Tools & Resources

• TeenScreen National Center Webinar: Rethinking Adolescent Mental Health Care: Using Common Factors to Improve Your Practice Potential
• Adolescent Depression Module for Primary Care and Behavioral Health Providers, University of Nebraska Medical Center.
• Pediatric Primary Care Mental Health Specialty Certification, Pediatric Nursing Certification Board
• Medicaid.gov: State-specific information Medicaid’s Children’s Health Insurance Program

Spotlight: Research & Trends

Preventing Suicide: Research Connects Onset of Depression with First Attempt

High school students who attempt suicide are far more likely to have experienced serious depression that same year, while those who attempt suicide in middle school most often suffer from chronic depression, according to new findings in the Journal of Adolescent Health. The research assessed the validity of retrospective self-reporting of depression and suicidal behaviors in predicting suicidal risk.

Using data from the Raising Healthy Children (RHC) preventive program, researchers from the University of Washington asked 883 men and women (ages 18-19) four questions on past suicidal behaviors via a computer-based questionnaire. The young adults had all participated in the RHC program, which assessed their depressive symptoms via the Seattle Personality Questionnaire from 1993 – when most were in first grade– through their high school graduation 12 years later.

In the retrospective analysis, researchers found that those who made only one suicide attempt (36) did so in high school. They reported elevated depressive symptoms in the year of the attempt in comparison with symptoms in prior years. However, those who made multiple attempts were more likely to make a first attempt in elementary or middle school. In addition, they showed no increase in depression symptoms in the years they reported their attempts, indicating chronic, elevated depression over time.

Researchers concluded that asking questions about suicidality offers professionals a reliable tool in assessing a patient’s suicidal risk. With their data showing that nearly 40% of repeat attempters were in elementary/middle school at the time of their first attempt, they urged increase attention to suicide prevention in earlier grades.

Stigma, Other Intangibles, Cited as Parental Barriers in Urban Communities

Although transportation, logistics and other tangible barriers are often cited as hindering access to adolescent mental health care in urban, low-income communities, a new study finds that ‘intangible’ barriers of parent perceptions of mental illness and stigma may pose greater obstacles.

Research published in Administration and Policy in Mental Health and Mental Health Services Research evaluated the connection between parent-reported barriers and follow-through on mental health referrals. The study was conducted at a pediatric primary care clinic at the Department of Pediatrics at Johns Hopkins University School of Medicine in Baltimore with 55 families whose child or adolescent had been referred to the Children’s Mental Health Center between November 2008 and July 2009. Justine Larson, M.D., Susan dosReis, PhD, et al., found that 64% followed up on the mental health referral, while 36% failed to attend the initial evaluation or never made an appointment. Approximately 40% of parents indicated no tangible barriers to accessing care, and the majority (94%) agreed that their child or adolescent did have a mental health problem and understood the reason for referral.

Of those who did not follow through, 15% said they did not feel their child’s problem was “bad enough” to warrant therapy, or did not need treatment at all, while an additional 15% believed their decision would not be supported by family and friends. Others said their child would refuse to go to the mental health center, and some expressed concerns about medication. Researchers were surprised to learn that these barriers – rather than logistical/tangible obstacles – impeded access to care.
Study authors noted that discussions about mental health care initiated by the patient’s pediatrician increased successful referrals and adherence to treatment – even after mental health care had begun. They recommended incorporating such discussions in primary care settings.

Managing Adolescent Mental Health in Primary Care: Combination Treatment Remains First-Line

Although major clinical trials show conflicting results for first-line management of adolescent depression in primary care, current practice guidelines support a stepped-care approach that starts with psychotherapy and introduces pharmacotherapy if necessary, as discussed in a recent review in Current Opinion in Psychiatry.

In their overview of three major clinical trials (TORDIA, TADS, and ADAPT) and meta-analyses, authors Valsamma Eapen and Rudi Crncec, University of New South Wales, Australia, noted that some studies show optimal benefit from combining cognitive behavioral therapy (CBT) with fluoxetine or another SSRI, other studies indicate SSRI treatment alone can be as effective in severe or resistant cases of adolescent depression.

The low-risk associated with psychotherapy, ongoing concerns with the safety of SSRIs in adolescents, and research showing adolescents prefer talk therapy to pharmacologic treatment underscore its value as first-line treatment. However, the authors emphasized that medication should be added if improvement is not seen in six weeks or less.

Overall guidelines include:

• Mild Depression: “Watchful waiting,” psychoeducation, guided self-help, CBT therapy
• Moderate to Severe Depression: Brief psychological therapy; family support, psychoeducation, relapse prevention; pharmacotherapy with SSRI (fluoxetine)
• Unresponsive/Recurrent/Psychotic: Intensive therapy and psychoeducation; family support; relapse prevention; pharmacotherapy with SSRI; augmentation with antipsychotic

Patient care should also include identification and management of risk factors found to hinder response and promote relapse. Family conflict, physical abuse, parental aggression and co-morbidities, including substance abuse, are associated with prolonged and unremitting adolescent depression episodes.

Making Teen Mental Health a Priority: Doctors Changing Lives

David Keller, M.D.
Clinical Associate Professor, Pediatrics & Senior Analyst, Center for Health Policy and Research, University of Massachusetts Medical School

The gap between primary care providers and child and adolescent mental health specialists can be daunting. But, an innovative project in Massachusetts is fostering successful collaboration, and improving patient mental health care. A pediatrician discusses how the program has changed his practice.

A 17-year-old seemed clinically depressed and a 13-year-old boy arrived newly discharged from a psychiatric facility with a bag full of medications and the need for a referral to a specialist. Dr. David Keller wanted to help, but wasn’t sure how. He related his experience before a Capitol Hill audience of policymakers and mental health influencers at TeenScreen National Center’s 2011 Trendell Health Policy Forum.

A Massachusetts pediatrician, Dr. Keller recalled that he was unsure about mental disorders and had no professional connection to child and adolescent mental health specialists for consultation. As he continued to see more patients with mental health and behavioral issues, he knew the problem wasn’t going away. He also knew that he wasn’t alone. Adolescents experience high rates of depression, anxiety disorders and other mental health problems, and there are not – and never will be – enough child and adolescent psychiatrists to meet their needs.

“We can’t train enough child psychiatrists to meet the need,” said Dr. Keller, who is also a Clinical Associate Professor of Pediatrics and Senior Analyst at the Center for Health Policy and Research at the University of Massachusetts Medical School. “Pediatricians are frequently called on to close the gap. We see the patients, but we don’t feel like we’re trained. Child psychiatrists do have the training but they are rare and hard to access.”

In 2005, a group of primary care physicians and behavioral health specialists in Massachusetts broke through the conundrum by creating MCPAP – the Massachusetts Child Psychiatry Access Project. Now available or being developed in 26 states, the approach is providing primary care providers with the support they need to treat common mental health concerns with confidence.

Connecting Primary Care to Specialists

MCPAP focuses on building a partnership between primary care providers and child psychiatric specialists. As the two disciplines have historically had little collaboration, primary care providers first learn how to work with a behavioral health team.

“Our styles of work are different,” said Dr. Keller of mental health specialists and primary care. “We don’t know each other, and there is a trust factor.”

The MCPAP teams, based at one of six academic medical call centers throughout the state, are available to primary care providers around the clock. Typically, a phone consultation is sufficient. A child psychiatrist may occasionally request to see a patient in person for more complex cases.

For Dr. Keller, the consultations have helped guide his decisions on the newly discharged psychiatric patient, the clinically depressed 17-year-old and countless others. The project has also increased his level of comfort managing the mental health issues of his young patients, as it has for many of his colleagues. After five years, MCPAP, which now serves more than 6,000 youth annually, has bridged the primary care confidence gap. More than 63% of all primary care providers in Massachusetts say they are confident in managing adolescent mental health programs, compared with 8% in 2005.

“Primary care doctors have been helped with this collaboration,” he said. “It’s a practice transformation.”

Get more information on MCPAP and other psychiatry access programs.

Featured Primary Care Resource

Webinar Series Features Practical Strategies and Clinical Insights

Adolescent mental health is a primary care issue – but making it a primary care priority can be challenging. The TeenScreen National Center Webinar Series offers a rich source of information tailored to the needs of the primary care professional. All materials are free and easily downloadable.

Recent clinical topics include recognizing and managing teen anxiety, adolescent depression, and patient management approaches that can improve mental health practice potential. Webinars on obtaining payment and time-efficient screening strategies offer additional insights.