When his office began using a questionnaire to screen adolescents for depression, Dr. Robert Dudley was skeptical.
“What’s the chance these nine silly questions are going to pick something up?” he wondered. “I’ve known this kid forever. I’ll know if they’re having troubles or not.”
Then he started using the questionnaire.
The number of patients identified as having mental health issues skyrocketed.
“It’s really amazing how many kids come up positive with it,” he said. “It’s really sort of a shocker to me. I thought we were doing a pretty good job of asking kids [before].”
Screening tools like the one Dudley uses are relatively simple. They resemble multiple-choice quizzes, with questions like whether or how often a person felt down, had little interest in doing things, or had trouble sleeping. Patients can circle the answers.
There’s evidence that they can accurately identify major depression in adolescents, according to the U.S. Preventive Services Task Force. But Dudley, a pediatrician at Community Health Center in New Britain, is in the minority in using them regularly.
“It is the rare pediatric practice that routinely screens children for mental health problems,” said Lisa Honigfeld, vice president for health initiatives at the Child Health and Development Institute of Connecticut.
Why?
It can be a challenge for busy pediatricians to add one more thing to do during an already crammed visit. And if they find a patient needs more help, making a referral is often a struggle.
“They are uncertain about what to do next,” Honigfeld said. “That screening could highlight issues related to depression, related to suicidality, related to anxiety, a variety of mental health conditions. And that’s where child health providers are a little stuck in terms of what to do next.”
There aren’t enough pediatric mental health professionals in the state, so getting an appointment is tough. Then there are insurance issues. Some services aren’t covered by most health plans, and many clinicians in private practice don’t take insurance, leaving parents to pay out of pocket.
There’s also the issue of time, said Dr. Sandra Carbonari, a Waterbury pediatrician and president of the Connecticut chapter of the American Academy of Pediatrics.
At an adolescent’s visit, doctors are supposed to do a physical exam, and talk to patients about their social lives and school, their emotional well-being (including mental health issues), drugs and alcohol, and injury and violence prevention. Then there’s whatever the teen wants to talk about, like acne.
For all that, pediatricians have 15 or 20 minutes.
“I feel a little bit embarrassed to be talking to a reporter and saying no, I don’t do any screening for adolescent depression,” she said. “Yeah, we should do it, on the long list of things that possibly would be a good idea.”
Carbonari noted, though, that a major set of guidelines pediatricians use — called Bright Futures — doesn’t include depression in the screenings it recommends for adolescents.
Missing kids, referral struggles
Sometimes Carbonari finds patients have mental health issues because they have been cutting themselves. It’s rare for a teen to come in and say they’re feeling depressed, but “they may tell you in other ways,” Carbonari said, like acting out, losing weight, or struggling in school.
“I’m sure we’re missing a bunch of kids and that’s sort of heartbreaking, because it’s kind of what most pediatricians go into this for,” she said. “You want to have a positive effect on a child’s life, and their family.”
Like other pediatricians, Carbonari struggles with what to do when she needs to make a referral for mental health services. Her practice is affiliated with a behavioral health clinic, so patients often get referred there, but it can be challenging to make sure adolescents, who depend on others for transportation, can get to their appointments, she said.
One model that could help is school-based health centers, which provide mental health services where students are, Carbonari said.
It would also help to have mental health professionals available to primary care doctors, either on the phone or, better, working in the pediatric offices, she said.
Without an easy way to refer patients for mental health services, pediatricians are increasingly finding themselves handling behavioral health issues, said Jillian Wood, executive director of the Connecticut chapter of the American Academy of Pediatrics.
Research suggests that as many as one in five teens has depression at some point.
Someone to call
“Some of the pediatricians I’ve talked to say half of their day is dealing with mental health issues,” Wood said. That includes counseling, finding mental health professionals in the community, or prescribing medications. The pediatricians’ group now holds meetings to bring together pediatricians and child psychiatrists to educate each other about clinical issues and medications.
The Child Health and Development Institute has been visiting pediatric practices to talk about expanding their capacity to address mental health issues and building connections with community mental health providers. They also urge pediatricians to collect information on families’ mental health histories, just as they would ask whether a patient has a family history of asthma or heart disease.
The institute is also working on bringing together pediatricians and mental health provider to agree on how to manage depression and anxiety.
“We know that pediatricians will do more if there’s somebody whom they can call,” Honigfeld said.
Dudley, the New Britain pediatrician, considers himself fortunate; the health center where he works has behavioral health workers on site, so he can make immediate referrals. By contrast, many pediatricians work in small or solo practices.
New Britain also has school-based health centers, so Dudley’s patients can get mental health services there.
Careful wording
When adolescents’ answers to the screening questions suggest depression, Dudley begins a conversation about stress, what’s going on in their lives, and whether they want help. They almost always do.
He’s careful about the words he chooses, preferring “stress” to “depression.” He talks about getting a toolbox for dealing with stresses, rather than “seeing a shrink.”
One patient he had didn’t seem depressed, but her screening results suggested otherwise, so he asked her mother whether she was having problems. The mother told him that her daughter had been cutting herself all summer. The wounds had healed, but the screening led him to ask enough to discover a problem.
Dudley’s health center uses similar screening tools for other conditions, including postpartum depression in mothers. Each time a questionnaire has been introduced, he said, the number of referrals has increased between 30 percent and 50 percent.
Why would a piece of paper be better at detecting depression than a pediatrician who’s had a relationship with a teen for years?
It could be the format.
“An adolescent who sits by him or herself in the waiting room and only has to put it down on paper and doesn’t have to look somebody in the eye and tell them may be more likely to answer truthfully,” Honigfeld said.
Or it could be that it prompts doctors to ask questions.
“Most kids who are hurting really want help and don’t know how to ask for it,” Carbonari said.
“There’s a huge stigma attached in society to being depressed,” Dudley said.
“It’s really, for some families and some cultures, very difficult to say I might have a problem, and I think having this sort of screening allows you to open that up and talk about it. And it’s amazing when you ask folks.”
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