From the 2024 HVPA National Conference
Audrie Anne Lazaga MD (NYC Health and Hospitals/Harlem), Sundari Periasamy MD, Rianne Yap MD, Panagiotis Krepis MD, Marquis Joson MD
Background
Adolescent depression remains a significant concern in the United States. According to CDC’s Youth Risk Behavior Survey, the percentage of high school students who experience persistent feelings of sadness or hopelessness has been steadily increasing from 28% in 2011 to 42% in 2021. Mental Health America’s 2020 report indicated that 13% of adolescents experienced at least one major depressive episode, with over 9% enduring severe major depression. Social determinants of health such as race, ethnicity, insurance status, poverty level, and access to care may compound, leading to even higher mental health problems among socially disadvantaged adolescents. Some sources suggest an even higher prevalence of depressive disorders among adolescents, estimated at 55%. This surge in depression rates can be attributed to factors such as the COVID-19 pandemic, mandatory isolation measures, and remote schooling. However, only half received treatment before reaching adulthood.
Primary care serves as the initial point of contact for over 80% of adolescents with major depression, yet fewer than 12% seek help from mental health facilities. Both the American Academy of Pediatrics and the U.S. Preventive Services Task Force recommend annual depression screening for adolescents aged 12-18 using the Patient Health Questionnaire-9 (PHQ-9), which has sensitivity and specificity rates of 88% and 92% respectively. Besides, routine screening in primary care has shown significant improvements in outcomes through timely diagnosis, intervention, and access to care. Though annual adolescent depression screening has been recommended as the standard of care, two-thirds of affected adolescents remain undetected due to inconsistent screening in primary care settings. This barrier may be attributed to limited resources, time constraints, or competing priorities.
New York City DOH shows that in 2015, only 29.8% of uninsured citizens with mental health problems received care, and racial disparities negatively impact access to mental health care. Our institution provides healthcare to the underserved, diverse, and uninsured population with inherent social disadvantages serving the neighborhoods of Harlem and the South Bronx. In 2017, DOH data of depression rates among neighborhoods of Central Harlem and South Bronx were 21.4% and 16.9%, respectively, which were the highest among all other parts of the city.
Objective
To address these inequalities, the implementation of PHQ-9 screening in our primary care setting was a high priority. We initiated our quality improvement (QI) project with an aim to improve the annual depression screening rates among adolescents aged 12-17.
Methodology
Through staff training, education, and mandatory implementation of the screening tool in the electronic medical record (EMR), we have consistently improved our screening rates from 56.2% in 2020 to 85% in 2024.
Results – see Figure 1.
Conclusion and Clinical Implications
The increasing prevalence of adolescent depression underscores the necessity of screening in primary care settings. Regular training and support for primary care providers to incorporate the PHQ-9 screening tool into their routine practice will be the first step to address this problem and improve timely access to care and outcomes.