Carol Rockhill

Evaluation of the Patient Health Questionnaire-9 Item for Detecting Major Depression Among Adolescents

OBJECTIVE: The purpose of this study was to examine the performance characteristics and validity of the Patient Health Questionnaire-9 Item (PHQ-9) as a screening tool for depression among adolescents. METHODS: The PHQ-9 was completed by 442 youth (aged 13–17 years) who were enrolled in a large health care–delivery system and participated in a study on depression outcomes. Criterion validity and performance characteristics were assessed against an independent structured mental health interview (the Child Diagnostic Interview Schedule [DISC-IV]). Construct validity was tested by examining associations between the PHQ-9 and a self-report measure of functional impairment, as well as parental reports of child psychosocial impairment and internalizing symptoms. RESULTS: A PHQ-9 score of 11 or more had a sensitivity of 89.5% and a specificity of 77.5% for detecting youth who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression on the DISC-IV. Receiver-operator-curve analysis revealed that the PHQ-9 had an area under the curve of 0.88 (95% confidence interval: 0.82–0.94), and the cut point of 11 was optimal for maximizing sensitivity without loss of specificity. Increasing PHQ-9 scores were significantly correlated with increasing levels of functional impairment, as well as parental report of internalizing symptoms and psychosocial problems. CONCLUSIONS: Although the optimal cut point is higher among adolescents, the sensitivity and specificity of the PHQ-9 are similar to those of adult populations. The brief nature and ease of scoring of this instrument make this tool an excellent choice for providers and researchers seeking to implement depression screening in primary care settings.

Evaluation of the PHQ-2 as a Brief Screen for Detecting Major Depression Among Adolescents

OBJECTIVE: To examine the validity of the Patient Health Questionnaire 2 (PHQ-2), a 2-item depression-screening scale, among adolescents. METHODS: After completing a brief depression screen, 499 youth (aged 13–17 years) who were enrolled in an integrated health care system were invited to participate in a full assessment, including a longer depression-screening scale (Patient Health Questionnaire 9-item depression screen) and a structured mental health interview (Diagnostic Interview Schedule for Children). Eighty-nine percent (n = 444) completed the assessment. Criterion validity and construct validity were tested by examining associations between the PHQ-2 and other measures of depression and functional impairment. RESULTS: A PHQ-2 score of ≥3 had a sensitivity of 74% and specificity of 75% for detecting youth who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression on the Diagnostic Interview Schedule for Children and a sensitivity of 96% and specificity of 82% for detecting youth who met criteria for probable major depression on the Patient Health Questionnaire 9-item depression screen. On receiver operating characteristic analysis, the PHQ-2 had an area under the curve of 0.84 (95% confidence interval: 0.75–0.92), and a cut point of 3 was optimal for maximizing sensitivity without loss of specificity for detecting major depression. Youth with a PHQ-2 score of ≥3 had significantly higher functional-impairment scores and significantly higher scores for parent-reported internalizing problems than youth with scores of <3. CONCLUSIONS: The PHQ-2 has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.

Depressive symptoms in adolescence: the association with multiple health risk behaviors

OBJECTIVE Although multiple studies of adolescents have examined the association of depression with individual health risk behaviors such as obesity or smoking, this is one of the few studies that examined the association between depression and multiple risk behaviors. METHODS A brief mail questionnaire, which screened for age, gender, weight, height, sedentary behaviors, physical activity, perception of general health, functional impairment and depressive symptoms, was completed by a sample of 2291 youth (60.7% response rate) aged 13-17 enrolled in a health care plan. A subset of youth who screened positive on the two-item depression screen and a random sample of those screening negative were approached to participate in a telephone interview with more in-depth information obtained on smoking and at-risk behaviors associated with drug and alcohol use. RESULTS Youth screening positive for high levels of depressive symptoms compared to those with few or no depressive symptoms were significantly more likely to meet criteria for obesity, had a poorer perception of health, spent more time on the computer, got along less well with parents and friends, had more problems completing school work and were more likely to have experimented with smoking and a wide array of behaviors associated with drug and alcohol use. CONCLUSIONS Because many adverse health behaviors that develop in adolescence continue into adulthood, the association of depressive symptoms with multiple risk behaviors and poor functioning suggest that early interventions are needed at an individual, school, community and primary care level.

Social competence and social support as mediators between comorbid depressive and conduct problems and functional outcomes in middle school children

This study examined the roles of social competence and social support as potential mediators of the association between psychopathology and functional outcomes in a middle school sample (n=521). Participants were stratified into four psychopathology risk groups (depression only, conduct problems only, comorbid depression and conduct problems, low symptoms) based on screening during early 6th grade. Functional outcomes were 6th grade point average (GPA) and parent rating of global adaptive functioning in their 7th grade student. Low levels of social competence were found to mediate the association between symptoms and both lower grades and global functioning for adolescents with depressive symptoms alone and with comorbid symptoms, but not for those with conduct problems alone. Lack of social support mediated the association between psychiatric symptoms and lower grades for adolescents with depression alone and comorbid symptoms, but not for those with conduct problems alone. These findings suggest that intervention to improve social competence and social support may enhance functional outcomes, especially for youth with depressive symptoms or comorbid depressive and conduct symptoms.

Anxiety disorders in children and adolescents

Anxiety disorders are among the most common and functionally impairing mental health disorders to occur in childhood and adolescence. Primary care providers can expect to treat youth who have anxiety disorders frequently, and this article aims to provide the tools necessary to evaluate and manage patients who present with anxiety symptoms during childhood or adolescence. This article discusses the epidemiology of anxiety disorders, including the increased risk of future anxiety disorders and other mental health problems that are associated with having an anxiety disorder in childhood and adolescence. Next, the etiology of anxiety disorders is delineated, including discussion of genetic, cognitive-behavioral, physiological, and ecological explanatory models, and a summary of neurophysiological findings related to childhood and adolescent anxiety. Next, methods and tools are presented for assessment and treatment of anxiety disorders, with a focus on assessment and treatment that can be initiated in a primary care setting. Evidence-based therapy and medication interventions are reviewed. The article includes a focus on developmental differences in symptom presentation, assessment techniques, and treatment strategies, such that a primary care provider will have tools for working with the wide age range in their practices: preschool children through adolescents. We conclude that many effective intervention strategies exist, and their improving availability and ease of use makes it both critical and achievable for children and adolescents with anxiety disorders to be accurately diagnosed and treated with evidence-based medication and therapy.

Agreement between parents and children regarding anxiety and depression diagnoses in children with asthma.

This study examined parent-child agreement regarding anxiety and depressive disorders in youth with asthma and evaluated key demographic and health differences associated with parent-child agreement. Of 756 outpatient youth with asthma, 122 (16.0%) were diagnosed with a DSM-IV anxiety or depression disorder using the Diagnostic Interview Schedule for Children (C-DISC). Parents reported on internalizing symptoms using the Child Behavior Checklist (CBCL). Logistic regression analyses were used to examine factors related to parent- and child-reported symptom agreement. Low rates of agreement (48.9%) between youth and parents regarding diagnosis of a DSM-IV anxiety or depressive disorder were found among youth with asthma. Increased agreement was associated with higher externalizing behavior score on the CBCL and more anxiety and depressive symptoms on the C-DISC. Children without behavioral problems and with less severe anxiety and depression were recognized significantly less often by their parents.

Health care costs associated with traumatic brain injury and psychiatric illness in adults.

A cohort design was used to determine the contribution of traumatic brain injury (TBI) and psychiatric illness to health care costs for adolescents and adults in the 3 years following mild or moderate-to-severe TBI compared to a matched cohort without TBI, controlling for confounders. In all, 3756 subjects 15 years or older from a large health maintenance organization database were examined. We identified subjects who sustained a TBI in 1993 (n=939) and selected three control subjects per TBI-exposed subject (n=2817), matched for age, sex, and enrollment at the time of injury. Unadjusted mean costs in 2009-adjusted dollars were compared using Kruskal-Wallis tests and Mann-Whitney U tests, and adjusted mean costs were compared using gamma regression analyses. Average costs were 76% higher in the 3 years after injury for the mild TBI group, and 5.75 times greater for the moderate-to-severe TBI group compared to controls. The presence of psychiatric illness was associated with more than doubling of total costs for both inpatient and outpatient non-mental health care. Gamma regression analyses confirmed significantly higher costs in patients with TBI or psychiatric illness. A significant interaction between moderate-to-severe TBI and psychiatric illness indicated a 3.39 times greater cost among patients with both exposures compared with those exposed to moderate-to-severe TBI without psychiatric illness. TBI and psychiatric illness were each associated with significant increases in health care costs; those with the combination of moderate-to-severe TBI and psychiatric illness had much higher costs than any other group.

Healthcare costs associated with mild traumatic brain injury and psychological distress in children and adolescents.

Primary objective: Comparison of healthcare costs for youth with mild traumatic brain injuries (TBIs) to costs in a matched cohort of children without TBI in the 3 years following injury. Research design: This study used a prospective cohort design with 3-year follow-up. Costs were examined using the well-established two-step model and controlling for potential confounding variables. Methods and procedures: Four-hundred and ninety subjects from a large health maintenance organization, 14 years old or younger, who sustained a mild TBI in 1993, were identified using computerized records. For each youth with mild TBI, three control subjects were selected (n = 1470), matched on age, sex and enrolment at the time of injury. Experimental interventions: Not applicable. Main outcomes and results: TBI exposure was associated with an increase in the proportion of subjects who had non-zero medical costs in all categories examined and a 75% increase in mean total costs. Presence of psychological distress was also associated with increased proportion of subjects with costs in all categories examined and was associated with an approximate doubling of mean total costs. Conclusions: Mild TBI and psychological distress were each associated with significant increases in healthcare costs in an HMO setting.

Determinants of mental health service use among depressed adolescents

OBJECTIVE Evaluate determinants of mental health service use among depressed adolescents. METHOD We assessed mental health services use over the 12 months following screening among 113 adolescents (34 males, 79 females) from an integrated healthcare system who screened positive for depression (Patient Health Questionnaire-9 score ≥11). Youth characteristics (demographics, depression severity, and co-morbidity) and parent characteristics (parent history of depression, parent-report of youth externalizing and internalizing problems) were compared among youth who had received mental health services and those who had not. Multivariate regression was used to evaluate the strongest factors associated with mental health service use. RESULTS Overall, 52% of adolescents who screened positive for depression received mental health service in the year following screening. Higher parent-reported youth internalizing problems (OR 5.37, CI 1.77-16.35), parental history of depression/anxiety (OR 4.12, CI 1.36-12.48) were significant factors associated with mental health service use. Suicidality and functional impairment were not associated with increased mental health services use. CONCLUSION Parental factors including recognition of the adolescents internalizing symptoms and parental experience with depression/anxiety are strongly associated with mental health service use for depressed adolescents. This highlights the importance of educating parents about depression and developing systems to actively screen and engage youth in treatment for depression.

Pharmacotherapy for Anxiety Disorders in Children and Adolescents

Anxiety disorders comprise the most prevalent mental health disorders among children and adults. Psychotherapy and pharmacotherapy are effective in improving clinical impairments from anxiety disorders and maintaining these improvements. This article discusses how to obtain a suitable diagnosis for anxiety disorders in youth for implementing appropriate treatments, focusing on the evidence base for pharmacologic treatment. Clinical guidelines are discussed, including Food and Drug Administration indications and off-label use of medications, and considerations for special populations and youth with comorbidities are highlighted. Findings suggest moderate effectiveness of medication, particularly selective serotonin reuptake inhibitors, in the treatment of anxiety disorders in youth.