-four (13.6%) patients endorsed lifetime suicidal ideation, 9 (1.5%) had at least one instance of suicidal behavior, 30 (5.0%) endorsed nonsuicidal self-injury, and 2 (0.3%) engaged in self-injurious behavior. Compared with CLP, those with other craniofacial conditions had similar odds of endorsing suicidal ideation and behavior ( P ≥0.05). Compared with those with isolated cleft palates, CLP had greater odds of endorsing suicidal ideation and behavior, though those differences were not significant ( P ≥0.05). Incidence of suicidality was unchanged before, during, and after the COVID-19 pandemic ( P ≥0.05). Dividing patients by sex or insurance type revealed no difference in suicidality ( P ≥0.05).

CONCLUSION

Patients with CLP and craniofacial conditions have a high incidence of suicidal ideation and behavior, though levels are similar between these groups. Suicidality in these patients was not negatively impacted by the COVID-19 pandemic. Early identification of safety risks and psychosocial challenges through regular screening can facilitate connection with appropriate clinical interventions.

Adolescent Depression Symptom Trajectories Detected Via Universal Screening in Pediatric Primary Care

Unique trajectories of adolescent depression symptoms have been identified, yet less is known about whether such patterns translate to real-world clinical settings. Because annual adolescent depression screening is becoming more prevalent in primary care, we examined whether longitudinal patterns of depression symptoms documented in the developmental psychopathology literature can also be detected via routine screening in primary care and explored how membership in the identified trajectories varied based on concurrent suicide risk and sociodemographic factors. A total of 1,359 adolescents aged 12-16 years old at the first timepoint were included in the current analyses. These adolescents completed three depression screeners during their well-visits in a large pediatric primary care network between November 15, 2017 and February 1, 2020. Retrospective electronic health record data were extracted, including sociodemographic variables and depression screening results. Dynamic functional time series clustering results indicated the optimal number of clusters was five. The five depression symptom trajectories were: (1) A-Shaped (i.e., relatively low depression symptoms at Time 1, a substantial increase in symptoms at Time 2, and a return to low symptoms at Time 3), (2) Increasing, (3) Low-Stable, (4) High-Decreasing, and (5) Low-Decreasing. Cluster differences in suicide risk largely mapped onto depression symptom levels at each assessment. We found cluster differences based on practice location, insurance type, and adolescent race. The symptom trajectories observed in this study resemble those found in the developmental psychopathology literature, though some key differences were noted. Findings can inform future research and symptom monitoring in primary care.

Measurement Choices for Youth Suicidality

Suicide is among the leading causes of death among individuals ages 10-24, making suicidal thoughts and behaviors (STBs) a serious public health crisis among youth. Suicide risk screening and assessment are vital to addressing this public health crisis. In fact, many youths that screen positive for suicidal ideation do not have known mental health concerns and would have been missed if not asked directly. Medical settings are an optimal setting to detect suicidality early and provide appropriate follow-up monitoring and care as needed. To support effective and efficient screening and assessment of suicidal thoughts and behaviors, providers must choose measures with both strong psychometric properties and clinical utility. While measurement of STBs can vary across health settings, suicide risk screening and assessment typically involves gathering information about current suicidal ideation, suicidal behaviors, and suicidal plans via self-report questionnaires, clinical interviews, and/or computerized adaptive screens. In alignment with measurement-based care efforts, the current manuscript will provide a scoping review of measures of youth suicidal ideation, behavior, plans, and their risk factors. Specifically, the psychometric properties, clinical utility, and other key considerations for screening and assessment of adolescent suicide risk are discussed.

Risk of suicide in children and adolescents in the emergency department-is universal screening the answer?

OBJECTIVE

Suicide is a leading cause of death among children and adolescents. Suicide risk screening tools can detect the risk of suicide among patients presenting to healthcare settings. The aim of this review was to describe the effectiveness of universal suicide risk screening (all patients) compared with selective screening (behavioural health patients only) in children and adolescents in emergency departments (EDs).

METHOD

A literature search was conducted on PubMed for articles related to suicide risk screening in paediatric EDs between January 2016 and February 2022.

RESULTS

8 studies met the selection criteria. The review showed that 46%-93% of patients that screened positive for suicide risk had presented with a medical concern. These patients would have been missed without universal suicide risk screening. In both selective and universal screening scenarios, use of a suicide risk screening tool was better at detecting suicide risk compared with use of presenting problem alone. Suicide risk screening was found to be acceptable without increasing length of stay in the ED.

CONCLUSION

Based on this review, using a suicide screening tool can help detect patients at risk who would otherwise have been missed.

Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study

BACKGROUND

To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting.

METHOD

Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed.

RESULTS

Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14).

LIMITATIONS

Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings.

CONCLUSIONS

To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.

Assessing Suicide Risk in a Pediatric Outpatient Behavioral Health System: A Quality Improvement Report

Introduction

Standardized suicide risk assessment improves the detection of individuals at risk of suicide. We conducted a quality improvement initiative in a system of outpatient behavioral health practices affiliated with a free-standing children's hospital to implement standardized suicide risk assessment for new patients.

Methods

Clinicians received education in suicide risk assessment and were trained to use an evidence-based suicide risk assessment tool, the Columbia Suicide Severity Rating Scale (C-SSRS). We standardized workflow processes and integrated the C-SSRS in the electronic health record with a feature to communicate instances of elevated risk across care teams through a problem list. We analyzed C-SSRS responses and adherence to standardized processes and compared the percentage of patients with a suicide-related item on the problem list before and after implementation. We assessed clinician knowledge through a survey. All patients with identified suicide risk received treatment to reduce their risk of suicide in the context of usual care.

Results

For 3,972 new patient visits occurring postimplementation (November 2016-December 2018), the average monthly adherence to the standardized process was 97.7%. The mean monthly incidence of nonspecific active suicidal thoughts was 16%, aborted suicide attempts were 2%, and actual suicide attempts were 3%. The mean monthly incidence of a suicide-related item documented on the problem list was 5.66% in the postimplementation period compared with 1.47% in the 1-year preimplementation. Clinicians demonstrated statistically significant increases in knowledge about suicide risk factors and assessment.

Conclusions

Standardization of suicide risk assessment processes improved detection and documentation of suicide risk in a pediatric outpatient behavioral health setting.

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.

Suicide Screening Tools for Pediatric Emergency Department Patients: A Systematic Review

BACKGROUND

According to the Centers for Disease Control and Prevention, suicidality and suicidal behavior among youth continues to increase significantly each year. Many of those who die by suicide interact with health services in the year before death. This systematic review sought to identify and describe empirically tested screening tools for suicidality in youth presenting to Emergency Departments (ED).

OBJECTIVE

(1) To identify and compare existing tools used to screen for suicidality in children and adolescents who present to the ED and (2) to ascertain the prevalence of suicidality in pediatric populations found with these tools.

METHODS

We searched Ovid Medline, CINAHL, Scopus, and Cochrane databases for primary research studies that identified and evaluated screening tools for suicide risk in pediatric ED patients. A total of 7,597 publications published before August 25, 2021 met search criteria and were screened by two independent reviewers based on our inclusion and exclusion criteria, with any conflicts resolved via consensus meetings or an independent reviewer. A total of 110 papers were selected for full text review, of which 67 were excluded upon further inspection. Covidence was used to extract and synthesize results.

RESULTS

43 articles were eligible for inclusion. Most studies (n = 33) took place in general pediatric EDs; the quality was generally high. Patients ranged from 4-24 years old, with most screening tested in patients 12 years and older. The most researched tools were the Ask-Suicide Screening Questions (ASQ) (n = 15), Columbia-Suicide Severity Rating Scale (C-SSRS) (n = 12), Suicidal Ideation Questionnaire (SIQ) (n = 11), and the Risk of Suicide Questionnaire (RSQ) (n = 7). Where screening was applied to all patients, about one-fifth of pediatric ED patients screened positive; where suicide screening was applied to psychiatric patients only, over half screened positive. Positive screens were more likely to be female and older than negative screens and they were more likely to be assessed and admitted.

CONCLUSION

Several validated screening tools exist for the purpose of screening pediatric populations in EDs for suicidality. Such tools may help to support early detection and appropriate intervention for youth at risk of suicide.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=276328, identifier: 276328.