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Butler W, Lewis KL, Benheim TS, Arauz Boudreau A, Brigham KS, Feldman M, Jellinek M, Murphy JM. Screening and Follow-Up Treatment Practices for Suicide Risk in Adolescent Primary Care: A Retrospective Chart Review. Clin Pediatr (Phila) 2024:99228241253158. [PMID: 38742439 DOI: 10.1177/00099228241253158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Universal depression screening in adolescent primary care often encompasses questions about suicide risk. We conducted a retrospective chart review of well-child visits where adolescents (ages 13-17.9) had endorsed self-injurious thoughts and behaviors or suicidal ideation. The goal was to investigate primary care providers' follow-up actions, including documentation, further assessment, and referrals. Over 3-quarters of the progress notes showed evidence of further assessment, and two-thirds documented same-day actions, including mental health referrals, emergency department referrals, safety plans, medication changes, primary-care follow-up, and talking to parents. Actions varied by depression severity. Cases without interventions often had justifications. Owing to the variety of possible meanings and severity underlying positive screens, providers implemented an array of interventions, using clinical judgment to tailor actions to patients' individual needs and preferences. From these observations, we propose that standardized guidelines for suicide risk screening and follow-up should involve a clinical assessment and individualized treatment planning.
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Affiliation(s)
- William Butler
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Kristina L Lewis
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Talia S Benheim
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Alexy Arauz Boudreau
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kathryn S Brigham
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Mitchell Feldman
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Michael Jellinek
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - J Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Dalal M, Holcomb JM, Sundaresan D, Dutta A, Riobueno-Naylor A, Peloquin GD, Benheim TS, Jellinek M, Murphy JM. Identifying and responding to depression in adolescents in primary care: A quality improvement response. Clin Child Psychol Psychiatry 2023; 28:623-636. [PMID: 35642512 DOI: 10.1177/13591045221105198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The American Academy of Pediatrics (AAP) recommends adolescent depression screening and subsequent follow-up for those scoring at-risk. The current study assessed the outcomes of a Quality Improvement (QI) project that implemented these guidelines during annual well-child visits in a network of pediatric practices. This project used a two-stage screening process. First, adolescents were screened with the Pediatric Symptom Checklist (PSC-17). Second, adolescents who screened at-risk on the PSC-17 were asked to complete the Patient Health Questionnaire (PHQ-9). QI-participating providers received training on how to categorize the severity of their patient's depression based on PHQ-9 cut-off scores and clinical interview, and to implement and document appropriate options for follow-up. Patients in the QI group were significantly more likely to be screened with both the PSC-17 (93.8% vs. 89.1%, p < .001) and the PHQ-9 (54.8% vs. 16.4%, p < .001) compared to those in the non-QI group. Of the 80 adolescents in the QI group at-risk on the PSC-17 and with a completed PHQ-9, 65 (81.3%) received at least one type of referral for mental health, ranging from behavioral health services to lifestyle interventions. Findings support the feasibility of adolescent depression screening and referrals within pediatric primary care.
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Affiliation(s)
- Michelle Dalal
- Practice Research Network, Pediatrics Department, 486522Reliant Medical Group, Milford, MA, USA
- Department of Pediatrics, 12262University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Devi Sundaresan
- Practice Research Network, Pediatrics Department, 486522Reliant Medical Group, Milford, MA, USA
| | - Anamika Dutta
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Alexa Riobueno-Naylor
- Department of Counseling Psychology, 196058Boston College Lynch School of Education and Human Development, Chestnut Hill, MA, USA
| | - Gabrielle D Peloquin
- Practice Research Network, Pediatrics Department, 486522Reliant Medical Group, Milford, MA, USA
| | - Talia S Benheim
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Michael Jellinek
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, 1811Harvard Medical School, Boston, MA, USA
| | - J Michael Murphy
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, 1811Harvard Medical School, Boston, MA, USA
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Farley AM, Canenguez KM, Squicciarini AM, Dutta A, Green JG, Benheim TS, Jellinek M, Murphy JM. The Relationship Between First-Grade Psychosocial Functioning and Educational Outcomes through Eighth Grade in a Large Sample of Chilean Youth. J Sch Health 2023. [PMID: 36967296 DOI: 10.1111/josh.13327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/13/2023] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The association between early childhood psychosocial problems and poorer educational outcomes is well-documented, but the extent to which this association persists is less understood. The current study assessed the correlations between first-grade psychosocial functioning and educational outcomes through eighth grade in a large longitudinal sample of Chilean students. METHODS The Pediatric Symptom Checklist-Chilean (PSC-CL) and Teacher Observation of Classroom Adaptation Re-Revised (TOCA-RR) assessed psychosocial functioning for 9736 students who were screened four times from first through eighth grade through the Skills for Life program. Adjusted linear mixed effects models assessed the association between first grade PSC-CL and TOCA-RR risk and third, sixth, and eighth grade GPA and school attendance. RESULTS First-grade PSC-CL and TOCA-RR risk both significantly predicted lower third, sixth, and eighth grade GPAs; all p < .001. The relationships between first-grade psychosocial functioning and later school attendance rates were less consistent but still significant at certain time points. CONCLUSIONS First-grade psychosocial risk was persistently associated with lower academic performance in a longitudinal sample of Chilean students followed through elementary and middle school. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY Early school-based psychosocial screening and follow-up interventions have the potential to improve students' long-term educational outcomes.
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Affiliation(s)
- Alyssa M Farley
- Center for Anxiety and Related Disorders, Boston University, 900 Commonwealth Avenue, Second Floor, Boston, MA, 02215, USA
| | - Katia M Canenguez
- Department of Psychiatry, Massachusetts General Hospital; Instructor of Psychology, Department of Psychiatry, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ana María Squicciarini
- Department of School Welfare, National Board of School Aid and Scholarships, Monjitas 565, Sixth Floor, Santiago, Chile
| | - Anamika Dutta
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Avenue, Second Floor, Boston, MA, 02215, USA
| | - Jennifer Greif Green
- Wheelock College of Education and Human Development, Boston University, Two Silber Way, Boston, MA, 02215, USA
| | - Talia S Benheim
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael Jellinek
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - J Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital; Associate Professor of Psychology, Department of Psychiatry, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Canenguez KM, Farley AM, Squicciarini AM, Dutta A, Simonsohn A, Holcomb JM, Peña F, Leiva L, Benheim TS, Guzmán J, Jellinek M, Murphy JM. Implementation and Outcomes of a National School-Based Mental Health Program for Middle School Students in Chile. School Ment Health 2023; 15:165-176. [PMID: 36160322 PMCID: PMC9489263 DOI: 10.1007/s12310-022-09541-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 11/25/2022]
Abstract
Background Chile's national school-based mental health program, Skills for Life (SFL), has demonstrated effectiveness in improving behavioral and academic outcomes in first- through third-grade students. The current study assessed the feasibility and outcomes of SFL's program for sixth- through eighth-grade students. Methods We assessed the percentage of students who participated in the program and longitudinal changes on teacher-reported Teacher Observation of Classroom Adaptation Re-Revised (TOCA-RR) scores, youth-reported Pediatric Symptom Checklist-Chile (PSC-Y-CL) scores, grade-point average, and school attendance from sixth to eighth grade (2016-2018) for SFL's workshop intervention. Linear mixed effects models analyzed the association between outcome variables and workshop attendance. Results Of the 30,649 sixth graders who attended the 754 participating schools in 2016, 28,204 (92.0%) were screened with the TOCA-RR. Of the 1829 students who screened at risk, 1344 had available workshop data for seventh grade, with 86.9% of them participating in most (≥ 7) workshop sessions. Workshop attendance was significantly associated with improvements in school attendance and peer relationships (a TOCA-RR subscale) in eighth grade. Conclusions With high rates of behavioral health screening and workshop attendance, this study demonstrated the feasibility of implementing SFL's middle school program on a national scale. Higher workshop attendance by at-risk students was associated with better school attendance and peer relationships in eighth grade, as well as better but not significantly different outcomes on other measures (e.g., teacher-rated school performance and aggressive behavior in the classroom). Overall, these findings provide preliminary evidence of the feasibility and benefits of SFL's middle school program.
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Affiliation(s)
- Katia M. Canenguez
- Department of Psychiatry, Massachusetts General Hospital, Yawkey 6A, 55 Fruit Street, Boston, MA 02114 USA
- Department of Psychiatry, Harvard Medical School, Boston, MA USA
| | - Alyssa M. Farley
- Center for Anxiety and Related Disorders, Boston University, Boston, MA USA
| | | | - Anamika Dutta
- Department of Psychiatry, Massachusetts General Hospital, Yawkey 6A, 55 Fruit Street, Boston, MA 02114 USA
| | - Ariela Simonsohn
- Department of School Health, Junta Nacional de Auxilio Escolar y Becas, Santiago, Chile
| | - Juliana M. Holcomb
- Department of Psychiatry, Massachusetts General Hospital, Yawkey 6A, 55 Fruit Street, Boston, MA 02114 USA
| | | | - Loreto Leiva
- Department of Psychology, University of Chile, Santiago, Chile
| | - Talia S. Benheim
- Department of Psychiatry, Massachusetts General Hospital, Yawkey 6A, 55 Fruit Street, Boston, MA 02114 USA
| | - Javier Guzmán
- Department of School Health, Junta Nacional de Auxilio Escolar y Becas, Santiago, Chile
| | - Michael Jellinek
- Department of Psychiatry, Massachusetts General Hospital, Yawkey 6A, 55 Fruit Street, Boston, MA 02114 USA
- Department of Psychiatry, Harvard Medical School, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - J. Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Yawkey 6A, 55 Fruit Street, Boston, MA 02114 USA
- Department of Psychiatry, Harvard Medical School, Boston, MA USA
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Holcomb JM, Dutta A, Bergmann P, Riobueno-Naylor A, Haile H, Benheim TS, Sturner R, Howard B, Murphy JM, Jellinek M. Suicidal Ideation in Adolescents: Understanding Results from Screening with the PHQ-9M and the PSC-17P. J Dev Behav Pediatr 2022; 43:346-352. [PMID: 35125467 PMCID: PMC9329154 DOI: 10.1097/dbp.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 12/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the study was to help pediatricians understand and respond to suicidal ideation (SI) in adolescents based on data from 2 widely used screening measures that assessed SI and other psychosocial vulnerabilities in a large, national sample. METHODS Adolescents (ages 11-17 years) completed the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) using the Comprehensive Health and Decision Information System software before their well-child visits. Question 9 asks about past 2-week SI. Their parents filled out the Pediatric Symptom Checklist (PSC-17P), which screens for a broad range of psychosocial problems. Chi-square analyses and one-way analysis of variances assessed the relationship between SI and psychosocial problems. RESULTS Among 5411 adolescents, 266 (4.9%) reported SI at least several days in the past 2 weeks. Among adolescents with SI, 187 (70.3%) reported moderate to very severe depression on the PHQ-9M (≥10), 68.1% were at risk on at least 1 PSC-17P problem subscale, 59.7% on the PSC-17P internalizing scale, 42.9% on PSC-17P overall, 20.6% on PSC-17P externalizing, and 18.5% on PSC-17P attention. Within the subsample endorsing SI nearly all days, 35.7% had a former suicide attempt. CONCLUSION The PHQ-9M identifies a clinically heterogeneous subset of approximately 5% of adolescents who report occasional to frequent SI. The PSC-17P corroborates their high degree of overall risk and offers additional information that can help pediatricians assess clinical severity and range of psychosocial problems. Given our limited knowledge of how to predict and prevent an individual adolescent's suicide, the focus of screening should be to identify and help the subset of patients with chronic psychosocial vulnerability of any type.
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Affiliation(s)
- Juliana M. Holcomb
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychology, Suffolk University, Boston, MA, USA
| | - Anamika Dutta
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - Alexa Riobueno-Naylor
- Department of Counseling, Developmental, and Educational Psychology, Lynch School of Education and Human Development, Boston College, Boston, MA, USA
| | - Haregnesh Haile
- Department of Psychology, The Catholic University of America, DC, USA
| | - Talia S. Benheim
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Raymond Sturner
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Promotion of Child Development through Primary Care, Baltimore, MD, USA
| | - Barbara Howard
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Total Child Health, Baltimore, MD, USA
| | - J. Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Michael Jellinek
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Dutta A, Peña F, Holcomb JM, Leiva L, Squicciarini AM, Canenguez KM, Bergmann P, Riobueno-Naylor A, Farley AM, Simonsohn A, Garfin DR, Silver RC, Benheim TS, Guzmán J, Jellinek MS, Murphy JM. Earthquake exposure, adverse childhood experiences, and psychosocial functioning in Chilean children: A longitudinal study. J Trauma Stress 2022; 35:1177-1188. [PMID: 35355336 PMCID: PMC9704030 DOI: 10.1002/jts.22826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023]
Abstract
The impact of an 8.8 magnitude Chilean earthquake on elementary school students' psychosocial functioning was assessed along with exposure to adverse childhood experiences (ACEs). Skills for Life, a national school-based mental health program in Chile, routinely assesses first- and third-grade students' psychosocial functioning and classroom adaptation. Students (N = 19,627) were screened before (2009) and after (2011) the 2010 earthquake with parent- and teacher-report measures and with a parent-report of four ACEs (family psychopathology, child chronic illness, family social isolation, father absence). Earthquake exposure was categorized as mild, moderate, or severe for Chile's 15 regions. Multilevel models analyzed the unadjusted and adjusted impacts of earthquake exposure and ACEs on functioning while clustering for school- and district-level effects. In covariate-adjusted models, earthquake exposure and three ACEs were significantly associated with worsened psychosocial functioning; earthquake exposure and all four ACEs were significantly associated with worsened classroom adaptation. New family psychopathology, B = 1.90, p < .001; chronic illness, B = 2.25, p < .001; and severe earthquake impact, B = 1.29, p < .001, held the strongest negative effects on psychosocial well-being. Moderate, B = 3.04, p = .011, and severe earthquake exposure, B = 2.53, p = .047, and new family psychopathology, B = 1.99, p < .001, were associated with the worst classroom functioning 1-year postdisaster. Findings suggest that both exogenous and home-based stressors can have significant consequences for children's psychosocial functioning and classroom adaptation, and routine screening helps quantify how individual students are affected by chronic versus acute stressors.
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Affiliation(s)
- Anamika Dutta
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Juliana M. Holcomb
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychology, Suffolk University, Boston, MA
| | - Loreto Leiva
- Department of Psychology, University of Chile, Santiago, Chile
| | | | - Katia M. Canenguez
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alexa Riobueno-Naylor
- Department of Counseling, Developmental, and Educational Psychology, Boston College, Chestnut Hill, Massachusetts, USA
| | - Alyssa M. Farley
- Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts, USA
| | - Ariela Simonsohn
- Department of School Health, Junta Nacional de Auxilio Escolar y Becas, Santiago, Chile
| | - Dana Rose Garfin
- Sue & Bill Gross School of Nursing and Program in Public Health, University of California, Irvine, Irvine, California, USA
| | - Roxane Cohen Silver
- Department of Psychological Science, Department of Medicine, Program in Public Health, University of California, Irvine, Irvine, California, USA
| | - Talia S. Benheim
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Javier Guzmán
- Department of School Health, Junta Nacional de Auxilio Escolar y Becas, Santiago, Chile
| | - Michael S. Jellinek
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - J. Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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