WASHINGTON – Several years after the U.S. Preventive Services Task Force recommended screening adolescents for depression in primary care, only half of pediatricians and other primary care providers are routinely using standardized instruments, according to a statewide survey of pediatricians, family physicians and nurse practitioners in Minnesota.
"In general, clinicians most frequently used clinical observation or overall impressions to identify adolescents experiencing depression [rather] than other methods," Lindsay Taliaferro, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.
The estimated overall prevalence of major depressive disorder among adolescents is 5.6%, and the point prevalence in primary care settings is reported as ranging from 9% to 21%, according to the U.S. Preventive Services Task Force (USPSTF) recommendations.
Dr. Taliaferro and her colleagues at the University of Minnesota, Minneapolis, administered an online survey to a statewide sample of physicians and nurse practitioners (NPs) who provide direct ambulatory primary care services to adolescents aged 12-18 years. The clinicians were identified from lists obtained from the state’s boards of nursing and medical practice; there was a 20% response rate, which Dr. Taliaferro said is low but typical of such surveys.
The analytical sample included 127 pediatricians and 54 pediatric NPs, as well as 260 family physicians and 96 family medicine NPs.
Asked to report which depression identification practices they "usually/almost always" employ, 80% said they use clinical observation/overall impression, while 50% said they use a standardized written depression screening instrument, 40% use a "depression screening item within a comprehensive behavioral screening instrument," and 20% use a psychosocial interview (such as the HEADSS assessment, which stands for home, education and employment, activities, drugs, sexuality, suicide/depression).
There were no significant differences between physicians and nurse practitioners in the methods used to identify depression. There were differences, however, between pediatrics and family medicine in both the use of a psychosocial interview and the use of clinical observation/overall impression, with pediatric clinicians (both physicians and NPs) significantly more likely to report use of these methods, Dr. Taliaferro noted.
In another survey item, 75% of the pediatric providers reported routinely "asking about" depressive symptoms when providing health supervision. For family physicians and family nurse practitioners, this rate was 66%, she reported.
Asked if they had "ever" administered a standardized written depression instrument, 76% of providers indicated they had.
All told, Dr. Taliaferro said, it appears from the survey that "most [clinicians] don’t screen everyone, but instead are screening only high-risk patients after they identify some warning signs or in response to specific complaints."
The USPSTF issued its recommendation for adolescent screening in 2009, saying that clinicians should screen for major depressive disorder in adolescents (12- to 18-year-olds) when systems are in place to ensure accurate diagnosis, treatment, and follow-up.
"We all know that many adolescents in distress present with medical problems rather than psychological symptoms, and that adolescents may not verbalize their feelings or disclose their psychological issues without prompting from clinicians," said Dr. Taliaferro, who is now with the University of Missouri School of Health Professions, Columbia.
According to the task force, two screening instruments – the PHQ-A (the Patient Health Questionnaire–9 modified for adolescents) and the BDI-PC (Beck Depression Inventory for Primary Care) – have demonstrated good sensitivity and specificity for adolescents seen in primary care settings.
Dr. Taliaferro said after the meeting that "an overwhelming majority" of survey participants who use standardized instruments indicated that they use the PHQ-9, presumably the adolescent version. The PHQ-9 is integrated into the electronic medical record of many of the systems being utilized in primary care, she noted.
The investigators analyzed survey data to determine what factors were associated with use of a standardized written depression screening instrument and with inquiries about depression symptoms. Factors that increased the likelihood of administering a screening instrument included being female, being a family medicine clinician, having clear protocols for follow-up after depression, and feeling better prepared to address depression among adolescents.
Factors that increased the likelihood of asking about depression symptoms included believing more strongly that providers should be responsible for addressing depression among adolescents and being more familiar with recommendations regarding screening, Dr. Taliaferro reported.
Approximately 40% of participants reported having on-site mental health services that are available to their adolescent patients, she noted.
Dr. Taliaferro reported that she had no relevant financial disclosures. The investigators received funding for the survey from the Minnesota Department of Human Services.