PolicyLab

Last month, the United States Preventive Services Task Force (USPSTF), a government-appointed health panel, recommended screening for depression in adolescents ages 12 to 18.

PolicyLab’s Andrea Knight has researched how to improve mental health for children and adolescents with lupus, a chronic autoimmune disease in which the body's immune system attacks multiple organs. Dr. Knight answered questions about the new screening guidelines and explained how adolescents with chronic disease may face barriers to identifying and treating their depression.

Q: What is the significance of the new screening guidelines, issued by the United States Preventive Services Task Force, that adolescents ages 12 to 18 school be screened for depression?

The new screening guidelines address a need for routine and systematic screening of depression in adolescents. Adolescence is the peak age of onset for childhood depression. Approximately 15% of adolescents will experience depression at some point in their child and adolescent years.  Through routine screening, health care providers have an important opportunity to intervene and connect depressed adolescents with appropriate treatment and resources.

Q: Why is it important for adolescents to be screened for depression?

Routine screening among adolescents is important to maximize detection and treatment of depression. Research indicates that multiple patient-, parent- and provider-level barriers prevent discussion of mental health needs, and detection rates of depression are low in the absence of a systematic approach. Routine screening can help overcome several of these barriers to enable timely detection and treatment of depression. As depression in adults is likely to first emerge in adolescence, screening of adolescents, followed by early intervention, may prevent later development of major depression and suicide.

Q:  The task force notes that some adolescents, such as adolescents with chronic medical illnesses, are at higher risk for depression. Why are they more at risk?

About 20 percent to 40 percent of adolescents with chronic medical illnesses develop depression. Depression can result from enduring ongoing psychological distress related to physical limitations, the burdens of taking long-term medications, frequent medical visits and testing, feelings of uncertainty and stigma, and tolls on family and peer relationships. Additionally, some disease processes can exert effects on the brain that contribute to depression. Evidence suggests that brain inflammation can cause depression in disorders such as lupus and multiple sclerosis. But despite being at increased risk, most adolescents with chronic medical illness are not appropriately screened for depression.

Q:  Are there barriers to care for adolescents, specifically those with chronic diseases?

Barriers to mental health care for adolescents include fear and stigma regarding discussion of mental health, uncertainty about where and when to seek help, and difficulty in accessing affordable mental health services. These barriers may be magnified for adolescents with chronic disease, who often see multiple doctors and may view a subspecialist as their primary doctor. These adolescents and their parents may feel most comfortable discussing mental health concerns with a subspecialist, who may lack the training and resources to facilitate mental health intervention. Once depression symptoms are detected, adolescents with chronic medical illness and their families may face difficulty with financing and coordinating multiple appointments, and ensuring appropriate communication between medical and mental health providers.

Q: What is CHOP already doing around this issue? What does CHOP do if a teen screens positive for depression?

CHOP has been working to improve mental health care for pediatric patients on several fronts. In recent years, routine depression screening has been implemented in most CHOP primary care practices and the CHOP emergency room. Collaborative care models, which integrate medical and mental health services at the same location, have been implemented at several CHOP primary care sites, and some subspecialties have dedicated psychologists for pediatric patients with chronic medical illness.  The CHOP Division of Psychiatry has recently implemented the Behavioral Health Integrated Program to provide comprehensive inpatient and outpatient psychiatric assessment of children with medical illnesses. Additionally, a new inpatient unit is scheduled to open in 2017 for patients who are hospitalized for a medical reason and need behavioral health care.

What are the recommended treatment options for adolescents that screen positive for depression?

Adolescents screening positive for depression should have their results verified through a discussion with a clinician, and those screening positive for suicidal thoughts require urgent assessment. After these assessments, a variety of treatment options may be considered. Adolescents with mild symptoms may benefit from psychological counseling, enhanced psychosocial supports and follow-up to monitor for worsening symptoms. Those with moderate to severe symptoms should receive further evaluation by a mental health professional, who can determine the optimal treatment plan, which may include psychotherapy and/or antidepressants.

Q: What can physicians do to adequately carry out the task force’s recommendation, especially for adolescents with chronic diseases?

Primary care physicians and pediatric subspecialists caring for adolescents with chronic disease can carry out the task force’s recommendation by implementing routine depression screening in their practices. Because lack of clinician time, knowledge and resources are likely to be barriers to implementation, physicians need the support of their institutions and health care organizations. Hospitals and health systems can facilitate screening and appropriate depression treatment by enhancing mental health training for clinicians; developing educational tools for staff, patients and families; providing technical and personnel support for integrating screening practices into the clinic workflow; streamlining access to mental health services; and optimizing communication between medical and mental health providers.  For adolescents with chronic disease, these efforts should focus not only on primary care but also on subspecialty settings.

Andrea Knight, MD, MSCE, is a former faculty member at PolicyLab.