Screening for Mental Health Problems: Does It Work?
2014; Elsevier BV; Volume: 55; Issue: 1 Linguagem: Inglês
10.1016/j.jadohealth.2014.04.019
ISSN1879-1972
Autores Tópico(s)Adolescent and Pediatric Healthcare
ResumoSee Related Article p. 17It is widely recognized that mental health problems are important sources of adolescent morbidity and mortality. Elizabeth Costello and others [1Costello E.J. Primary care pediatrics and child psychopathology: A review of diagnosis, treatment, and referral practices.Pediatrics. 1986; 78: 1044-1051PubMed Google Scholar, 2Kelleher K.J. Childs G.E. Wasserman R.C. et al.Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.Arch Pediatr Adolesc Med. 1997; 151: 1109-1115Crossref PubMed Scopus (95) Google Scholar] found that primary care providers (PCPs), who see most adolescents, were failing to identify many of the youth with mental health concerns seen in their practices. These studies and other similar studies led to the development of primary care screening programs for behavioral health problems [[3]Stevens J. Kelleher K.J. Gardner W. et al.A trial of computerized screening for adolescent behavioral concerns.Pediatrics. 2008; 121: 1099-1105Crossref PubMed Scopus (61) Google Scholar]. In Massachusetts, such screening is mandated by a court order, and commercial payers reimburse for it. As a result, this state provides an excellent setting for studies of primary care behavioral health screening. The work of Hacker et al. [[4]Hacker K. Arsenault L. Franco I. et al.Referral and follow-up after mental health screening in commercially insured adolescents.J Adolesc Health. 2014; 55: 17-23Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar] in this issue of the Journal of Adolescent Health is therefore of great interest in learning how well screening is working.Hacker et al. studied 117 teens who were not currently in mental health care but who screened positive on the Pediatric Symptom Checklist (PSC) [[5]Jellinek M.S. Murphy J.M. Robinson J. et al.Pediatric symptom checklist: Screening school-age children for psychosocial dysfunction.J Pediatr. 1988; 112: 201-209Abstract Full Text PDF PubMed Scopus (293) Google Scholar]. They propensity score matched these teens with 110 youth who screened negative. Matches were based on age, gender, race, and date of visit. The authors found that adolescents with positive scores were more likely to be referred for mental health care, with an astronomical odds ratio of 43, and also more likely to have a mental health visit. One could raise a statistical worry that only a few of the potentially confounding variables were available to the authors for the propensity score matching. Nonetheless, the finding by Hacker et al. is powerful, and it is difficult to imagine that inclusion of additional variables would undermine it. So in one sense, screening works in Massachusetts.However, this is only one way to look at whether screening is succeeding. Consider what happened to the positive youth in the study by Hacker after they were screened. Of the 117 who screened positive, 112 (96%) received a mental health evaluation during the visit. Given the many competing clinical demands of a primary care visit, this is excellent performance by the PCPs. Of these 112, 46 (42%) received a mental health diagnosis during the visit. This may seem low. However, if we assume that the PSC has a sensitivity and specificity of 85% among youth attending primary care who are not currently in treatment and further assume that the prevalence of mental health disorders among these populations is 10%, then the positive predictive value of the PSC is 50%. So it is reasonable that PCPs disagreed with many of the positive PSC scores. We have no idea, however, whether the PCPs are making accurate diagnoses.But screening and diagnosis are only valuable if they lead to further interactions with the mental health system either to confirm whether there is a problem or to deliver care. Hacker et al. found that 63 (54%) of the positive youth were referred for mental health care. Of those 63, 21 (33%) refused the referral. Only 14 (22% of referred patients and 12% of PSC-positive patients) attended a face-to-face visit with a mental health professional. These findings are consistent with other studies [6Campo JV, Bridge J, Lucas A, et al. “Treatment as usual” for pediatric emotional disorders in primary care. Presented at: 2005 Joint Annual Meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry; October 18–23, 2005; Toronto, Ontario, Canada.Google Scholar, 7Grupp-Phelan J. Delgado S.V. Kelleher K.J. Failure of psychiatric referrals from the pediatric emergency department.BMC Emerg Med. 2007; 7: 12Crossref PubMed Scopus (26) Google Scholar].To appreciate what this means, consider how it looks from the point of view of a PCP trying to decide whether she should spend precious visit time screening the youth in her practice. There are many factors that limit the efficiency of mental health screening, including the relatively low prevalence of serious mental health problems among adolescents, the limited sensitivity and specificity of mental health screens, and the limited efficacy of current mental health treatments [[8]Tsapakis E.M. Soldani F. Tondo L. Baldessarini R.J. Efficacy of antidepressants in juvenile depression: Meta-analysis.Br J Psychiatry. 2008; 193: 10-17Crossref PubMed Scopus (123) Google Scholar]. These factors mean that a PCP has to screen scores of youth so that one will benefit from treatment. The worst problem, however, is that, as Hacker et al. found, a PCP has to refer almost five youths to get one to complete a mental health appointment. In effect, this multiplies the PCP's work by five, and therefore, she needs to screen hundreds of youths to benefit one. In the highly time-constrained world of primary care, effort spent screening has an opportunity cost in terms of other beneficial care that the PCP can deliver to the patient. Many mental health specialists believe that some PCPs are reluctant to screen because of the stigma associated with mental illness. We should also entertain the hypothesis that PCP reluctance to screen is a rational response to the inefficiency of screening.The data by Hacker et al. show that in an important sense primary care screening for mental health problems is not working. Their finding is consistent with the U.S. Preventive Services Task Force recommendation to “screen for major depressive disorder (MDD) in adolescents (ages 12–18 years) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up” [[9]U.S. Preventive Services Task Force. Screening for major depressive disorder in children and adolescents. 2009. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm. Accessed May 7, 2014.Google Scholar] (emphasis added). These systems are not generally in place.The implication is that we need research that moves beyond screening which includes how to achieve higher rates of identification of youth in need of care and higher rates of treatment completion among identified youths. We need to consider doing the following. First, primary care practices need better information technology, including improved assessments grounded in computerized adaptive testing that can efficiently achieve better sensitivity and specificity [10Gardner W. Kelleher K.J. Pajer K.A. Multidimensional adaptive testing for mental health problems in primary care.Med Care. 2002; 40: 812-823Crossref PubMed Scopus (92) Google Scholar, 11Gibbons R.D. Weiss D.J. Pilkonis P.A. et al.Development of a computerized adaptive test for depression.Arch Gen Psychiatry. 2012; 69: 1104-1112Crossref PubMed Scopus (125) Google Scholar]. Better assessments would better distinguish those youth most in need of care. These youth should be included in case registries that would facilitate longitudinal follow-up. To make this follow-up happen, PCPs should join with mental health specialists in regional teams organized to provide collaborative care [[12]Unützer J. Park M. Strategies to improve the management of depression in primary care.Prim Care. 2012; 39: 415-431Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar]. And at each step in care, providers need to integrate evidence-based engagement interventions into real world outpatient adolescent health care and social services settings to increase access to care and to reinforce family engagement in care [13Kazak A.E. Hoagwood K. Weisz J.R. et al.A meta-systems approach to evidence-based practice for children and adolescents.Am Psychol. 2006; 65: 85-97Crossref Scopus (140) Google Scholar, 14McKay M.M. Bannon W.M. Engaging families in child mental health services.Child Adolesc Psychiatr Clin N Am. 2004; 13 (vii): 905-921Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar]. See Related Article p. 17 See Related Article p. 17 See Related Article p. 17 It is widely recognized that mental health problems are important sources of adolescent morbidity and mortality. Elizabeth Costello and others [1Costello E.J. Primary care pediatrics and child psychopathology: A review of diagnosis, treatment, and referral practices.Pediatrics. 1986; 78: 1044-1051PubMed Google Scholar, 2Kelleher K.J. Childs G.E. Wasserman R.C. et al.Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.Arch Pediatr Adolesc Med. 1997; 151: 1109-1115Crossref PubMed Scopus (95) Google Scholar] found that primary care providers (PCPs), who see most adolescents, were failing to identify many of the youth with mental health concerns seen in their practices. These studies and other similar studies led to the development of primary care screening programs for behavioral health problems [[3]Stevens J. Kelleher K.J. Gardner W. et al.A trial of computerized screening for adolescent behavioral concerns.Pediatrics. 2008; 121: 1099-1105Crossref PubMed Scopus (61) Google Scholar]. In Massachusetts, such screening is mandated by a court order, and commercial payers reimburse for it. As a result, this state provides an excellent setting for studies of primary care behavioral health screening. The work of Hacker et al. [[4]Hacker K. Arsenault L. Franco I. et al.Referral and follow-up after mental health screening in commercially insured adolescents.J Adolesc Health. 2014; 55: 17-23Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar] in this issue of the Journal of Adolescent Health is therefore of great interest in learning how well screening is working. Hacker et al. studied 117 teens who were not currently in mental health care but who screened positive on the Pediatric Symptom Checklist (PSC) [[5]Jellinek M.S. Murphy J.M. Robinson J. et al.Pediatric symptom checklist: Screening school-age children for psychosocial dysfunction.J Pediatr. 1988; 112: 201-209Abstract Full Text PDF PubMed Scopus (293) Google Scholar]. They propensity score matched these teens with 110 youth who screened negative. Matches were based on age, gender, race, and date of visit. The authors found that adolescents with positive scores were more likely to be referred for mental health care, with an astronomical odds ratio of 43, and also more likely to have a mental health visit. One could raise a statistical worry that only a few of the potentially confounding variables were available to the authors for the propensity score matching. Nonetheless, the finding by Hacker et al. is powerful, and it is difficult to imagine that inclusion of additional variables would undermine it. So in one sense, screening works in Massachusetts. However, this is only one way to look at whether screening is succeeding. Consider what happened to the positive youth in the study by Hacker after they were screened. Of the 117 who screened positive, 112 (96%) received a mental health evaluation during the visit. Given the many competing clinical demands of a primary care visit, this is excellent performance by the PCPs. Of these 112, 46 (42%) received a mental health diagnosis during the visit. This may seem low. However, if we assume that the PSC has a sensitivity and specificity of 85% among youth attending primary care who are not currently in treatment and further assume that the prevalence of mental health disorders among these populations is 10%, then the positive predictive value of the PSC is 50%. So it is reasonable that PCPs disagreed with many of the positive PSC scores. We have no idea, however, whether the PCPs are making accurate diagnoses. But screening and diagnosis are only valuable if they lead to further interactions with the mental health system either to confirm whether there is a problem or to deliver care. Hacker et al. found that 63 (54%) of the positive youth were referred for mental health care. Of those 63, 21 (33%) refused the referral. Only 14 (22% of referred patients and 12% of PSC-positive patients) attended a face-to-face visit with a mental health professional. These findings are consistent with other studies [6Campo JV, Bridge J, Lucas A, et al. “Treatment as usual” for pediatric emotional disorders in primary care. Presented at: 2005 Joint Annual Meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry; October 18–23, 2005; Toronto, Ontario, Canada.Google Scholar, 7Grupp-Phelan J. Delgado S.V. Kelleher K.J. Failure of psychiatric referrals from the pediatric emergency department.BMC Emerg Med. 2007; 7: 12Crossref PubMed Scopus (26) Google Scholar]. To appreciate what this means, consider how it looks from the point of view of a PCP trying to decide whether she should spend precious visit time screening the youth in her practice. There are many factors that limit the efficiency of mental health screening, including the relatively low prevalence of serious mental health problems among adolescents, the limited sensitivity and specificity of mental health screens, and the limited efficacy of current mental health treatments [[8]Tsapakis E.M. Soldani F. Tondo L. Baldessarini R.J. Efficacy of antidepressants in juvenile depression: Meta-analysis.Br J Psychiatry. 2008; 193: 10-17Crossref PubMed Scopus (123) Google Scholar]. These factors mean that a PCP has to screen scores of youth so that one will benefit from treatment. The worst problem, however, is that, as Hacker et al. found, a PCP has to refer almost five youths to get one to complete a mental health appointment. In effect, this multiplies the PCP's work by five, and therefore, she needs to screen hundreds of youths to benefit one. In the highly time-constrained world of primary care, effort spent screening has an opportunity cost in terms of other beneficial care that the PCP can deliver to the patient. Many mental health specialists believe that some PCPs are reluctant to screen because of the stigma associated with mental illness. We should also entertain the hypothesis that PCP reluctance to screen is a rational response to the inefficiency of screening. The data by Hacker et al. show that in an important sense primary care screening for mental health problems is not working. Their finding is consistent with the U.S. Preventive Services Task Force recommendation to “screen for major depressive disorder (MDD) in adolescents (ages 12–18 years) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up” [[9]U.S. Preventive Services Task Force. Screening for major depressive disorder in children and adolescents. 2009. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm. Accessed May 7, 2014.Google Scholar] (emphasis added). These systems are not generally in place. The implication is that we need research that moves beyond screening which includes how to achieve higher rates of identification of youth in need of care and higher rates of treatment completion among identified youths. We need to consider doing the following. First, primary care practices need better information technology, including improved assessments grounded in computerized adaptive testing that can efficiently achieve better sensitivity and specificity [10Gardner W. Kelleher K.J. Pajer K.A. Multidimensional adaptive testing for mental health problems in primary care.Med Care. 2002; 40: 812-823Crossref PubMed Scopus (92) Google Scholar, 11Gibbons R.D. Weiss D.J. Pilkonis P.A. et al.Development of a computerized adaptive test for depression.Arch Gen Psychiatry. 2012; 69: 1104-1112Crossref PubMed Scopus (125) Google Scholar]. Better assessments would better distinguish those youth most in need of care. These youth should be included in case registries that would facilitate longitudinal follow-up. To make this follow-up happen, PCPs should join with mental health specialists in regional teams organized to provide collaborative care [[12]Unützer J. Park M. Strategies to improve the management of depression in primary care.Prim Care. 2012; 39: 415-431Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar]. And at each step in care, providers need to integrate evidence-based engagement interventions into real world outpatient adolescent health care and social services settings to increase access to care and to reinforce family engagement in care [13Kazak A.E. Hoagwood K. Weisz J.R. et al.A meta-systems approach to evidence-based practice for children and adolescents.Am Psychol. 2006; 65: 85-97Crossref Scopus (140) Google Scholar, 14McKay M.M. Bannon W.M. Engaging families in child mental health services.Child Adolesc Psychiatr Clin N Am. 2004; 13 (vii): 905-921Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar]. Referral and Follow-Up After Mental Health Screening in Commercially Insured AdolescentsJournal of Adolescent HealthVol. 55Issue 1PreviewAlthough mental health screening is recommended for adolescents, little is known about the predictors of referral to mental health services or engagement in treatment. We examined predictors of mental health referral from primary care and service use for commercially insured youth who had been screened using the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist. Full-Text PDF
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