COMMENTARY

Identifying Mental Illness Early Through Routine Mental Health Screening

John H. Genrich, MD; Leslie C. McGuire, MSW

Disclosures

November 02, 2009

In This Article

Early Detection

Routine mental health screening in primary care can detect possible symptoms of depression and other mental illness, much like a blood pressure test can identify possible cardiovascular risk factors. Making mental health checkups routine is key to early identification and critical to prognosis for those who suffer from mental illness.[2,5]

Primary care settings are ideal for implementing mental health checkups, given the regularity with which patients see their PCPs and the existing screening practices already in place there for other health issues. More than 70% of adolescents see a PCP at least once each year, and more than 50% visit a PCP for routine healthcare each year. However, according to one survey of pediatricians and family physicians, only 23% of respondents routinely screen their adolescent patients for mental illness.[31]

Screenings provide prime opportunities for health providers to ask adolescents about their emotional and behavioral health -- something that is often not shared otherwise. Studies examining parental awareness of their children's self-injurious behavior have indicated that fewer than 25% of parents know of their children's self-harm behavior,[32] and that only a minority of mothers are aware of their children's suicidal ideation or suicide attempts.[33]

In a recent study that assessed PCPs' rates of addressing emotional distress with adolescent patients, only 34% of youth reported that their doctors talked to them about their emotional health -- with older teens, Latino adolescents, and girls more likely to report that discussion than any other group.[10] Although 1 of 4 teens (27%) reported emotional distress, distress was not a significant predictor for teens talking to their PCPs about their emotional health.[10] In another study, 45% of all suicide victims were shown to visit their PCPs in the month prior to their death, and 77% were shown to have contact with their PCPs in the year before their death.[34] This stresses the importance of systematic screening for mental health problems in the primary care setting.

Screening Questionnaires

Validated screening questionnaires proven to accurately assess potential mental health disorders are widely available at little or no cost. Numerous questionnaires have been evaluated and found to accurately identify symptoms of mental illness and current mental disorders in diverse adolescent populations.[2] According to research, youth are comfortable answering sensitive questions about their mental health on a screening questionnaire.[35] This method of assessment has also been shown to be more effective than observation or nonstructured interview or assessment.[7]

Studies of primary care screening programs have indicated that approximately 12%-14% of those receiving a mental health checkup receive a positive score, and require an interview with a physician or other health professional to determine whether there is evidence of a possible mental illness, and if necessary a referral to a mental health professional.[36,37]

Many evidence-based screening questionnaires are available, including several that detect symptoms of single mental illnesses only and others that are not designed to be used in the primary care setting. Because of its ability to detect a wide range of mental health problems and its thorough validation in primary care settings, the screening tool most widely used in the primary care setting is the Pediatric Symptom Checklist (PSC) (Figure 3).[37] When an individual receives a positive score on the PSC, it is recommended that he/she be further evaluated by a health or mental health professional.[37]

Figure 3.

 

Pediatric Symptom Checklist Youth Report: Screening Questionnaire.

The PSC was developed at Harvard University, Boston, Massachusetts, and is promoted by the AAP as the chosen instrument for its Bright Futures program. The questionnaire is a 35-item youth self-completion screen designed to detect behavioral and psychosocial problems. The PSC's validity has been examined in a diversity of medical settings and a range of socioeconomic backgrounds. It has been shown that the tool determines impairment and the presence of psychiatric disorders with the same case classifications as the Children's Behavior Checklist (CBCL) and Clinicians' Global Assessment Scale (CGAS).[38] The PSC has also exhibited high rates of overall agreement, sensitivity, and specificity (at 79%/92%, 95%/88%, and 68%/100%, respectively) when analyzed against CGAS scores for middle- and lower-income populations, and has been shown to produce an estimated 12% prevalence rate for psychosocial disorders among middle-class patients or when administered in general settings; this is comparable to national estimates of psychosocial impairment.[38]

Clinical Acceptance and Adaptability

A 2007 study published in the Journal of the American Academy of Pediatrics found that depression screening was proven to be feasible in primary care settings and accepted by patients, parents, and providers.[9] In a national survey of randomly selected primary care pediatricians, 90% of pediatricians said that they felt responsible for identifying adolescent depression.[39] This study indicated that a significant proportion of primary care pediatricians would be willing to change how they identified and managed child and adolescent depression.[39]

Mental health checkups can be implemented in regular adolescent health visits at minimal cost and inconvenience. Screening is acceptable to many parents and adolescents in the primary care setting and does not disrupt the flow of patient care.[36,40] They are quick and simple to administer for both the patient and healthcare provider and require no more time than other preventive and wellness screenings.[9] (See the "Personal Commentary: 'A Pediatrician's Experience With Mental Health Screening'" accompanying this article.)

Additionally, studies implemented in primary care practices serving adult patients have demonstrated that by identifying and delivering effective treatments to depressed patients, use of inpatient and outpatient medical services can be decreased and cost reductions can be achieved.[41,42,43]

TeenScreen Primary Care: PCP Materials and Demonstration Projects

TeenScreen Primary Care is an initiative of the TeenScreen National Center for Mental Health Checkups at Columbia University, New York, NY, designed to assist healthcare professionals by integrating mental health checkups into routine adolescent healthcare. TeenScreen provides free evidence-based screening tools to medical providers to help them determine whether their adolescent patients are suffering from depression, anxiety, or other mental health conditions, and to ascertain whether they are at risk for suicide.

TeenScreen's mental health checkup is designed for 11- to 18-year-olds and involves the administration of the youth self-completion version of the PSC followed by a brief assessment by the PCP (Figure 4). The screening is typically incorporated into well-child exams, sports physicals, and other routine office visits. The PSC can be completed and scored in less than 5 minutes, and can be administered in a private area of the medical office by a nurse, medical technician, or other office staff. Adolescents who score positive on the PSC are evaluated by their PCPs to determine whether the symptoms endorsed on the questionnaire are significant, causing impairment and warranting further attention. If the PCP determines that mental health services are needed, the adolescent's parents are then notified, and he/she is either referred for mental health services or offered follow-up or treatment by the PCP. Free implementation materials are available at http://www.teenscreen.org/teenscreen-primary-care.

Figure 4.

Mental health checkups in primary care.

TeenScreen is partnered with ValueOptions, Kaiser Permanente, and EmblemHealth -- all managed care organizations -- and other medical organizations and practices on primary care demonstration projects in 20 states. These programs have shown that mental health checkups for adolescents are adaptable in a wide range of settings, including small medical practices, emergency departments, federally qualified health centers, and children's wellness centers. They can also be implemented by diverse payers, such as managed care and behavioral health organizations, physicians' staff plans, fee-for-service plans, and multiparty/payer consortiums. These programs each use the core elements recommended by the USPSTF, including an evidence-based screening questionnaire and a referral system that can link patients requiring additional assessment to qualified health providers.

Future Challenges

Despite available tools and easy implementation guidelines, reimbursement and adequate referral resources remain the 2 most significant challenges to implementing mental health checkups in primary care. PCPs find difficulty in obtaining reimbursement from insurers for mental health services offered in a primary care setting, which can lead to deincentivizing of screening and follow-up. PCPs also report that the shortage of mental health providers, specifically child and adolescent psychiatrists, complicates evaluation and treatment of youth identified with a potential mental illness.

However, TeenScreen demonstration programs have shown that with dedicated behavioral health services and referral hotlines, which are provided by most of the major health plans, necessary referrals can be made quickly and efficiently. These demonstration programs have also highlighted how effective and foresighted leadership in managed care can lead to policy change. All of the health plans participating in TeenScreen's demonstration projects have assessed their reimbursement policies and now provide proper reimbursement for mental health screening and assessment services offered in primary care settings.

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