1
|
Kelleher KJ, Gardner W, Kemper AR, Chavez L, Pajer K, Rosic T. Principles for Primary Care Screening in the Context of Population Health. Acad Pediatr 2024; 24:719-727. [PMID: 38458490 DOI: 10.1016/j.acap.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/16/2023] [Accepted: 02/29/2024] [Indexed: 03/10/2024]
Abstract
A key component of primary care pediatrics is health promotion through screening: applying a test or procedure to detect a previously unrecognized disease or disease risk. How do we decide whether to screen? In 1965, Wilson and Jungner published an influential set of screening principles focused on the health problem's importance, the screening tool's performance, and the evidence for treatment efficacy. However, if we want realistic estimates of the population effects of routine screening, we must also account for the health care system's real-world functioning and disparities in care. We offer revised principles to guide discussions about routine screening in the primary care setting. We add to Wilson and Jungner's principles: 1. A focus on life course epidemiology and its consequences for population health, 2. A need to screen for the early stages of chronic health problems, 3. A concern for screening's acceptability to providers and the community, 4. A recommendation for estimating the uncertainty in benefits and harms in evaluating screening, 5. Inclusion of systematic plans for population data collection and monitoring, and 6. Recognition that achieving population health improvement requires a high-performing system with sufficient throughput and monitoring to deliver accessible, affordable, and effective care, especially for the groups experiencing the greatest inequities in access. Above all, instead of assuming best practices in treatment delivery and monitoring after screening, we argue for realism about the health care system functioning in routine practice.
Collapse
Affiliation(s)
- Kelly J Kelleher
- Department of Pediatrics (KJ Kelleher), The Ohio State University, and The Abigail Wexner Research Institute Nationwide Children's Hospital, Columbus, Ohio.
| | - William Gardner
- School of Epidemiology and Public Health and CHEO Research Institute (W Gardner), Ottawa, Ontario, Canada
| | - Alex R Kemper
- Department of Pediatrics (AR Kemper and L Chavez), The Ohio State University, and The Abigail Wexner Research Institute Nationwide Children's Hospital, Columbus, Ohio
| | - Laura Chavez
- Department of Pediatrics (AR Kemper and L Chavez), The Ohio State University, and The Abigail Wexner Research Institute Nationwide Children's Hospital, Columbus, Ohio
| | - Kathleen Pajer
- Department of Psychiatry (K Pajer), University of Ottawa, and CHEO Research Institute, Ottawa, Ontario, Canada
| | - Tea Rosic
- Department of Health Research Methodology, Children's Hospital of Eastern Ontario (T Rosic), Ottawa, Ontario, Canada
| |
Collapse
|
2
|
Sarakbi D, Groll D, Tranmer J, Kessler R, Sears K. Supporting Quality Integrated Care for Adolescent Depression in Primary Care: A Learning System Approach. Int J Integr Care 2024; 24:6. [PMID: 38312480 PMCID: PMC10836164 DOI: 10.5334/ijic.7685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024] Open
Abstract
Background Quality integrated care, which involves primary care and mental health clinicians working together, can help identify and treat adolescent depression early. We explored systemic barriers to quality integrated care at the provincial level in Ontario, Canada using a learning system approach. Methods Two Ontario Health Teams (OHTs), regional networks designed to support integrated care, completed the Practice Integration Profile (PIP) and participated in focus groups. Results The OHTs had a median PIP score of 69 out of 100. Among the PIP domains, the lowest median score was case identification (50), and the highest one was workspace (100). The focus groups generated 180 statements mapped to the PIP domains. Workflow had the highest number of coded statements (59, 32.8%). Discussion While the primary care practices included mental health clinicians on-site, the findings highlighted systemic barriers with adhering to the integrated care pathway for adolescent depression. These include limited access to mental health expertise for assessment and diagnosis, long wait times for treatment, and shortages of clinicians trained in evidence-based behavioral therapies. These challenges contributed to the reliance on antidepressants as the first line of treatment due to their accessibility rather than evidence-based guidelines. Conclusion Primary care practices, within regional networks such as OHTs, can form learning systems to continuously identify the strategies needed to support quality integrated care for adolescent depression based on real-world data.
Collapse
Affiliation(s)
- Diana Sarakbi
- Health Quality Programs, Queen’s University, Ontario, Canada
| | - Dianne Groll
- Department of Psychiatry and Psychology, Queen’s University, Ontario, Canada
| | - Joan Tranmer
- School of Nursing and Department of Public Health Sciences, Queen’s University, Ontario, Canada
| | - Rodger Kessler
- Department of Family Medicine, University of Colorado, Colorado, United States
| | - Kim Sears
- School of Nursing and Health Quality Programs, Queen’s University, Ontario, Canada
| |
Collapse
|
3
|
Hutchinson T, Riddleston L, Pile V, Meehan A, Shukla M, Lau J. Is Future Mental Imagery Associated with Reduced Impact of the COVID-19 Pandemic on Negative Affect and Anhedonic Symptoms in Young People? COGNITIVE THERAPY AND RESEARCH 2023; 47:168-180. [PMID: 36779180 PMCID: PMC9899113 DOI: 10.1007/s10608-023-10352-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 02/05/2023]
Abstract
Background Difficulties with prospective mental images are associated with adolescent depression. Current treatments mainly focus on verbal techniques to reduce negative affect (e.g. low mood) rather than enhancing positive affect, despite anhedonia being present in adolescents. We investigated the concurrent relationships between the vividness of negative and positive prospective mental imagery and negative affect and positive affect; and examined whether negative and positive prospective mental imagery moderated the impact of recent stress (COVID-19-linked stress) on negative and positive affect. Methods 2602 young people (12-25 years) completed the Prospective Imagery Task and self-reported on symptoms of negative affect, anhedonia and COVID-19 linked stress. Results Elevated vividness of negative future mental imagery and reduced vividness of positive future mental imagery were associated with increased negative affect, whereas only reduced vividness of positive future imagery was associated with increased symptoms of anhedonia. Elevated vividness of negative future images amplified the association between COVID-19 linked stress and negative affect, while elevated vividness of positive future images attenuated the association between COVID-19 linked stress and anhedonia. Conclusions Future mental imagery may be differentially associated with negative and positive affect, but this needs to be replicated in clinical populations to support novel adolescent psychological treatments. Supplementary Information The online version contains supplementary material available at 10.1007/s10608-023-10352-1.
Collapse
Affiliation(s)
- Taryn Hutchinson
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Laura Riddleston
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Victoria Pile
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alan Meehan
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Meenakshi Shukla
- Department of Psychology, University of Allahabad, Prayagraj, India
| | - Jennifer Lau
- Youth Resilience Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| |
Collapse
|
4
|
Parhiala P, Marttunen M, Gergov V, Torppa M, Ranta K. Predictors of outcome after a time-limited psychosocial intervention for adolescent depression. Front Psychol 2022; 13:955261. [DOI: 10.3389/fpsyg.2022.955261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Research on the predictors of outcome for early, community-based, and time-limited interventions targeted for clinical depression in adolescents is still scarce. We examined the role of demographic, psychosocial, and clinical variables as predictors of outcome in a trial conducted in Finnish school health and welfare services to identify factors associating to symptom reduction and remission after a brief depression treatment. A total of 55 12–16-year-olds with mild to moderate depression received six sessions of either interpersonal counseling for adolescents (IPC-A) or brief psychosocial support (BPS). Both interventions resulted in clinical improvement at end of treatment and 3- and 6-month follow-ups. Main outcome measures were self-rated BDI-21 and clinician-rated Adolescent Depression Rating Scale (ADRSc). Latent change score (LCS) models were used to identify predictors of change in depressive symptom scores and clinical remission at end of treatment and 3- and 6-month follow-ups over the combined brief intervention group. Symptom improvement was predicted by younger age and having a close relationship with parents. Both symptom improvement and clinical remission were predicted by male gender, not having comorbid anxiety disorder, and not having sleep difficulties. Our results add to knowledge on factors associating with good treatment outcome after a brief community intervention for adolescent depression. Brief depression interventions may be useful and feasible especially for treatment of mild and moderate depression among younger adolescents and boys, on the other hand clinicians may need to cautiously examine sleep problems and anxiety comorbidity as markers of the need for longer treatment.
Collapse
|
5
|
Falek I, Acri M, Dominguez J, Havens J, McCord M, Sisco S, Wilcox W, Hoagwood K. Management of depression during the perinatal period: state of the evidence. Int J Ment Health Syst 2022; 16:21. [PMID: 35468808 PMCID: PMC9036756 DOI: 10.1186/s13033-022-00531-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perinatal depression (PND) is a prevalent ailment that affects both the woman and her family. Addressing PND in primary health care, such as pediatrics and obstetric care settings, has been proposed as an effective way to identify and treat women. OBJECTIVE The purpose of this study is to examine best practices for management of PND in obstetric and pediatric settings, as well as investigate the evidence that supports the guidelines. METHODS Guidelines were identified through a literature search and discussion with experts in the field of perinatal depression, while evidence was examined through a literature search of reviews and thereafter experimental studies. RESULTS Twenty-five guidelines, across 17 organizations were retained for analysis. Findings suggest that there is little or varied guidance on the management of PND, as well as a lack of specificity. Treatment was the topic most frequently reported, followed by screening. However best practices vary greatly and often contradict one another. Across all areas, there is inadequate or contrasting evidence to support these guidelines. CONCLUSIONS Although there was consensus on the key steps in the pathway to care, the review revealed lack of consensus across guidelines on specific issues relating to identification and management of depression during the perinatal period. Clinicians may use these recommendations to guide their practice, but they should be aware of the limitations of the evidence supporting these guidelines and remain alert to new evidence. There is a clear need for researchers and policymakers to prioritize this area in order to develop evidence-based guidelines for managing perinatal depression.
Collapse
Affiliation(s)
- Idan Falek
- Department of Child & Adolescent Psychiatry, NYU School of Medicine, One Park Avenue, 7th Floor, New York, NY, 10016, USA.
| | - Mary Acri
- Department of Child & Adolescent Psychiatry, NYU School of Medicine, One Park Avenue, 7th Floor, New York, NY, 10016, USA
| | - Joanna Dominguez
- Department of Child & Adolescent Psychiatry, NYU School of Medicine, One Park Avenue, 7th Floor, New York, NY, 10016, USA
| | - Jennifer Havens
- Department of Child & Adolescent Psychiatry, NYU School of Medicine, One Park Avenue, 7th Floor, New York, NY, 10016, USA
| | - Mary McCord
- New York City Health and Hospitals Corporation, 55 Water St., New York, NY, 10041, USA
| | - Sarah Sisco
- New York City Health and Hospitals Corporation, 55 Water St., New York, NY, 10041, USA
| | - Wendy Wilcox
- New York City Health and Hospitals Corporation, 55 Water St., New York, NY, 10041, USA
| | - Kimberly Hoagwood
- Department of Child & Adolescent Psychiatry, NYU School of Medicine, One Park Avenue, 7th Floor, New York, NY, 10016, USA
| |
Collapse
|
6
|
Improving Primary Care Adolescent Depression Screening and Initial Management: A Quality Improvement Study. Pediatr Qual Saf 2022; 7:e549. [PMID: 35369419 PMCID: PMC8970087 DOI: 10.1097/pq9.0000000000000549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022] Open
Abstract
Although recommended, adolescent depression screening with appropriate initial management is challenging. This project aimed to improve adolescent depression screening rates during preventive care visits in 12 primary care clinics from 65.4% to 80%, increase the proportion of documented initial management for those with a positive screen from 69.5% to 85%, then sustain improvements for 12 months.
Collapse
|
7
|
Harper A, Brewer TL. A homeschool-based cognitive behavioral program to improve adolescent mental health. JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2021; 35:179-188. [PMID: 34951077 DOI: 10.1111/jcap.12364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/01/2021] [Accepted: 12/12/2021] [Indexed: 11/30/2022]
Abstract
PROBLEM Anxiety and depression are prevalent in the adolescent population and can have significant consequences. Treatment recommendations are established but rates of utilization remain low, often due to a lack of access to mental health providers. Availability of mental health services in a school-based setting may increase access, but homeschooled children do not have access to these services. Additionally, the COVID-19 pandemic has increased the number of homeschooled children and compounded the problem of adolescent mental health disorders. METHODS This pilot evidence-based practice project aimed to increase access to cognitive behavioral therapy (CBT) in adolescents. Eight students from a local homeschool cooperative participated in the Creating Opportunities for Personal Empowerment (COPE) program. A Friedman test was used to evaluate median differences on anxiety and depression screening instruments at baseline, program completion, and 1 month after the program. Students also completed an adapted COPE program evaluation. RESULTS Median scores on screening instruments decreased from pre-COPE to 1 month after, although results were not statistically significant. Students reported that the COPE program was helpful, and they learned new ways to deal with their thoughts, feelings, and behaviors. CONCLUSION COPE is a feasible option to increase access to CBT in a homeschool setting.
Collapse
Affiliation(s)
- Amanda Harper
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| | - Tracy L Brewer
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| |
Collapse
|
8
|
Luccarelli J, McCoy TH, Uchida M, Green A, Seiner SJ, Henry ME. The Efficacy and Cognitive Effects of Acute Course Electroconvulsive Therapy Are Equal in Adolescents, Transitional Age Youth, and Young Adults. J Child Adolesc Psychopharmacol 2021; 31:538-544. [PMID: 34619038 PMCID: PMC8669295 DOI: 10.1089/cap.2021.0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective: Electroconvulsive therapy (ECT) is the most effective acute treatment for depression, but its use in younger patients is rare and heavily regulated in many U.S. states. It is unclear whether age modifies treatment response or tolerability in adolescents, transitional age youth, and young adults. We examined the effects of ECT on depression and cognition in patients aged 16-30 years. Methods: A retrospective cohort study of patients aged 16-30 years receiving ECT between 2011 and 2020 who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and following treatment #10. Results: Among the 424 patients who met the inclusion criteria, ECT was associated with a decrease in depression symptoms (ΔQIDS -6.7; Kruskal-Wallis rank sum test; χ2 = 293.37; df = 2; p < 0.0001) and improvement in overall self-reported mental health status (ΔBASIS-24 - 0.70; Kruskal-Wallis rank sum test; χ2 = 258.5; df = 2; p < 0.0001) during the first 10 treatments, with a slight reduction in cognition as measured by the MoCA (ΔMoCA -1.1; Kruskal-Wallis rank sum test; χ2 = 33.7; df = 1; p < 0.0001). Age was not a significant predictor of QIDS, BASIS-24, or MoCA changes. Conclusions: Among 424 patients aged 16-30 years receiving acute course ECT, age was not a significant predictor of improvement in depression, change in overall self-reported mental health status, or change in cognition. These results support the utility of ECT in the treatment of adolescents and young adults.
Collapse
Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Address correspondence to: James Luccarelli, MD, DPhil, Department of Psychiatry, Massachusetts General Hospital, 32 Fruit Street, Yawkey 6A, Boston, MA 02114, USA
| | - Thomas H. McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Mai Uchida
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Green
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephen J. Seiner
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael E. Henry
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Ballard PJ, Daniel SS, Anderson G, Nicolotti L, Caballero Quinones E, Lee M, Koehler AN. Incorporating Volunteering Into Treatment for Depression Among Adolescents: Developmental and Clinical Considerations. Front Psychol 2021; 12:642910. [PMID: 34025511 PMCID: PMC8131855 DOI: 10.3389/fpsyg.2021.642910] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Volunteering, or taking part in unpaid work for the benefit of others, can be a powerful positive experience with returns to both individual well-being and community projects. Volunteering is positively associated with mental health in observational studies with community samples but has not been systematically examined as a potential part of treatment interventions with clinical adolescent samples. In this manuscript, we review the empirical evidence base connecting volunteerism to mental health and well-being, outline potential mechanisms based in the theoretical literature from developmental science, and discuss the existing clinical approaches that support community volunteering as a part of treatment. Drawing on this review, we propose that including volunteering as a component of clinical treatment approaches for adolescent depression can be a powerful intervention for adolescents.
Collapse
Affiliation(s)
- Parissa J Ballard
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Stephanie S Daniel
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Grace Anderson
- Department of Psychology, Wake Forest University, Winston-Salem, NC, United States
| | - Linda Nicolotti
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | | | - Min Lee
- Department of Psychiatry, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Aubry N Koehler
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| |
Collapse
|
10
|
Holcomb JM, Arauz Boudreau A, Riobueno-Naylor A, Haile H, Lucke CM, Bergmann P, Joseph B, Jellinek M, Murphy JM. Beyond Initial Screening: One-Year Follow-up of Adolescents with Internalizing Problems on the Pediatric Symptom Checklist. J Dev Behav Pediatr 2021; 42:283-290. [PMID: 33908902 DOI: 10.1097/dbp.0000000000000890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/01/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Screening for adolescent depression is a quality indicator for pediatric care, and the parent-completed, 17-item Pediatric Symptom Checklist's internalizing (PSC-17P-INT) subscale has been validated for this purpose. The current study assessed the feasibility of PSC-17P-INT screening, the prevalence of risk on 2 consecutive PSC-17P-INTs, and rates of behavioral health (BH) service use before and after screening. METHODS The parent-report PSC-17 was completed on tablet devices before well-child visits (WCVs) with results instantaneously available to clinicians in the electronic health record. Billing data were used to identify adolescents with 2 consecutive WCVs and possible BH service utilization 6 months before and after their first screen. RESULTS In 2017, 1,068 adolescents (12-17 years old) were seen for a WCV, and 637 (59.6%) of them had one in 2018. Most (93.9%; N = 604) completed a PSC at both visits. Patients who scored positively on their first PSC-17P-INT were about 9 times more likely to receive subsequent BH services than patients who screened negative (24.3% vs 2.6%, χ2 = 59.65, p < 0.001). However, risk prevalence increased from the first (11.6%) to the second (14.9%) screen, and only 37.1% of at-risk patients remitted. CONCLUSION The current study demonstrated that screening adolescents for depression using the PSC-17P-INT was feasible and associated with a significant increase in BH treatment rates. The study also demonstrated that the PSC could be used to track adolescents at risk for depression, found that most youth who screened positive remained at risk 1 year later, and supported recent quality guidelines calling for annual depression screening and follow-up for adolescents with depression.
Collapse
Affiliation(s)
| | - Alexy Arauz Boudreau
- Pediatrics, Massachusetts General Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Haregnesh Haile
- Department of Psychology, The Catholic University of America, Washington, DC
| | - Cara M Lucke
- Institute of Child Development, University of Minnesota, Twin Cities, MN
| | | | | | - Michael Jellinek
- Departments of Psychiatry
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - J Michael Murphy
- Departments of Psychiatry
- Department of Psychiatry, Harvard Medical School, Boston, MA
| |
Collapse
|
11
|
Abstract
OBJECTIVE Primary care has been promoted as a setting to identify and manage adolescent depression. This study examined primary care-based adolescent depression identification and follow-up care when elevated symptoms were identified. METHODS Data came from a large pediatric care network with an organizational recommendation to screen for depression at age 16 well-visits using an electronic health record (EHR)-integrated standardized measure. Analyses examined rates of screening and elevated symptoms, pediatricians' initial responses to elevated scores, and types of follow-up care received over 1 year using retrospective EHR data extraction and manual chart reviews. RESULTS Across program sites, 76.3% (n = 6981) of patients attending their age 16 well-visits were screened. About one-quarter had an elevated score (19.2% mild and 6.7% moderate-to-severe), many of whom received active follow-up on their well-visit date. Over 1 year, three-fourths of patients with scores in the moderate-to-severe range and 40.0% of patients with scores in the mild range received follow-up care (e.g., antidepressant prescriptions) as per EHR extraction. Follow-up rates were higher as per manual chart reviews. CONCLUSION Routine adolescent depression screening is feasible across diverse primary care sites. Most patients with elevated scores were not already receiving behavioral health services, suggesting screening identified previously undetected concerns. In turn, many adolescents with elevated scores initiated treatment after screening, which indicates providing screen results at the point of care may facilitate pediatrician actions. Still, gaps in follow-up care demonstrate the need for greater investment in primary care-based behavioral health services to support high-quality treatment and ultimately decrease the burden of adolescent depression.
Collapse
|
12
|
Cortés Rico O, Gallego Iborra A, García Aguado J, Pallás Alonso CR, Rando Diego Á, San Miguel Muñoz MJ, Sánchez Ruiz-Cabello FJ, Colomer Revuelta J, Esparza Olcina MJ, Galbe Sánchez-Ventura J, Mengual Gil JM. [Childhood and adolescence PAPPS summary 2020]. Aten Primaria 2020; 52 Suppl 2:149-160. [PMID: 33388113 PMCID: PMC7801204 DOI: 10.1016/j.aprim.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 08/18/2020] [Indexed: 11/25/2022] Open
Abstract
Four important topics about children and adolescents in our Primary Care activity are presented in this update document: support for breastfeeding, promotion of physical activity, prevention of child injuries due to traffic accidents, and screening for major depression.
Collapse
Affiliation(s)
- Olga Cortés Rico
- Centro de Salud Delicias Sur, Servicio Aragonés de Salud, Zaragoza, España.
| | - Ana Gallego Iborra
- Centro de Salud Delicias Sur, Servicio Aragonés de Salud, Zaragoza, España
| | | | | | - Álvaro Rando Diego
- Centro de Salud Delicias Sur, Servicio Aragonés de Salud, Zaragoza, España
| | | | | | | | | | | | - José M Mengual Gil
- Centro de Salud Delicias Sur, Servicio Aragonés de Salud, Zaragoza, España
| |
Collapse
|
13
|
Beirão D, Monte H, Amaral M, Longras A, Matos C, Villas-Boas F. Depression in adolescence: a review. MIDDLE EAST CURRENT PSYCHIATRY 2020. [DOI: 10.1186/s43045-020-00050-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Abstract
Background
Depression is a common mental health disease, especially in mid to late adolescence that, due to its particularities, is a challenge and requires an effective diagnosis. Primary care providers are often the first line of contact for adolescents, being crucial in identifying and managing this pathology. Besides, several entities also recommend screening for depression on this period. Thus, the main purpose of this article is to review the scientific data regarding screening, diagnosis and management of depression in adolescence, mainly on primary care settings.
Main body
Comprehension of the pathogenesis of depression in adolescents is a challenging task, with both environmental and genetic factors being associated to its development. Although there are some screening tests and diagnostic criteria, its clinical manifestations are wide, making its diagnosis a huge challenge. Besides, it can be mistakenly diagnosed with other psychiatric disorders, making necessary to roll-out several differential diagnoses. Treatment options can include psychotherapy (cognitive behavioural therapy and interpersonal therapy) and/or pharmacotherapy (mainly fluoxetine), depending on severity, associated risk factors and available resources. In any case, treatment must include psychoeducation, supportive approach and family involvement. Preventive programs play an important role not only in reducing the prevalence of this condition but also in improving the health of populations.
Conclusion
Depression in adolescence is a relevant condition to the medical community, due to its uncertain clinical course and underdiagnosis worldwide. General practitioners can provide early identification, treatment initiation and referral to mental health specialists when necessary.
Collapse
|
14
|
Abright AR, Grudnikoff E. Measurement-Based Care in the Treatment of Adolescent Depression. Child Adolesc Psychiatr Clin N Am 2020; 29:631-643. [PMID: 32891366 DOI: 10.1016/j.chc.2020.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Measurement-based care is a helpful adjunct to clinical assessment in improving outcomes in depression in adults and adolescents. Measurement-based care principles are incorporated in current regulatory requirements for use of standardized instruments in efforts to improve care and prevent suicide. Challenges for child and adolescent psychiatrists and other clinicians in implementing measurement-based care include concerns about time and expense involved in administration and interpretation of results from rating scales and other instruments. Implementation can be facilitated by selection of instruments that are brief, easy to administer and score, compatible with electronic health record systems, and available in the public domain.
Collapse
Affiliation(s)
- Arthur Reese Abright
- New York City Health + Hospitals/Elmhurst, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, NY 11373, USA.
| | - Eugene Grudnikoff
- New York City Health + Hospitals/Elmhurst, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, NY 11373, USA; South Oaks Hospital, 400 Sunrise Highway, Amityville, NY 11701, USA
| |
Collapse
|
15
|
Kelleher KJ, Rubin D, Hoagwood K. Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children. Psychiatr Serv 2020; 71:706-712. [PMID: 32188362 DOI: 10.1176/appi.ps.201900417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The cost, side effects, and unprecedented growth rate at which these drugs are prescribed have raised alarms from health care clinicians, patient advocates, and agencies about the appropriateness of how these drugs are distributed to parents and their children. This article examines current prescribing of three classes of psychoactive drugs-stimulants, antidepressants, and antipsychotics-and efforts to improve pediatric prescribing of these agents. Federal policy efforts to curb questionable prescribing of psychoactive medications to children have focused particularly on oversight of antipsychotic use among foster care children. The article reviews system-level interventions, including delivery system enhancements, which increase availability of alternatives to medication treatments, employ electronic medical record reminders, and increase cross-sector care coordination; clinician prescribing enhancements, which disseminate best-practice guidelines, create quality and learning collaboratives, and offer "second opinion" psychiatric consultations; and prescriber monitoring programs, which include retrospective review and prospective monitoring of physicians' prescribing to identify patterns suggestive of inappropriate prescribing. Potential interventions to deter inappropriate pediatric prescribing are briefly described, such as transparency in drug prices and incentives among insurers, public agencies, and pharmacy benefit managers; value-based purchasing, specifically value-based payment for medications; and preventive interventions, such as parent training.
Collapse
Affiliation(s)
- Kelly J Kelleher
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood)
| | - David Rubin
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood)
| | - Kimberly Hoagwood
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood)
| |
Collapse
|
16
|
Baum RA, Hoholik S, Maciejewski H, Ramtekkar U. Using Practice Facilitation to Improve Depression Management in Rural Pediatric Primary Care Practices. Pediatr Qual Saf 2020; 5:e295. [PMID: 32656464 PMCID: PMC7297391 DOI: 10.1097/pq9.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 03/31/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Depression is a common and serious mental health condition frequently encountered in pediatric primary care. Pediatricians report discomfort in managing depression due in part to limited training and limited access to mental health care, which is accentuated in rural areas. METHODS We developed an evidence-based, quality improvement project designed to help pediatricians increase screening and initial management of depression in the primary care setting. We recruited practices from a pediatric accountable care organization as part of a larger quality improvement portfolio that used a practice facilitation model to support practices with data collection and project management. Practitioners received training on quality improvement, depression screening, and a depression management plan (referred to as the depression management bundle). Practices completed Plan-Do-Study-Act cycles to improve their performance. RESULTS We recruited 4 practices in rural Ohio to participate. Screening increased from 0% to 81% within 6 months. All 4 practices measured documentation of the depression management bundle for patients diagnosed with depression. Composite data from these practices showed an increase in documentation from 59% to 86% by month 6. CONCLUSIONS This study provides preliminary support for the use of practice facilitation combined with skills training to increase screening and improve documentation of depression management in rural primary care practices, where specialty mental health resources may be limited. Further research is needed to determine if this approach can be successfully disseminated and if patient outcomes improved.
Collapse
Affiliation(s)
- Rebecca A. Baum
- From the Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Suzanne Hoholik
- From the Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Heather Maciejewski
- From the Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Ujjwal Ramtekkar
- From the Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| |
Collapse
|
17
|
Stafford AM, Garbuz T, Etter DJ, Adams ZW, Hulvershorn LA, Downs SM, Aalsma MC. The Natural Course of Adolescent Depression Treatment in the Primary Care Setting. J Pediatr Health Care 2020; 34:38-46. [PMID: 31548140 PMCID: PMC6910991 DOI: 10.1016/j.pedhc.2019.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Little is known about how adolescents receive depression follow-up in primary care. The purpose of this study was to describe the rates of symptom assessment and depression treatment over time in a group of adolescents screening positive for moderate or severe depression in the primary care setting. METHODS Retrospective chart reviews were conducted to gather information related to symptom reassessments, antidepressant prescriptions, psychotherapy referrals, and treatment discontinuation. Descriptive statistics were calculated, and a qualitative content analysis was conducted to determine the reasons for treatment discontinuation. RESULTS Eighty records were reviewed (mean age = 15.3, 73% female, 59% Black). Treatment was initiated for 83% (n = 66) of patients, and 45% (n = 30) of patients discontinued treatment during the review period for a variety of reasons. DISCUSSION To improve adolescents' adherence to depression treatment, providers should address factors that contribute to treatment discontinuation and use tools to manage depression follow-up care.
Collapse
|
18
|
Reid GJ, Stewart SL, Barwick M, Carter J, Leschied A, Neufeld RWJ, St Pierre J, Tobon JI, Vingilis E, Zaric GS. Predicting patterns of service utilization within children's mental health agencies. BMC Health Serv Res 2019; 19:993. [PMID: 31870372 PMCID: PMC6929287 DOI: 10.1186/s12913-019-4842-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 12/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Some children with mental health (MH) problems have been found to receive ongoing care, either continuously or episodically. We sought to replicate patterns of MH service use over extended time periods, and test predictors of these patterns. METHODS Latent class analyses were applied to 4 years of visit data from five MH agencies and nearly 6000 children, 4- to 13-years-old at their first visit. RESULTS Five patterns of service use were identified, replicating previous findings. Overall, 14% of cases had two or more episodes of care and 23% were involved for more than 2 years. Most children (53%) were seen for just a few visits within a few months. Two patterns represented cases with two or more episodes of care spanning multiple years. In the two remaining patterns, children tended to have just one episode of care, but the number of sessions and length of involvement varied. Using discriminant function analyses, we were able to predict with just over 50% accuracy children's pattern of service use. Severe externalizing behaviors, high impairment, and high family burden predicted service use patterns with long durations of involvement and frequent visits. CONCLUSIONS Optimal treatment approaches for children seen for repeated episodes of care or for care lasting multiple years need to be developed. Children with the highest level of need (severe pathology, impairment, and burden) are probably best served by providing high intensity services at the start of care.
Collapse
Affiliation(s)
- Graham J Reid
- Departments of Psychology, Family Medicine, and Paediatrics, The University of Western Ontario, Westminster Hall Room 319E, London, ON, N6A 3K7, Canada.
- Children's Health and Therapeutics, Children's Health Research Institute, London, Canada.
| | - Shannon L Stewart
- Children's Health and Therapeutics, Children's Health Research Institute, London, Canada
- Faculty of Education, The University of Western Ontario, London, Canada
| | - Melanie Barwick
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- The Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jeffrey Carter
- Quality Improvement, Vanier Children's Services, London, Canada
- Departments of Psychology and Psychiatry, The University of Western Ontario, London, Canada
| | - Alan Leschied
- Faculty of Education, The University of Western Ontario, London, Canada
| | - Richard W J Neufeld
- Departments of Psychology, Psychiatry, and Neuroscience, The University of Western Ontario, London, Canada
| | - Jeff St Pierre
- Departments of Psychology and Psychiatry, The University of Western Ontario, London, Canada
- Child and Parent Resource Institute, London, Canada
| | - Juliana I Tobon
- Department of Psychology, The University of Western Ontario, London, Canada
- St. Michael's Hospital Academic Family Health Team, Toronto, Canada
| | - Evelyn Vingilis
- Departments of Family Medicine and Epidemiology and Biostatistics, The University of Western Ontario, London, Canada
| | - Gregory S Zaric
- Ivey Business School, The University of Western Ontario, London, Canada
- Department of Epidemiology and Biostatistics, The University of Western Ontario, London, Canada
| |
Collapse
|
19
|
Stafford AM, Aalsma MC, Bigatti S, Oruche U, Draucker CB. Getting a Grip on My Depression: How Latina Adolescents Experience, Self-Manage, and Seek Treatment for Depressive Symptoms. QUALITATIVE HEALTH RESEARCH 2019; 29:1725-1738. [PMID: 30810095 PMCID: PMC6935425 DOI: 10.1177/1049732319831043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Latina (female) adolescents are more likely to experience depressive symptoms and less likely to receive mental health services than their non-Latina White peers. We aimed to develop a framework that explains how Latina adolescents experience, self-manage, and seek treatment for depressive symptoms. Latina young women (n = 25, M age = 16.8 years) who experienced depressive symptoms during adolescence were recruited from clinical and community settings and interviewed about experiences with depressive symptoms. The framework was developed using constructivist grounded theory methods. Participants experienced a psychosocial problem that we labeled being overburdened and becoming depressed. They responded to this problem through a five-phase psychosocial process that we labeled Getting a Grip on My Depression. Family members, peer groups, and mainstream authorities were influential in how participants experienced these phases. Future research should further develop this framework in diverse samples of Latino/a youth. Clinicians can use this framework in discussions with Latina adolescents about depressive symptoms.
Collapse
Affiliation(s)
| | - Matthew C Aalsma
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Silvia Bigatti
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Ukamaka Oruche
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | | |
Collapse
|
20
|
Stempel H, Cox-Martin MG, O'Leary S, Stein R, Allison MA. Students Seeking Mental Health Services at School-Based Health Centers: Characteristics and Utilization Patterns. THE JOURNAL OF SCHOOL HEALTH 2019; 89:839-846. [PMID: 31359431 DOI: 10.1111/josh.12823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 10/17/2018] [Accepted: 03/31/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND School-based health centers (SBHC) can address unmet mental health needs. Little is known about how students seek care from different providers at SBHCs. We describe and compare how students' SBHC visits differ for students seen by mental health providers (MH group) relative to students seen only by primary care providers (PC group). METHODS Using administrative data with ICD-9 codes from 9 SBHCs in Denver, Colorado serving youth 10-19 years old during the 2014-2015 school year, we analyzed predictors of SBHC clinic visits via negative binomial regression and ICD-9 codes for first visit to MH providers. RESULTS Mental health users (N = 516) had an average of 14.2 ± 12.9 SBHC visits and PC users (N = 4026) had an average of 2.6 ± 2.4 SBHC visits annually. Students in the MH group, those with public insurance, and females had a higher incidence rate ratio for SBHC clinic visits than PC group students, those with private insurance, and males respectively. Depression was the most common primary diagnosis for the first MH visit. CONCLUSIONS Students accessing MH services at SBHC return for follow up visits at higher rates than students only seeing PC providers. SBHCs represent a valuable opportunity to enhance integrated mental health services.
Collapse
Affiliation(s)
- Hilary Stempel
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Mail Stop F443, Aurora, CO, 80045
| | - Matthew G Cox-Martin
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 335, Mail Stop F443, Aurora, CO, 80045
| | - Sonja O'Leary
- Denver Health and Hospital, 601 Broadway, Mail Code 7779, Denver, CO, 80204
| | - Rachel Stein
- University of Colorado Denver, School of Education and Human Development, 1380 Laurence Street Room 1116, Denver, CO, 80204
| | - Mandy A Allison
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Mail Stop F443, Aurora, CO, 80045
| |
Collapse
|
21
|
Russell JK, Strodl E, Connolly J, Kavanagh DJ. A Metacognitive Intervention of Narrative Imagery for young people with cystic fibrosis: A feasibility study. J Health Psychol 2019; 26:1389-1403. [PMID: 31530184 DOI: 10.1177/1359105319876336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cystic fibrosis and its treatment can have substantial functional and emotional impacts on patients and their families. This feasibility study assessed a new cystic fibrosis treatment, Metacognitive Intervention of Narrative Imagery, integrating narrative and meta-cognitive therapies with mental imagery. A total of 13 patients, aged 10-17 years, received three 1-hour sessions and were assessed on emotional functioning, anxiety, and depression at baseline and 4 and 8 weeks post-baseline. Participants had significant improvements in anxiety, and changes in emotional functioning and anxiety had a medium effect size. Participants and parents rated Metacognitive Intervention of Narrative Imagery highly on usability and favourability. Further clinical trials are indicated.
Collapse
|
22
|
Gunlicks-Stoessel M, Mufson L, Bernstein G, Westervelt A, Reigstad K, Klimes-Dougan B, Cullen K, Murray A, Vock D. Critical Decision Points for Augmenting Interpersonal Psychotherapy for Depressed Adolescents: A Pilot Sequential Multiple Assignment Randomized Trial. J Am Acad Child Adolesc Psychiatry 2019; 58:80-91. [PMID: 30577943 PMCID: PMC7549148 DOI: 10.1016/j.jaac.2018.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/25/2018] [Accepted: 06/21/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Practice parameters recommend systematic assessment of depression symptoms over the course of treatment to inform treatment planning; however, there are currently no guidelines regarding how to use symptom monitoring to guide treatment decisions for psychotherapy. The current study compared two time points (week 4 and week 8) for assessing symptoms during interpersonal psychotherapy for depressed adolescents (IPT-A) and explored four algorithms that use the symptom assessments to select the subsequent treatment. METHOD Forty adolescents (aged 12-17 years) with a depression diagnosis began IPT-A with an initial treatment plan of 12 sessions delivered over 16 weeks. Adolescents were randomized to a week 4 or week 8 decision point for considering a change in treatment. Insufficient responders at either time point were randomized a second time to increased frequency of IPT-A (twice per week) or addition of fluoxetine. Measures were administered at baseline and weeks 4, 8, 12, and 16. RESULTS The week 4 decision point for assessing response and implementing treatment augmentation for insufficient responders was more efficacious for reducing depression symptoms than the week 8 decision point. There were significant differences between algorithms in depression and psychosocial functioning outcomes. CONCLUSION Therapists implementing IPT-A should routinely monitor depression symptoms and consider augmenting treatment for insufficient responders as early as week 4 of treatment. CLINICAL TRIAL REGISTRATION INFORMATION An Adaptive Treatment Strategy for Adolescent Depression. https://clinicaltrials.gov; NCT02017535.
Collapse
Affiliation(s)
| | - Laura Mufson
- Columbia University College of Physicians & Surgeons and New York State Psychiatric Institute, New York, NY
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Wilkinson PO, Cestaro V, Pinchen I. Pilot mixed-methods evaluation of interpersonal counselling for young people with depressive symptoms in non-specialist services. EVIDENCE-BASED MENTAL HEALTH 2018; 21:134-138. [PMID: 30352883 PMCID: PMC10270401 DOI: 10.1136/ebmental-2018-300028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/17/2018] [Accepted: 09/25/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND The majority of young people receive treatment for depressive symptoms in the UK from staff with minimal specialist mental health/therapeutic training. There is no evidence to guide them as to what treatments are likely to be effective. Interpersonal counselling (IPC) is a reduced form of interpersonal psychotherapy and may be an appropriate treatment to use in this population. OBJECTIVES To test the effectiveness and acceptability of IPC delivered by youth workers to young people with primarily depressive symptoms. METHODS Youth workers received a 2-day training course in IPC, followed by regular supervision. They delivered IPC to 23 young people who they would normally see in their service, with depressive symptoms as their main problem. Symptoms were assessed by the Revised Child Depression and Anxiety Scale (RCADS). Qualitative interviews of youth workers and young people assessed acceptability. FINDINGS Mean (SD) RCADS depression-T scores fell from 78.2 (11.1) to 52.9 (16.8). All young people and youth workers interviewed were positive about it. Participants detailed specific advantages of IPC above standard counselling, including practical help, the use of goals, psychoeducation and integrating a self-rated questionnaire into treatment. CONCLUSIONS AND CLINICAL IMPLICATIONS IPC is likely to be an effective and acceptable treatment for young people with primarily depressive symptoms seen in local authority non-specialist mental health services. Further research is needed to determine if it is more effective than current treatment as usual.
Collapse
Affiliation(s)
- Paul Oliver Wilkinson
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Children and Young People's Services, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Viktoria Cestaro
- Suffolk South Integrated Delivery Team, Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | | |
Collapse
|
24
|
Abstract
The increased prevalence of adolescent obesity and associated short-term and long-term complications emphasize the need for effective treatment. In this Review, we aim to describe the evidence for, and elements of, behaviour management and adjunctive therapies and highlight the opportunities and challenges presented by obesity management in adolescence. The broad principles of treatment include management of obesity-associated complications; a developmentally appropriate approach; long-term behaviour modification (dietary change, increased physical activity, decreased sedentary behaviours and improved sleep patterns); long-term weight maintenance strategies; and consideration of the use of pharmacotherapy, more intensive dietary therapies and bariatric surgery. Bariatric surgery should be considered in those with severe obesity and be undertaken by skilled bariatric surgeons affiliated with teams experienced in the medical and psychosocial management of adolescents. Adolescent obesity management strategies are more reliant on active participation than those for childhood obesity and should recognize the emerging autonomy of the patient. The challenges in adolescent obesity relate primarily to the often competing demands of developing autonomy and not yet having attained neurocognitive maturity.
Collapse
Affiliation(s)
- Katharine S Steinbeck
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Natalie B Lister
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Megan L Gow
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Louise A Baur
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.
- Weight Management Services, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
| |
Collapse
|
25
|
Zuckerbrot RA, Cheung A, Jensen PS, Stein RE, Laraque D, Levitt A, Birmaher B, Campo J, Clarke G, Emslie G, Kaufman M, Kelleher KJ, Kutcher S, Malus M, Sacks D, Waslick B, Sarvet B. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics 2018; 141:peds.2017-4081. [PMID: 29483200 DOI: 10.1542/peds.2017-4081] [Citation(s) in RCA: 240] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings. METHODS By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience. RESULTS Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan. CONCLUSIONS This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.
Collapse
Affiliation(s)
- Rachel A. Zuckerbrot
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University Medical Center, and New York State Psychiatric Institute, New York, New York
| | | | - Peter S. Jensen
- University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Ruth E.K. Stein
- Albert Einstein College of Medicine, Bronx, New York, New York; and
| | - Danielle Laraque
- State University of New York Upstate Medical University, Syracuse, New York
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein RE, Levitt A, Birmaher B, Campo J, Clarke G, Emslie G, Kaufman M, Kelleher KJ, Kutcher S, Malus M, Sacks D, Waslick B, Sarvet B. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management. Pediatrics 2018; 141:peds.2017-4082. [PMID: 29483201 DOI: 10.1542/peds.2017-4082] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting. METHODS By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience. RESULTS These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized. CONCLUSIONS The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.
Collapse
Affiliation(s)
| | - Rachel A. Zuckerbrot
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, New York, New York
| | - Peter S. Jensen
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Danielle Laraque
- State University of New York Upstate Medical University, Syracuse, New York; and
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Deans KJ, Minneci PC, Nacion KM, Leonhart K, Cooper JN, Scholle SH, Kelleher KJ. Health care quality measures for children and adolescents in Foster Care: feasibility testing in electronic records. BMC Pediatr 2018; 18:79. [PMID: 29471817 PMCID: PMC5822488 DOI: 10.1186/s12887-018-1064-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 02/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preventive quality measures for the foster care population are largely untested. The objective of the study is to identify healthcare quality measures for young children and adolescents in foster care and to test whether the data required to calculate these measures can be feasibly extracted and interpreted within an electronic health records or within the Statewide Automated Child Welfare Information System. METHODS The AAP Recommendations for Preventive Pediatric Health Care served as the guideline for determining quality measures. Quality measures related to well child visits, developmental screenings, immunizations, trauma-related care, BMI measurements, sexually transmitted infections and depression were defined. Retrospective chart reviews were performed on a cohort of children in foster care from a single large pediatric institution and related county. Data available in the Ohio Statewide Automated Child Welfare Information System was compared to the same population studied in the electronic health record review. Quality measures were calculated as observed (received) to expected (recommended) ratios (O/E ratios) to describe the actual quantity of recommended health care that was received by individual children. RESULTS Electronic health records and the Statewide Automated Child Welfare Information System data frequently lacked important information on foster care youth essential for calculating the measures. Although electronic health records were rich in encounter specific clinical data, they often lacked custodial information such as the dates of entry into and exit from foster care. In contrast, Statewide Automated Child Welfare Information System included robust data on custodial arrangements, but lacked detailed medical information. Despite these limitations, several quality measures were devised that attempted to accommodate these limitations. CONCLUSIONS In this feasibility testing, neither the electronic health records at a single institution nor the county level Statewide Automated Child Welfare Information System was able to independently serve as a reliable source of data for health care quality measures for foster care youth. However, the ability to leverage both sources by matching them at an individual level may provide the complement of data necessary to assess the quality of healthcare.
Collapse
Affiliation(s)
- Katherine J. Deans
- The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB3145, Columbus, OH 43205 USA
| | - Peter C. Minneci
- The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB3145, Columbus, OH 43205 USA
| | - Kristine M. Nacion
- National Quality Forum, 1030 15th Street NW, Suite 800, Washington, DC 20005 USA
| | - Karen Leonhart
- The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB3145, Columbus, OH 43205 USA
| | - Jennifer N. Cooper
- The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB3145, Columbus, OH 43205 USA
| | - Sarah Hudson Scholle
- National Committee for Quality Assurance, 1100 13th St, NW, Suite 1000, Washington, DC 20005 USA
| | - Kelly J. Kelleher
- The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB3145, Columbus, OH 43205 USA
| |
Collapse
|
28
|
Hughes LP, Austin-Ketch T, Volpe EM, Campbell-Heider N. Identification and Treatment of Adolescents With Perinatal Anxiety and Depression. J Psychosoc Nurs Ment Health Serv 2017; 55:23-29. [PMID: 28585664 DOI: 10.3928/02793695-20170519-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/04/2017] [Indexed: 11/20/2022]
Abstract
Perinatal mood and anxiety disorders (PMAD) are the most common, yet under-diagnosed and undertreated complication of pregnancy, affecting up to 50% of pregnant and parenting teens. PMAD are a global health issue that can have devastating effects on the mental, physical, emotional, developmental health, and social life of the mother, infant, and family. Adolescents present with similar symptoms of PMAD as their adult counterparts, but also experience isolation from their peer group and lack of resources and coping strategies, as well as difficulty sleeping and lack of concentration and ability to focus. Nurses and nurse practitioners are in an ideal position to assess preexisting risk factors for PMAD. The current applied evidence-based article addresses the diagnosis of PMAD, provides a conceptual framework for understanding the intra- and interpersonal dynamics affecting teens with PMAD, and suggests a new screening tool to guide diagnosis. An easy to recall mnemonic for diagnosis and referral (SAIL AHEAD) is proposed. By using the SAIL AHEAD mnemonic, providers will impact adolescents' parenting success and resiliency, thereby enhancing their future success in life. [Journal of Psychosocial Nursing and Mental Health Services, 55(6), 23-29.].
Collapse
|
29
|
Chen RY, Feltes JR, Tzeng WS, Lu ZY, Pan M, Zhao N, Talkin R, Javaherian K, Glowinski A, Ross W. Phone-Based Interventions in Adolescent Psychiatry: A Perspective and Proof of Concept Pilot Study With a Focus on Depression and Autism. JMIR Res Protoc 2017; 6:e114. [PMID: 28623183 PMCID: PMC5493787 DOI: 10.2196/resprot.7245] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 04/05/2017] [Accepted: 04/24/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Telemedicine has emerged as an innovative platform to diagnose and treat psychiatric disorders in a cost-effective fashion. Previous studies have laid the functional framework for monitoring and treating child psychiatric disorders electronically using videoconferencing, mobile phones (smartphones), and Web-based apps. However, phone call and text message (short message service, SMS) interventions in adolescent psychiatry are less studied than other electronic platforms. Further investigations on the development of these interventions are needed. OBJECTIVE The aim of this paper was to explore the utility of text message interventions in adolescent psychiatry and describe a user feedback-driven iterative design process for text message systems. METHODS We developed automated text message interventions using a platform for both depression (EpxDepression) and autism spectrum disorder (ASD; EpxAutism) and conducted 2 pilot studies for each intervention (N=3 and N=6, respectively). The interventions were prescribed by and accessible to the patients' healthcare providers. EpxDepression and EpxAutism utilized an automated system to triage patients into 1 of 3 risk categories based on their text responses and alerted providers directly via phone and an online interface when patients met provider-specified risk criteria. Rapid text-based feedback from participants and interviews with providers allowed for quick iterative cycles to improve interventions. RESULTS Patients using EpxDepression had high weekly response rates (100% over 2 to 4 months), but exhibited message fatigue with daily prompts with mean (SD) overall response rates of 66.3% (21.6%) and 64.7% (8.2%) for mood and sleep questionnaires, respectively. In contrast, parents using EpxAutism displayed both high weekly and overall response rates (100% and 85%, respectively, over 1 to 4 months) that did not decay significantly with time. Monthly participant feedback surveys for EpxDepression (7 surveys) and EpxAutism (18 surveys) preliminarily indicated that for both interventions, daily messages constituted the "perfect amount" of contact and that EpxAutism, but not EpxDepression, improved patient communication with providers. Notably, EpxDepression detected thoughts of self-harm in patients before their case managers or caregivers were aware of such ideation. CONCLUSIONS Text-message interventions in adolescent psychiatry can provide a cost-effective and engaging method to track symptoms, behavior, and ideation over time. Following the collection of pilot data and feedback from providers and patients, larger studies are already underway to validate the clinical utility of EpxDepression and EpxAutism. TRIAL REGISTRATION Clinicaltrials.gov NCT03002311; https://clinicaltrials.gov/ct2/show/NCT03002311 (Archived by WebCite at http://www.webcitation.org/6qQtlCIS0).
Collapse
Affiliation(s)
- Robert Yuzen Chen
- Washington University School of Medicine, St. Louis, MO, United States
| | | | | | - Zoe Yunzhu Lu
- Washington University School of Medicine, St. Louis, MO, United States
| | - Michael Pan
- Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Nan Zhao
- Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Rebecca Talkin
- Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Kavon Javaherian
- Washington University School of Medicine, St. Louis, MO, United States
| | - Anne Glowinski
- Washington University School of Medicine, Department of Psychiatry, Division of Child and Adolescent Psychiatry, St. Louis, MO, United States
| | - Will Ross
- Washington University School of Medicine, St. Louis, MO, United States
| |
Collapse
|
30
|
Antidepressant Use by Youth with Minimal or Mild Depression: Evidence from 3 Health Systems. Pediatr Qual Saf 2017; 2:e017. [PMID: 29862381 PMCID: PMC5625815 DOI: 10.1097/pq9.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/01/2017] [Indexed: 11/26/2022] Open
Abstract
Background: There is concern about the prevalence of prescribing antidepressant medications to youth without appropriate diagnoses or who have subthreshold (mild) depression. Methods: Electronic records data from 3 large healthcare systems identified youth aged ≤21 years starting a new episode of antidepressant treatment between January 1, 2009, and December 31, 2013. For those with a diagnosis of depression, Patient Health Questionnaire (PHQ9) scores at the time of treatment initiation were used to examine the distribution of symptom severity and patients' demographic and clinical characteristics. Results: Of the 15,460 episodes of treatment, a depression diagnosis was recorded in 95% of the cases. PHQ9 scores were available for 4,329 youth with a diagnosis of depression. Younger age, sex, previous treatment, co-occurring anxiety, treatment setting, concurrent psychotherapy, and site were significant predictors of completing a PHQ9. Among youth with a baseline score, 87% reported moderate or severe symptoms (PHQ9 score ≥ 10) and 13% reported mild or minimal symptoms (PHQ9 < 10). The proportion reporting PHQ9 < 10 when starting treatment decreased with age, ranging from 19% in those aged 13–14 years and 12% in those aged 18–21 years. Patients treated by psychiatrists were 1.54 times (95% Confidence Interval [CI], 1.21–1.97) more likely to have PHQ9 scores < 10 compared with primary care physicians. Patients with prior treatment history (odds ratio = 1.76; 95% CI, 1.45–2.13) and concurrent psychotherapy (odds ratio = 1.24; 95% CI, 1.02–1.52) were more likely to have PHQ9 < 10. Conclusions: In these health systems, prescribing of antidepressant medication to adolescents for minimal or mild depression is much less common than previous reported.
Collapse
|
31
|
Volpe EM, Quinn CR, Resch K, Sommers MS, Wieling E, Cerulli C. Narrative Exposure Therapy: A Proposed Model to Address Intimate Partner Violence-Related PTSD in Parenting and Pregnant Adolescents. FAMILY & COMMUNITY HEALTH 2017; 40:258-277. [PMID: 26422231 PMCID: PMC4811746 DOI: 10.1097/fch.0000000000000072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pregnant and parenting adolescents experience high rates of intimate partner violence (IPV) and its sequelae posttraumatic stress disorder (PTSD) and depression. Narrative exposure therapy (NET) is an innovative intervention that has demonstrated strong preliminary evidence in improving mental health. The specific aims of this article are 3-fold: (1) provide a brief background about IPV-related PTSD and depression among pregnant and parenting adolescents; (2) describe NET's theoretical principles, its therapeutic process, and provide a review of existing evidence; and (3) discuss NET as a potential treatment to address the mental health burden among adolescents experiencing IPV-related PTSD and depression.
Collapse
Affiliation(s)
- Ellen M. Volpe
- University at Buffalo, State University of New York, School of
Nursing, 3435 Main St, Buffalo, New York 14214,
| | - Camille R. Quinn
- Department of Psychiatry, School of Medicine & Dentistry,
University of Rochester Medical Center, 300 Crittenden Boulevard, Rochester,
NY 14642,
| | - Kathryn Resch
- Department of Psychiatry, School of Medicine & Dentistry,
University of Rochester Medical Center, 300 Crittenden Boulevard, Rochester,
NY 14642,
| | - Marilyn S. Sommers
- Medical-Surgical Nursing, University of Pennsylvania School of
Nursing, 418 Curie Boulevard, Fagin Hall, Room 402, Philadelphia, PA 19104
(w) 215-746-8320,
| | - Elizabeth Wieling
- Family Social Science, University of Minnesota, 293 McNH, 1985
Buford Avenue, St Paul, MN 55108,
| | - Catherine Cerulli
- Director of Susan B. Anthony Center for Woman’s Leadership,
Department of Psychiatry, School of Medicine & Dentistry, University
of Rochester Medical Center, 300 Crittenden Boulevard, Rochester, NY 14642,
| |
Collapse
|
32
|
MacQueen GM, Frey BN, Ismail Z, Jaworska N, Steiner M, Lieshout RJV, Kennedy SH, Lam RW, Milev RV, Parikh SV, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:588-603. [PMID: 27486149 PMCID: PMC4994788 DOI: 10.1177/0706743716659276] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. METHODS Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on "Special Populations" is the sixth of six guidelines articles. RESULTS Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported. CONCLUSIONS Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.
Collapse
Affiliation(s)
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Zahinoor Ismail
- Department of Psychiatry, University of Calgary, Calgary, Alberta
| | | | - Meir Steiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Ryan J Van Lieshout
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Sidney H Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
| | - Roumen V Milev
- Department of Psychiatry, Queen's University, Kingston, Ontario
| | - Sagar V Parikh
- Department of Psychiatry, University of Toronto, Toronto, Ontario Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | |
Collapse
|
33
|
Lewandowski RE, O'Connor B, Bertagnolli A, Beck A, Tinoco A, Gardner WP, Jelinek-Berents CX, Newton DA, Wain KF, Boggs JM, Brace NE, deSa P, Scholle SH, Hoagwood K, Horwitz SM. Screening for and Diagnosis of Depression Among Adolescents in a Large Health Maintenance Organization. Psychiatr Serv 2016; 67:636-41. [PMID: 26876655 PMCID: PMC5556930 DOI: 10.1176/appi.ps.201400465] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this analysis was to determine changes in patterns of depression screening and diagnosis over three years in primary and specialty mental health care in a large health maintenance organization (HMO) as part of a project to develop quality measures for adolescent depression treatment. METHODS Two series of aggregate data (2010-2012) were gathered from the electronic health records of the HMO for 44,342 unique adolescents (ages 12 to 21) who had visits in primary and mental health care. Chi square tests assessed the significance of changes in frequency and departmental location of Patient Health Questionnaire-9 (PHQ-9) administration, incidence of depression symptoms, and depression diagnoses. RESULTS There was a significant increase in PHQ-9 use, predominantly in primary care, consistent with internally generated organizational recommendations to increase screening with the PHQ-9. The increase in PHQ-9 use led to an increase in depression diagnoses in primary care and a shift in the location of some diagnoses from specialty mental health care to primary care. The increase in PHQ-9 use was also linked to a decrease in the proportion of positive PHQ-9 results that led to formal depression diagnoses. CONCLUSIONS The rate of depression screening in primary care increased over the study period. This increase corresponded to an increase in the number of depression diagnoses made in primary care and a shift in the location in which depression diagnoses were made, from the mental health department to primary care. The frequency of positive PHQ-9 administrations not associated with depression diagnoses also increased.
Collapse
Affiliation(s)
- R Eric Lewandowski
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Briannon O'Connor
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Andrew Bertagnolli
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Arne Beck
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Aldo Tinoco
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - William P Gardner
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Christine X Jelinek-Berents
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Douglas A Newton
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Kris F Wain
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Jennifer M Boggs
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Nancy E Brace
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Patricia deSa
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Sarah Hudson Scholle
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Kimberly Hoagwood
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| | - Sarah McCue Horwitz
- Dr. Lewandowski, Dr. O'Connor, Dr. Hoagwood, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University, New York (e-mail: ). Dr. Bertagnolli and Ms. deSa are with the Care Management Institute, Kaiser Permanente, Oakland, California. Dr. Beck, Mr. Wain, Ms. Boggs, and Ms. Brace are with the Institute for Health Research, Dr. Jelinek-Berents is with the Department of Pediatrics, and Dr. Newton is with the Care Management Institute and the Department of Child and Adolescent Psychiatry, all at Kaiser Permanente of Colorado, Denver. Dr. Tinoco and Dr. Hudson Scholle are with the National Committee for Quality Assurance, Washington, D.C. Dr. Gardner is with the Research Institute of Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, and with the Department of Pediatrics, Ohio State University, Columbus
| |
Collapse
|
34
|
O’Connor BC, Lewandowski RE, Rodriguez S, Tinoco A, Gardner W, Hoagwood K, Scholle SH. Usual Care for Adolescent Depression From Symptom Identification Through Treatment Initiation. JAMA Pediatr 2016; 170:373-80. [PMID: 26832387 PMCID: PMC5541862 DOI: 10.1001/jamapediatrics.2015.4158] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Published guidelines describing effective adolescent depression care in primary care settings include screening, assessment, treatment initiation, and symptom monitoring. It is unclear the extent to which these steps are documented in patient health records. OBJECTIVE To determine rates of appropriate follow-up care for adolescents with newly identified depression symptoms in 3 large health systems. DESIGN, SETTING, AND PARTICIPANTS In this analysis conducted from March to September 2014, structured data retrospectively extracted from electronic health records were analyzed for 3 months following initial symptom identification to determine whether the patient was followed up and, if so, whether treatment was initiated and/or symptoms were monitored. Records were collected from 2 large health maintenance organizations in the western United States and a network of community health centers in the Northeast. The study group included adolescents (N = 4612) with newly identified depression symptoms, defined as an elevated score on the Patient Health Questionnaire (≥ 10) and/or a diagnosis of depression. MAIN OUTCOMES AND MEASURES Rates of treatment initiation, symptom monitoring, and follow-up care documented within 3 months of initial symptom identification. RESULTS Among the 4612 participants, the mean (SD) age at index event was 16.0 (2.3) years, and 3060 were female (66%). Treatment was initiated for nearly two-thirds of adolescents (79% of those with a diagnosis of major depression; n = 023); most received psychotherapy alone or in combination with medications. However, in the 3 months following identification, 36% of adolescents received no treatment (n = 1678), 68% did not have a follow-up symptom assessment (n = 3136), and 19% did not receive any follow-up care (n = 854). Further, 40% of adolescents prescribed antidepressant medication did not have any documentation of follow-up care for 3 months (n = 356). Younger age (ages 15-17 years: odds ratio [OR], 0.78; 95% CI, 0.67-0.92 and ages 18-20 years: OR, 0.83; 95% CI, 0.70-0.99; P = .008), more severe initial symptoms (moderate: OR, 0.99; 95% CI, 0.82-1.21; moderate to severe: OR, 1.46; 95% CI, 1.19-1.80; and severe: OR, 2.14; 95% CI, 1.65-2.79; P < .001), and receiving a diagnosis (major depression/dysthymia: OR, 2.65; 95% CI, 2.20-3.20 and unspecified depression/adjustment disorder: OR, 1.75; 95% CI, 1.43-2.14; P < .001) were significantly associated with treatment initiation. Differences in rates of follow-up care were evident between sites (site 2: OR, 1.77; 95% CI, 1.45-2.16 and site 3: OR, 2.10; 95% CI, 1.72-2.57), suggesting that differences within health systems may also affect care received. CONCLUSIONS AND RELEVANCE Most adolescents with newly identified depression symptoms received some treatment, usually including psychotherapy, within the first 3 months after identification. However, follow-up care was low and substantial variation existed between sites. These results raise concerns about the quality of care for adolescent depression.
Collapse
Affiliation(s)
| | - R. Eric Lewandowski
- Department of Child and Adolescent Psychiatry, New York University Child Study Center, New York University School of Medicine
| | - Stephanie Rodriguez
- National Committee for Quality Assurance, 1100 13 St., NW Suite 1000, Washington DC, 20005
| | - Aldo Tinoco
- Evolent Health, 800 N. Glebe Rd, Suite 500, Arlington VA, 22203
| | - William Gardner
- Children’s Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa ON K1H 8L1, Canada
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Child Study Center, New York University School of Medicine
| | - Sarah Hudson Scholle
- Department of Child and Adolescent Psychiatry, New York University Child Study Center, New York University School of Medicine
| |
Collapse
|
35
|
Creatine target engagement with brain bioenergetics: a dose-ranging phosphorus-31 magnetic resonance spectroscopy study of adolescent females with SSRI-resistant depression. Amino Acids 2016; 48:1941-54. [PMID: 26907087 PMCID: PMC4974294 DOI: 10.1007/s00726-016-2194-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/03/2016] [Indexed: 12/18/2022]
Abstract
Major depressive disorder (MDD) often begins during adolescence and is projected to become the leading cause of global disease burden by the year 2030. Yet, approximately 40 % of depressed adolescents fail to respond to standard antidepressant treatment with a selective serotonin reuptake inhibitor (SSRI). Converging evidence suggests that depression is related to brain mitochondrial dysfunction. Our previous studies of MDD in adult and adolescent females suggest that augmentation of SSRI pharmacotherapy with creatine monohydrate (CM) may improve MDD outcomes. Neuroimaging with phosphorus-31 magnetic resonance spectroscopy (31P-MRS) can measure the high-energy phosphorus metabolites in vivo that reflect mitochondrial function. These include phosphocreatine (PCr), a substrate for the creatine kinase reaction that produces adenosine triphosphate. As part of the National Institute of Mental Health’s experimental medicine initiative, we conducted a placebo-controlled dose-ranging study of adjunctive CM for adolescent females with SSRI-resistant MDD. Participants were randomized to receive placebo or CM 2, 4 or 10 g daily for 8 weeks. Pre- and post-treatment 31P-MRS scans were used to measure frontal lobe PCr, to assess CM’s target engagement with cerebral energy metabolism. Mean frontal lobe PCr increased by 4.6, 4.1 and 9.1 % in the 2, 4 and 10 g groups, respectively; in the placebo group, PCr fell by 0.7 %. There was no group difference in adverse events, weight gain or serum creatinine. Regression analysis of PCr and depression scores across the entire sample showed that frontal lobe PCr was inversely correlated with depression scores (p = 0.02). These results suggest that CM achieves target engagement with brain bioenergetics and that the target is correlated with a clinical signal. Further study of CM as a treatment for adolescent females with SSRI-resistant MDD is warranted.
Collapse
|
36
|
Affiliation(s)
- Kelly J Kelleher
- Colleges of Medicine and Public Health, The Ohio State University, Columbus, Ohio.
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, New York
| |
Collapse
|
37
|
Radovic A, Reynolds K, McCauley HL, Sucato GS, Stein BD, Miller E. Parents' Role in Adolescent Depression Care: Primary Care Provider Perspectives. J Pediatr 2015; 167:911-8. [PMID: 26143382 PMCID: PMC4586359 DOI: 10.1016/j.jpeds.2015.05.049] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 04/09/2015] [Accepted: 05/26/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To understand how primary care providers (PCPs) perceive barriers to adolescent depression care to inform strategies to increase treatment engagement. STUDY DESIGN We conducted semistructured interviews with 15 PCPs recruited from community pediatric offices with access to integrated behavioral health services (ie, low system-level barriers to care) who participated in a larger study on treating adolescent depression. Interviews addressed PCP perceptions of barriers to adolescents' uptake of care for depression. Interviews were audiorecorded, transcribed, and coded for key themes. RESULTS Although PCPs mentioned several adolescent barriers to care, they thought parents played a critical role in assisting adolescents in accessing mental health services. Important aspects of the parental role in accessing treatment included transportation, financial support, and social support. PCPs perceived that parental unwillingness to accept the depression diagnosis, family dysfunction, and trauma were common barriers. PCPs contrasted this with examples of good family support they believed would enable adolescents to attend follow-up appointments and have a "life coach" at home to help monitor for side effects and watch for increased suicidality when starting antidepressants. CONCLUSIONS In this PCP population, which had enhanced access to mental health specialists, PCPs primarily reported attitudinal barriers to adolescent depression treatment, focusing mainly on perceived parent barriers. The results of these qualitative interviews provide a framework for understanding PCP perceptions of parental barriers to care, identifying that addressing complex parental barriers to care may be important for future interventions.
Collapse
Affiliation(s)
- Ana Radovic
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine,Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Kerry Reynolds
- RAND Corporation, University of Pittsburgh School of Medicine
| | - Heather L. McCauley
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine,Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Gina S. Sucato
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine,Department of Pediatrics, University of Pittsburgh School of Medicine,Group Health, University of Pittsburgh School of Medicine
| | - Bradley D. Stein
- RAND Corporation, University of Pittsburgh School of Medicine,Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Elizabeth Miller
- Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine,Department of Pediatrics, University of Pittsburgh School of Medicine
| |
Collapse
|
38
|
Southammakosane C, Schmitz K. Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety. Pediatrics 2015; 136:351-9. [PMID: 26148950 DOI: 10.1542/peds.2014-1581] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2015] [Indexed: 11/24/2022] Open
Abstract
The pediatric practitioner is often the first point-of-contact for children and adolescents suffering from mental illness. Part of the treatment planning for psychiatric diagnoses includes consideration of medication. Attention-deficit/hyperactivity disorder, one of the most common diagnoses, is very responsive to stimulant medications; for children who are unable to tolerate stimulants or who do not achieve satisfactory symptom management, central α-agonists and atomoxetine are effective and generally well-tolerated alternative or augmentative agents. Depression and anxiety disorders are also frequently encountered in the pediatric office setting. The use of selective serotonin reuptake inhibitors is considered first-line psychopharmacology for depression and anxiety symptoms. Despite concerns for suicidal ideation related to this medication class, the benefits typically outweigh the risks. This review provides basic clinical pharmacology of stimulant and nonstimulant attention-deficit/hyperactivity disorder medications and selective serotonin reuptake inhibitors intended to serve as a primer for the general pediatrician.
Collapse
Affiliation(s)
| | - Kristine Schmitz
- Children's National Medical Center, Washington, District of Columbia
| |
Collapse
|
39
|
Abstract
BACKGROUND Increasing mental health treatment of young people and broadening conceptualizations of psychopathology have triggered concerns about a disproportionate increase in the treatment of youths with low levels of mental health impairment. METHODS We analyzed the 1996-1998, 2003-2005, and 2010-2012 Medical Expenditure Panel Surveys, which were nationally representative surveys of U.S. households, for trends in outpatient use of mental health services by persons 6 to 17 years of age; 53,622 persons were included in the analysis. Mental health impairment was measured with the use of the Columbia Impairment Scale (range, 0 to 52, with higher scores indicating more severe impairment); we classified youths with scores of 16 or higher as having more severe impairment and those with scores of less than 16 as having less severe impairment. RESULTS The percentage of youths receiving any outpatient mental health service increased from 9.2% in 1996-1998 to 13.3% in 2010-2012 (odds ratio, 1.52; 95% confidence interval, 1.35 to 1.72). The proportionate increase in the use of mental health services among youths with more severe impairment (from 26.2% to 43.9%) was larger than that among youths with less severe or no impairment (from 6.7% to 9.6%). However, the absolute increase in annual service use was larger among youths with less severe or no impairment (from 2.74 million to 4.19 million) than among those with more severe impairment (from 1.56 million to 2.28 million). Significant overall increases occurred in the use of psychotherapy (from 4.2% to 6.0%) and psychotropic medications (from 5.5% to 8.9%), including stimulants and related medications (from 4.0% to 6.6%), antidepressants (from 1.5% to 2.6%), and antipsychotic drugs (from 0.2% to 1.2%). CONCLUSIONS Outpatient mental health treatment and psychotropic-medication use in children and adolescents increased in the United States between 1996-1998 and 2010-2012. Although youths with less severe or no impairment accounted for most of the absolute increase in service use, youths with more severe impairment had the greatest relative increase in use, yet fewer than half accessed services in 2010-2012. (Funded by the Agency for Healthcare Research and Quality and the New York State Psychiatric Institute.).
Collapse
Affiliation(s)
- Mark Olfson
- From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute - both in New York (M.O.); the Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (B.G.D.); and the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, and the School of Social Practice and Policy, University of Pennsylvania - both in Philadelphia (S.C.M.)
| | | | | |
Collapse
|
40
|
Abstract
Depressive disorders are common in children and adolescents, with estimates for depressive episodes as high as 18.2% for girls and 7.7% for boys by age 17 years, and are a major cause of morbidity and even mortality. The primary care pediatrician should be able to (1) diagnose depressive disorders and use standardized instruments; (2) ask about suicide, self-harm, homicide, substance use, mania, and psychosis; (3) triage the severity of illness; (4) be aware of the differential diagnosis, including normal development, other depressive disorders, bipolar disorders, and comorbid disorders, such as anxiety and substance use; (5) refer to evidenced-based psychotherapies; (6) prescribe first-line medications; and (7) provide ongoing coordination in a medical home. Pediatric bipolar disorders and the new disruptive mood dysregulation disorder (DMDD) diagnoses are controversial but not uncommon, with prevalence estimates ranging from 0.8% to 4.3% in children at various ages. Although the pediatrician is not likely to be prescribing medications for children with bipolar disorder and DMDD diagnoses, all clinicians should be familiar with common neuroleptics and other mood stabilizers, including important potential adverse effects. Basic management of depressive and bipolar disorders is an important skill for primary care pediatricians.
Collapse
Affiliation(s)
- Michael H Tang
- Department of Psychiatry, Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital and McLean Hospital, Boston, MA
| | - Elizabeth G Pinsky
- Department of Psychiatry, Harvard Medical School, and Departments of Psychiatry and Pediatrics, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
41
|
Byron SC, Gardner W, Kleinman LC, Mangione-Smith R, Moon J, Sachdeva R, Schuster MA, Freed GL, Smith G, Scholle SH. Developing measures for pediatric quality: methods and experiences of the CHIPRA pediatric quality measures program grantees. Acad Pediatr 2014; 14:S27-32. [PMID: 25169454 DOI: 10.1016/j.acap.2014.06.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 06/04/2014] [Accepted: 06/18/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Monitoring quality is an important way of understanding how the health care system is serving children and families. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Pediatric Quality Measures Program (PQMP) funded efforts to develop and enhance measures to assess care for children and adolescents. We describe the processes used by the PQMP grantees to develop measures to assess the health care of children and adolescents in Medicaid and the Children's Health Insurance Program. METHODS Key steps in the measures development process include identifying concepts, reviewing and synthesizing evidence, prioritizing concepts, defining how measures should be calculated, and measure testing. Stakeholder engagement throughout the process is critical. Case studies illustrate how PQMP grantees adapted the process to respond to the nature of measures they were charged to develop and overcome challenges encountered. RESULTS PQMP grantees used varied approaches to measures development but faced common challenges, some specific to the field of pediatrics and some general to all quality measures. Major challenges included the limited evidence base, data systems difficult or unsuited for measures reporting, and conflicting stakeholder priorities. CONCLUSIONS As part of the PQMP, grantees were able to explore innovative methods to overcome measurement challenges, including new approaches to building the evidence base and stakeholder consensus, integration of alternative data sources, and implementation of new testing methods. As a result, the PQMP has developed new quality measures for pediatric care while also building an infrastructure, expertise, and enhanced methods for measures development that promise to provide more relevant and meaningful tools for improving the quality of children's health care.
Collapse
Affiliation(s)
| | - William Gardner
- Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Ohio State University and Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | | | | | - JeanHee Moon
- Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ramesh Sachdeva
- Medical College of Wisconsin, Milwaukee, Wis; American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Mark A Schuster
- Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Gary L Freed
- Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, Mich
| | - Gwen Smith
- Illinois Department of Healthcare and Family Services, Springfield, Ill
| | | |
Collapse
|
42
|
Becker KD, Chorpita BF, Daleiden EL. Coordinating people and knowledge: Efficiency in the context of the Patient Protection and Affordable Care Act. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2014. [DOI: 10.1111/cpsp.12062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
43
|
Chor KHB, Olin SS, Hoagwood KE. Training and education in clinical psychology in the context of the Patient Protection and Affordable Care Act. ACTA ACUST UNITED AC 2014. [DOI: 10.1111/cpsp.12068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
44
|
Hoagwood KE, Olin SS, Horwitz S, McKay M, Cleek A, Gleacher A, Lewandowski E, Nadeem E, Acri M, Chor KHB, Kuppinger A, Burton G, Weiss D, Frank S, Finnerty M, Bradbury DM, Woodlock KM, Hogan M. Scaling up evidence-based practices for children and families in New York State: toward evidence-based policies on implementation for state mental health systems. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2014; 43:145-57. [PMID: 24460518 PMCID: PMC3954943 DOI: 10.1080/15374416.2013.869749] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the children's mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.
Collapse
|