Primary Care Gains Popularity as MH Screening Site

Even before the U.S. Preventive Services Task Force updated its recommendations to provide depression screening for adolescents aged 11 to 18 in April 2009, a variety of screening systems were used to identify young people with mental health problems.

Now, a program developed originally for use in schools is expanding into primary care.

TeenScreen was developed at Columbia University by David Shaffer, M.D., and colleagues in 1991 to identify children and adolescents with mood or substance abuse symptoms. The national program was launched in 2003 and is used at 563 school and community sites.

“Screening makes sense because we have the tools, mental illness is treatable, and no one else asks teens these questions,” said Leslie McGuire, M.S.W., deputy executive director of TeenScreen, speaking at last fall's American Academy of Child and Adolescent Psychiatry annual meeting in Honolulu. “We're really trying to find the kids no one knows about—the ones who are not acting out.”

The Fond du Lac County, Wis., schools began a pilot version of TeenScreen in 2002, and it now operates in all public and private schools in the county, in primary care settings, and at the juvenile-justice intake center.

“Before we began, we spent six months preparing the soil,” said Marian Sheridan, health and safety coordinator for the county schools, in an interview.

An advisory board was created that included psychiatrists and other physicians and mental health professionals to provide credibility and engage the provider community. Sheridan's office also set up a system for referrals, even finding funding to pay for care for poor children.

About 7,700 students (in a county of less than 100,000 population) have been offered screening, and 4,400 have been screened. So far, 835 young people have been referred for further evaluation or treatment, said Sheridan.

To determine if a referral is needed, TeenScreen uses two tools. The first is the 10-minute, 14-item Columbia Health Screen to assess symptoms of depression, anxiety, substance abuse, and suicidality. The second is the 52-item, 10-minute, computer-based Diagnostic Predictive Scales, assessing social phobia, anxiety, panic attacks, obsessive/compulsive disorder, depression, suicidality, and substance abuse.

In schools, TeenScreen tests an entire class at a time (provided that their parents have consented) rather than selecting “at-risk” individuals. Afterward, all the youth are debriefed individually, regardless of how they scored on the screens, to avoid publicly identifying and stigmatizing those with positive scores.

Teens who score positive can receive a follow-up clinical interview and may be referred for a more complete evaluation and diagnosis.

Getting Beyond ‘the Hard Part’

“The next step, getting kids to mental health services, is the hard part,” said McGuire. Parents are circumspectly told that their child “would benefit from further evaluation.”

Thus, follow-up and ready access to referral sources are also critical.

“We agree to work with a site only if they set up links to follow-up settings,” said Laurie Flynn, TeenScreen executive director, in a meeting with APA's Council on Children, Adolescents, and Their Families last September.

The program may sound like a welcome idea, but parents and insurance companies sometimes resist. In fact, parents often resist from the beginning, said McGuire. Only half of the permission forms are returned, and only 25 percent to 30 percent of parents contacted provide consent. Nonetheless, once parents had agreed to the child's screening, 85 percent to 90 percent of those young people also consented.

School boards or educators may erect other barriers because they feel that it is not up to the schools to look for mental health problems, said Jane Foy, M.D., a professor of pediatrics at Wake Forest University and chair of the American Academy of Pediatrics' Task Force on Mental Health. “But if there has been a suicide, they might be more open to prevent and reduce the impact of depression.”

Program Expands Into Primary Care

Because of resistance from some schools, there has been a push to expand and support screening in primary care settings.

Starting about two years ago, TeenScreen expanded its efforts to include primary care providers. Today, 295 primary care sites in 28 states include TeenScreen checkups.

Working in primary care has several advantages over school-based settings, said Susan Craig, M.P.H., TeenScreen's media relations director. On the practical side, there's no need for the deliberations involved in getting approval from a local school board. In addition, because the screening takes place in a doctor's office, there is no question about confidentiality. And in many states, there is no need for parental consent with older teenagers for screening in a physician's office.

In primary care settings, the Pediatric Symptom Checklist–Youth (PSC-Y) report is the screening instrument, which TeenScreen says takes five minutes to complete and score.

One user is Kaiser Permanente's Colorado operation, which is pilot testing the program with 27 physicians, Richard Spurlock, M.D., medical director for southern Colorado, told Psychiatric News. Kaiser encourages physicians to use TeenScreen with all of their adolescent patients. Nearly all the doctors report that it helps identify young patients with depression or suicidality.

Kaiser has developed a reimbursement system to cover office visits, questionnaire administration, and follow-up discussions. Doctors can consult with a “behavioral health specialist” on the phone—during the office visit, if necessary—and link the patient or family with a network of mental health care professionals.

Spurlock has done no formal evaluation yet, but is satisfied enough that he is expanding the program throughout Kaiser's southern Colorado network, for adolescents as well as adults.

Screening tools alone are no substitute for diagnostic judgment, noted Karen Hacker, M.D., M.P.H., an expert on screening in primary care at Cambridge Health Alliance and executive director of the Institute for Community Health in Massachusetts.

“The score alone is not reason to refer,” Hacker, who does not use TeenScreen, told Psychiatric News. “It's a tool to help, but you need clinical acumen to account for over- or under-reporting of symptoms.”

Hacker emphasized the need for systems and providers to back up the screen.

“Within Cambridge Health Alliance, we have worked closely with our colleagues in child psychiatry to break down barriers,” she said. “The pediatricians know they'll get support, and many are co-located with psychiatrists within the system.”

Information about TeenScreen is posted at <www.teenscreen.org>.