Screening for Depression in Pediatric Primary Care

Psychotropic Medication Usage in Pediatric CKD: Reporting from the CKD in Children Cohort

Key Points

Psychotropic medication use is prevalent in the pediatric CKD population. Central nervous system stimulant usage was more common in male patients, and antidepressant usage was more frequently reported at follow-up visits during teenage years.

Background

Mental health disorders within the pediatric CKD population are prevalent. The frequency is unknown with which psychotropic medications that commonly treat these conditions are used in this population.

Methods

Data from the CKD in Children (CKiD) cohort study were used to describe the use of psychotropic medications and patient-related characteristics of use. Medications were classified into three groups: antidepressants, central nervous system (CNS) stimulants, and antipsychotic/mood stabilizing medications. Participant age, sex, CKD severity, and duration of medication use were ascertained. Medication use was evaluated in parallel with CKD disease type, presence of urological comorbidity, and hypertension. Chi-square tests compared subgroup medication use.

Results

Among 1074 CKiD participants (median baseline age 9.8 years), 6% (n =60) used psychotropic medications at study entry with 11% reporting incident use of any medication category (n =120). CNS stimulants were most common at baseline. Antidepressants were more frequent among incident users at 7%. Use of two or more medications was rare (3%). Median eGFR at medication initiation was 45 ml/min per 1.73 m2. CNS stimulants were reported at a higher rate in male compared with female participants (P < 0.05).

Conclusions

Eleven percent of CKiD patients report incident use of any psychotropic medication, with 7% reporting incident use of antidepressants. Future work is warranted to better ascertain the frequency, safety, and efficacy of psychotropic medication usage in relationship to formal mental health disorder diagnoses in the pediatric CKD population.

A Chinese adaptation of the Patient Health Questionnaire for Adolescents (PHQ-A): factor structure and psychometric properties

BACKGROUND

To examine the factor structure and psychometric properties of the Patient Health Questionnaire for Adolescents (PHQ-A) in Chinese children and adolescents with major depressive disorder (MDD).

METHODS

A total of 248 MDD patients aged between 12 and 18 years were recruited and evaluated by the Patient Health Questionnaire for Adolescents (PHQ-A), the Center for Epidemiological Survey Depression Scale (CES-D), the Mood and Feelings Questionnaire (MFQ), and the improved Clinical Global Impression Scale, Severity item (iCGI-S). Thirty-one patients were selected randomly to complete the PHQ-A again one week later. Confirmatory factor analysis (CFA) was used to test the construct validity of the scale. Reliability was evaluated by Macdonald Omega coefficient. Pearson correlation coefficient was used to assess the item-total correlation and the correlation of PHQ-A with CES-D and MFQ respectively. Spearman correlation coefficient was used to assess test-retest reliability. The optimal cut-off value, sensitivity, and specificity of the PHQ-A were achieved by estimating the Receiver Operating Characteristics (ROC) curve.

RESULTS

CFA reported adequate loadings for all items, except for item 3. Macdonald Omega coefficient of the PHQ-A was 0.87. The Spearman correlation coefficient of the test-retest reliability was 0.70. The Pearson correlation coefficients of the PHQ-A with CES-D and MFQ were 0.87 and 0.85, respectively (p < 0.01). By taking the iCGI-S as the remission criteria for MDD, the optimal cut-off value, sensitivity and specificity of the PHQ-A were 7, 98.7%, 94.7% respectively.

CONCLUSION

The PHQ-A presented as a unidimensional construct and demonstrated satisfactory reliability and validity among the Chinese children and adolescents with MDD. A cut-off value of 7 was suggested for remission.

Enhancing Pediatric Mental Health Care in an Outpatient Primary Care Setting Using the Keep Your Children/Yourself Safe and Secure (KySS) Program: A Multidisciplinary Quality Improvement Project

INTRODUCTION

This project aimed to enhance access to pediatric mental primary health care.

METHOD

The Keep Your Children/Yourself Safe and Secure (KySS) training was offered to a multidisciplinary team at a Federally Qualified Health Clinic in the Midwest United States. Confidence was measured using the Healthcare Provider Confidence Scale (HPCS). Frequencies of visits and mental health referrals were compared preintervention/postintervention. HPCS scores were compared using Wilcoxon rank-sum and Cohen's d.

RESULTS

Referrals in 2022 were greater than in 2020 but less than in 2021 (p = .25). The total number of visits declined from 431 in 2021 to 385 in 2022. HPCS (n = 9) scores trended higher following the KySS Program in prescribing and general positive beliefs.

DISCUSSION

Referrals to mental health providers increased, although not significantly. The number of mental health visits varied between 2020-2022. Provider confidence was not significantly affected, whereas beliefs in prescribing did increase significantly. More work is necessary to understand the impact of delivery to a multidisciplinary team.

Evidence mapping of clinical practice guidelines recommendations and quality for depression in children and adolescents

This study systematically reviewed the clinical practice guidelines (CPGs) for depression in children and adolescents and assessed the quality and recommendation consistency of those CPGs. Evidence mapping was presented to illustrate the research trends and identify gaps to guide future research. Literature on CPGs for depression was systematically collected from PubMed, Embase, Web of Science, guideline databases, and psychiatric association/ society websites. The basic information, recommendations, methodological quality, and reporting quality of CPGs were extracted, and the supporting evidence strength for the included CPGs was analyzed in Excel. Four appraisers independently assessed the eligible CPGs using AGREE II instrument and the RIGHT checklist. All recommendations from the CPGs were summarized and analyzed, and the evidence mapping bubble charts were plotted in Excel. After excluding 15,184 records, 12 depression CPGs were eventually proved eligible, six of which were of high quality and six medium quality. A total of 39 major recommendations were summarized, 35 of which were supported by high-quality CPGs. Although direct comparisons are challenging due to differences in grading schemes and research quality, most CPGs share many pivotal recommendations that can help guide clinical practice. However, the evidence for some clinical problems is still lacking. Thus, more research is necessary on the screening and treatment of children and adolescents to put forward more evidence-based and high-quality recommendations.

Reliability and Validity of the Korean Version of Children's Depression Inventory 2 Short Version as a Screening Tool: A Comparison With the Standard 28-Item Version

OBJECTIVE

To investigate the reliability and validity of the Korean version of Children's Depression Inventory 2 Short Version (CDI 2:S) in comparison with its full-length version (CDI 2) as a screening tool for depressive youth.

METHODS

A total of 714 children from the community and 62 psychiatric patients were enrolled in this study. The Korean version of the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL-K) served as the reference standard for computing receiver operating characteristic (ROC) curves. To evaluate the ability of the CDI 2 and CDI 2:S to discriminate major depressive disorders, areas under the curves (AUCs) were compared. To investigate psychometric properties of the CDI 2:S, internal consistency was calculated and confirmatory factor analysis was conducted.

RESULTS

For the CDI 2, the cutoff at 20 yielded the best balance between sensitivity (83%) and specificity (91%). For the CDI 2:S, the cutoff point of 10 resulted in high sensitivity (82%) and high specificity (93%). The short form was proven to be as sensitive and specific as the CDI 2. Further analyses confirmed that the CDI 2:S also had good reliability and validity.

CONCLUSION

The CDI 2:S, a sensitive and brief form of the CDI 2, may serve as a better option in time-constrained psychiatric settings.

Exploring Adolescent Experiences with Disclosing Self-Injurious Thoughts and Behaviors Across Settings

Disclosure of self-injurious thoughts and behaviors (SITBs) is critical to current treatment and prevention programs. Limited research has examined patterns of and barriers to SITB disclosure in adolescents. This work is critical given the limits of confidentiality in this population. Over 1,000 adolescents aged 13-17 with a history of mental health treatment and SITBs were recruited online. Participants reported their history with disclosing SITBs across a range of relationships, honesty in and barriers to disclosure to health care providers, and their experiences with breaches of confidentiality to parents/guardians. We examined relationships among these experiences and a range of outcomes, including perceived likelihood of future disclosure. Participants reported most frequent disclosure of all SITBs to friends, and more frequent disclosure of nonsuicidal self-injury compared to suicide ideation or attempts. Adolescents were most likely to disclose SITBs when directly asked by health care providers, though many participants reported continued SITB concealment. The most commonly endorsed barrier to disclosure was fear that the provider would tell a parent/guardian. Experiences with confidentiality breaches involving a non-collaborative breach were negatively associated with future disclosure, mental health symptoms, and adolescent-parent relationships. SITB disclosure is a cornerstone to their treatment and prevention. Better understanding of to whom and when, barriers, and the impact of disclosure experiences is critical. Our research suggests that most adolescents do not want their parents to know about their SITBs, and that fear of parent involvement prevents disclosure. Results have several implications for SITB assessment across physical and mental healthcare settings.

The Use of Electronic Health Record Tools to Improve Evidence-Based Treatment of Adolescent Depression in Primary Care

OBJECTIVE

The aim of the current study was to evaluate primary care pediatrician (PCP) adoption of an electronic health record (EHR) documentation tool and their delivery of a behavioral activation (BA) intervention within their routine practice with adolescents who screened positive for depression.

METHODS

We used the RE-AIM framework to describe PCP adoption and implementation of EHR documentation tools and brief evidence-based protocols. Utilization was assessed using a customized toolbar (ie, actions toolbar) via retrospective chart review. A pre-post design was used to measure changes in PCP-reported knowledge, comfort, and feasibility managing depression before and after they were trained. A mixed-effects logistic regression model was used to analyze associations of resource utilization with depression severity.

RESULTS

PCPs used the actions toolbar to document responses to elevated Patient Health Questionnaire (PHQ-9) scores for 29.80% of encounters. The PCPs utilized the BA protocol for 10.5% of encounters with elevated PHQ-9 scores. Higher depression severity categories were associated with significantly higher odds of utilization relative to mild severity. The training was rated highly acceptable and PCPs reported significant post-training increases in comfort and feasibility.

CONCLUSION

This is the first study of its kind to implement and evaluate PCP utilization of an EHR documentation tool aimed to improve delivery of an evidence-based intervention for adolescent depression. Teaching PCPs to implement brief interventions has potential to increase access to evidence-based care; however, large-scale practice change requires an effective implementation strategy that does not increase provider burden and is fully integrated into physician documentation and workflow.

Depression in the Pediatric Otolaryngology Clinic Setting

OBJECTIVES/HYPOTHESIS

For most pediatric specialty clinics, mental health is not the primary presenting complaint, yet can portend unrecognized morbidity. We describe rates and risk factors of depression and suicidal ideation in adolescents seen at a pediatric specialty clinic and examine changes during COVID-19.

STUDY DESIGN

Retrospective database review.

METHODS

Outpatient pediatric otolaryngology clinic encounters of patients aged 12-19 years at a tertiary academic medical center were identified from October 2018 to July 2020. Demographic characteristics, ICD-10 primary diagnosis, Patient Health Questionnaire (PHQ)-2 score, and PHQ-9 score (if administered) were obtained. Multivariable regression examined risk factors for PHQ-9 administration, PHQ-9 scores ≥10, and suicidal ideation. Patient characteristics and PHQ scores were compared before and after March 23, 2020 (California COVID-19 Stay-at-Home order).

RESULTS

Three thousand six hundred nine encounters with PHQ-2 data were identified. Of these, 223 (6.2%) scored ≥3 and underwent PHQ-9 assessment, of which 121 (3.4% of 3,609) scored ≥10 on the PHQ-9 and 53 (1.5%) endorsed suicidal ideation. Factors associated with PHQ-9 administration were female gender (odds ratio [OR] 1.58, P = .001), obesity (OR 1.48, P = .043), and neck mass/neoplasm/cancer diagnosis (OR 1.99, P = .013). Female gender was also associated with suicidality (OR 2.47, P = .008). Comparison of pre-COVID-19 versus during COVID-19 showed no differences in depression or suicidality. However, subgroup analysis revealed some significant findings.

CONCLUSIONS

We demonstrate substantial prevalence of positive depression screening and suicidal ideation among adolescent pediatric otolaryngology clinic encounters. Depression rates were similar to pre-COVID-19 and during COVID-19, yet barriers to screening during this time were substantial. Pediatric specialty providers must remain vigilant for mental health issues in their patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

An examination of the association between risk of depression and academic performance according to weight status in adolescents: DADOS study

BACKGROUND

The early identification of emotional and psychological problems during adolescence seems helpful to improve academic performance (AP). However, the association between risk of depression and AP, as well as the role of health-related factors in this association remain to be elucidated. Therefore, the aims of this study were to analyze the association between risk of depression and AP in adolescents; to examine this association according to weight status; and to test the mediating role of weight status in this association.

METHODS

A sample of 265 adolescents (125 girls) aged 13.9 ± 0.3 years old from the DADOS (Deporte, ADOlescencia y Salud) study was included in the analyses. Risk of depression was self-reported through the Behavior Assessment System for Children and Adolescents. AP was assessed through academic grades and the Spanish version of the Science Research Associates Test of Educational Ability. Weight status was assessed by body mass index (BMI) (kg/m²) and dichotomized according to the international age- and sex-specific BMI cut-offs (non-overweight vs. overweight).

RESULTS

Linear regression analyses showed an inverse association between risk of depression and academic grades (all p<0.05). Further linear regressions analyzing risk of depression and AP (dependent variable) stratified by weight status showed stronger associations among overweight adolescents. Additionally, mediation analyses revealed that weight status acted as a mediator of this association.

LIMITATIONS

The cross-sectional design prevents from interfering causal relationships.

CONCLUSIONS

Educational institutions should promote the early identification of depression as well as the promotion of healthy weight status as strategies to enhance AP in adolescents.

Rural Communities and Violence

Among US geographic regions classified as rural, death rates are significantly higher for children and teens as compared with their urban peers; the disparity is even greater for Alaskan Native/American Indian and non-Hispanic black youth. Violence-related injuries and death contribute significantly to this finding. This article describes the epidemiology of violence-related injuries, with a limited discussion on child abuse and neglect and an in-depth analysis of self-inflicted injuries including unintentional firearm injuries and adolescent suicide. Potential interventions are also addressed, including strategies for injury prevention, such as firearm safe storage practices.

Utilization of Integrated and Colocated Behavioral Health Models in Pediatric Primary Care

Integrating behavioral health services within pediatric primary care may help address barriers to these services for youth, especially the underserved. Models of primary care behavioral health include coordinated, colocated, integrated, and collaborative care. This study began exploring the comparative utility of these models by investigating differences in the demographics and diagnoses of patients seen for a behavioral health warm handoff (integrated model) and a scheduled behavioral health visit (colocated model) across 3 pediatric primary care sites. The 3 sites differed in their rates of warm handoff usage, and there were differences in certain diagnoses given at warm handoffs versus scheduled visits. Depression diagnoses were more likely to be given in warm handoffs, and disruptive behavior, trauma/adjustment, and attention-deficit/hyperactivity disorder-related diagnoses were more likely to be given in scheduled visits. These results have implications for the influence of office structure and standardized procedures on behavioral health models used in pediatric primary care.

Behavioral and Emotional Disorders in Children and Their Anesthetic Implications

While most children have anxiety and fears in the hospital environment, especially prior to having surgery, there are several common behavioral and emotional disorders in children that can pose a challenge in the perioperative setting. These include anxiety, depression, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, post-traumatic stress disorder, and autism spectrum disorder. The aim of this review article is to provide a brief overview of each disorder, explore the impact on anesthesia and perioperative care, and highlight some management techniques that can be used to facilitate a smooth perioperative course.