What happens after you screen an adolescent for depression?

No one gets better just from getting a mental health assessment. Screening and diagnosis only benefit a patient if the assessments lead to successful mental health treatment. In the current JAMA Pediatrics, Briannon O’Connor and her co-authors (I am one) report research on the care that adolescents receive after symptoms of depression are detected.

OBJECTIVE To determine rates of appropriate follow-up care for adolescents with newly identified depression symptoms in 3 large health systems.

DESIGN, SETTING, AND PARTICIPANTS In this analysis conducted from March to September 2014, structured data retrospectively extracted from electronic health records were analyzed for 3 months following initial symptom identification to determine whether the patient was followed up and, if so, whether treatment was initiated and/or symptoms were monitored. Records were collected from 2 large health maintenance organizations in the western United States and a network of community health centers in the Northeast. The study group included adolescents (N = 4612) with newly identified depression symptoms, defined as an elevated score on the Patient Health Questionnaire (10) and/or a diagnosis of depression.

MAIN OUTCOMES AND MEASURES Rates of treatment initiation, symptom monitoring, and follow-up care documented within 3 months of initial symptom identification.

We looked at follow-up care in some of the best health care systems in the country. We found major gaps in the care kids received.

RESULTS Among the 4612 participants, the mean (SD) age at index event was 16.0 (2.3) years, and 3060 were female (66%). Treatment was initiated for nearly two-thirds of adolescents (79% of those with a diagnosis of major depression; n = 1023); most received psychotherapy alone or in combination with medications. However, in the 3 months following identification, 36% of adolescents received no treatment (n = 1678), 68% did not have a follow-up symptom assessment (n = 3136), and 19% did not receive any follow-up care (n = 854). Further, 40% of adolescents prescribed antidepressant medication did not have any documentation of follow-up care for 3 months (n = 356). (Emphasis added.)

So about a third of adolescents who were identified with depression were not treated and of those who were treated, many did not have a follow-up visit or follow-up assessment that could assess treatment progress. Unfortunately, we couldn’t get data in this study that could tell us why the care didn’t occur.

This is bad. Follow-up care is important because the first mental health treatment a clinician tries may not work. Medication doses often need to be changed. Sometimes the particular form of psychotherapy proves unsuitable for the patient. Finally, although the benefits of anti-depressant medications for depressed adolescents likely outweigh the risks, the drugs can have side effects. Follow-up care is important to monitor whether young patients are safe.

When the US Preventive Services Task Force* considered whether adolescents should be screened for depression, they wrote that

The USPSTF recommends screening for major depressive disorder (MDD) in adolescents ages 12 to 18 years when adequate systems are in place for diagnosis, treatment, and monitoring. (Emphasis added)

I think they included the latter qualification because screening is pointless and wasteful if a positive screen does not lead to care. This study showed that systems that can reliably deliver follow-up care to adolescents are not in place even in good health care systems.

This doesn’t mean that we shouldn’t screen kids for depression. For one thing, many of the kids who were identified with depression did get treatment with follow-up care. What it means is that it’s not enough to screen. You have to fix the treatment and follow-up care systems too.

* See Aaron’s post here on the USPSTF’s recommendations about adult depression screening. The language I quote here is a draft of the Task Force’s proposed recommendation, but I believe it is likely to become part of the final language.


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