Emergency Medicine Implementing Adolescent Depression Screening in the Emergency Department (ED)
March 1, 2005 - Feb. 29, 2008
Grant Number
H34MC04366
Project Overview
Adolescent depression is a pervasive and often devastating illness, yet is often undetected by healthcare professionals. This project addresses this problem through the development of a computerized screening process for depression in adolescent patients presenting to the emergency department. This project developed, implemented, and assessed the impact of an emergency department (ED) adolescent depression screening tool. Project objectives included: (1) identification of stakeholders' perceived barriers toward, and preferences for, a computerized adolescent depression screening tool for use in the ED; (2) development and pilot testing of the computer based ED screening process for adolescent depression; and (3) assessment of the impact of the screening process on identification and referral rates for children with suspected adolescent depression in the ED.
Characteristics and behavioral risk factors of firearm-exposed youth in an urban emergency department
Author(s)/Presenter(s)
Abaya, R., T. Atte, J. Herres, G. Diamond and J. A. Fein
Abstract/Description
Assessing firearm access among adolescents with behavioral health risk factors is important for the primary prevention of suicide and interpersonal violence. We describe self-reported firearm access and the associated behavioral risk factors and demographic characteristics in a cross-sectional study conducted in the emergency department of an urban pediatric hospital from June 2013 to June 2014. A total of 2258 adolescents received a behavioral health survey to assess access to firearms inside and outside the home, mental health symptoms, and risk behaviors. One of 6 patients in our sample (15%) endorsed access to a firearm. Male gender, lifetime alcohol use, lifetime marijuana use, and lifetime other drug use were associated with access. Participants reporting access were more likely to report clinical levels of lifetime suicidality and depression. The odds of current suicidality were highest in those with 24-h access (OR 2.77 CI 1.73-4.46), compared to those who did not endorse access.
Adolescent depression: views of health care providers in a pediatric emergency department
Objective: Pediatric emergency department (PED) providers are strategically positioned to identify adolescents with depression. Our objectives were to describe health care providers' perspectives on adolescent depression and the role of depression screening in the PED.
Methods: We conducted semistructured interviews with 41 health care providers from an urban, academic PED (including PED attending physicians and trainees, social workers, and psychiatrists). Interviews were audiotaped, transcribed, and entered into the N6 qualitative data analysis software version 6 (QSR International Pty Ltd, Cambridge, Mass) for coding and analysis. A multidisciplinary team used content analysis to identify 2 primary domains: (1) provider attitudes about adolescent depression and (2) factors associated with adolescent depression screening processes in a PED setting.
Results: The PED-based providers demonstrated a clear understanding of the clinical burden of adolescent depression but described complex individual and system-level barriers to addressing the issue. All providers recognized the high prevalence of adolescent depression and its impact on health and described adolescent depression as a moderate-to-large problem that was greatly underrecognized but applied primarily a biomedical model for treatment options. The respondents endorsed computerized screening as a useful approach. Concerns were raised universally regarding the ability of the health care system to respond to screened adolescents found to be depressed.
Conclusions: The study describes the perspectives of multiple, key stakeholders necessary for a system response to the identification, assessment, and management of adolescent depression in the PED. The PED providers were generally supportive of computerized depression screening in the PED setting but also voiced the need for system-level responses that facilitate access to quality mental health care services for adolescents.
Development, validation, and utility of internet-based, behavioral health screen for adolescents
Development, validation, and utility of internet-based, behavioral health screen for adolescents
Author(s)/Presenter(s)
Diamond G, Levy S, Bevans KB, Fein JA, Wintersteen MB, Tien A, Creed T
Abstract/Description
Objectives: The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care.
Methods: Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black.
Results: The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbach's alpha = 0.75-0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were > or =4 times more likely to endorse other risk behaviors or stressors.
Conclusions: The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.
Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department
Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department
Author(s)/Presenter(s)
Fein JA, Pailler ME, Barg FK, Wintersteen MB, Hayes K, Tien AY, Diamond GS
Abstract/Description
Objectives: To determine the adoption rate of the Web-based Behavioral Health Screening-Emergency Department (BHS-ED) system during routine clinical practice in a pediatric ED, and to assess this system's effect on identification and assessment of psychiatric problems.
Design: Descriptive design to evaluate the feasibility of a clinical innovation.
Setting: The ED of an urban tertiary care children's hospital.
Participants: Adolescents from 14 to 18 years of age, without acute or critical injuries or illness, presenting with nonpsychiatric symptoms.
Intervention: The ED clinical staff initiated the use of the BHS-ED system, which identifies and assesses adolescents for depression, suicidal ideation, posttraumatic stress, substance use, and exposure to violence. Treating clinicians reviewed results and followed routine care practices thereafter.
Main outcome measures: Adoption rate of the BHS-ED system by nursing staff, identification rates of occult psychiatric problems, and social worker or psychiatrist assessment. Data were collected for 19 months before implementation of the BHS-ED system and for 9 months during implementation.
Results: Of 3979 eligible patients, 1327 (33.4%) were asked by clinical staff to get screened using the BHS-ED; of these 1327 patients, 857 (64.6%) completed the screening and 470 (35.4%) refused. During implementation, identification of adolescents with psychiatric problems increased significantly (4.2% vs 2.5%; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.38-2.10), as did ED assessments by a social worker or psychiatrist (2.5% vs 1.7%; OR, 1.47; 95% CI, 1.13-1.90). Of the 857 patients who were screened with the BHS-ED, 90 (10.5%) were identified as having psychiatric problems (OR, 4.58; 95% CI, 3.53-5.94), and 71 (8.3%) were assessed (OR, 5.12; 95% CI, 3.80-6.88).
Conclusions: In a busy pediatric ED, computerized, self-administered adolescent behavioral health screening can be incorporated into routine clinical practice. This can lead to small but significant increases in the identification of unrecognized psychiatric problems.
Patients' and caregivers' beliefs about depression screening and referral in the emergency department
Patients' and caregivers' beliefs about depression screening and referral in the emergency department
Author(s)/Presenter(s)
Pailler, M. E., P. F. Cronholm, F. K. Barg, M. B. Wintersteen, G. S. Diamond and J. A. Fein
Abstract/Description
Objectives: To explore patients' and parents'/caregivers' beliefs about the acceptability of universal depression screening in the emergency department (ED) and their perceptions of the barriers and facilitators to a mental health referral following a positive screen.
Methods: We conducted semistructured interviews with 60 patients seeking care and 59 caregivers in the ED of an urban children's hospital. Interviews were audiotaped, transcribed, coded, and entered into N6 (version 6.0; QSR, Thousand Oaks, Calif) for coding and content analysis.
Results: Patients and caregivers supported the idea of depression screening in the ED, generally viewing screening as a reflection of care and concern. Respondents reported apprehension about stigma, privacy, and provider sensitivity. Introducing the screening concept early in the visit and as part of routine care was believed to reduce stigma. Respondents generally indicated that although they would likely follow through with a referral if given, stigma and denial were viewed as significant barriers. Caregivers also reported that logistical problems such as transportation, insurance, and agency hours created barriers to help seeking, but this could be offset by social supports and information about the agency and the provider.
Conclusions: Patients and caregivers generally support depression screening in the pediatric ED but identified several barriers to screening and referral for treatment. Recommendations include introduction of universal screening early in the ED visit, provision of specific information about the meaning of screening results, and support from family and health care providers to help reduce stigma and increase referral acceptability.
Computerized behavioral health screening in the emergency department
Computerized behavioral health screening in the emergency department
Author(s)/Presenter(s)
Pailler ME, Fein JA
Abstract/Description
The rate of untreated mental health problems among children and adolescents has increased over the past decade, and it is estimated that 70% of children in need do not receive mental health services. Untreated, mental health problems place children at risk for poor school performance and social isolation, and in some cases can lead to adult psychopathology and suicide. Routine screening in medical settings has been recommended as a mechanism for identifying adolescents with unmet mental health needs. The American Academy of Pediatrics (AAP) has acknowledged the role of the emergency department (ED) as a safety net for children and adolescents with unmet mental health needs and recommended the development of accurate mental health screening tools and best practices for follow-up programs for pediatric patients.
Screening for suicide risk in the pediatric emergency and acute care setting
Screening for suicide risk in the pediatric emergency and acute care setting
Author(s)/Presenter(s)
Wintersteen, M. B., G. S. Diamond and J. A. Fein
Abstract/Description
Purpose of review: This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings.
Recent findings: For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings.
Summary: Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up.