Incorporating Mental Health Checkups Into

Adolescent Visits at Rural Health Clinics

Leslie McGuire, MSWChristina Carro

July 14, 2009

TeenScreen National Center for Mental Health Checkups at Columbia University

• National resource center committed to early identification of mental illness in adolescents and prevention of teen suicide.

• Mission: to expand and improve early detection of mental illness by

mainstreaming mental health checkups as a routine procedure in adolescent health care, schools, and other youth-serving settings.

• Two major screening initiatives: TeenScreen Primary Care and TeenScreen Schools and Communities.

• Non-profit, privately funded organization housed in the Columbia University Division of Child and Adolescent Psychiatry.

542 Active TeenScreen Sites in 43 States

Mental Illness and Suicide in Youth

The Case for Mental Health Checkups

Mental Illness in U.S. Adolescents

• 11% of U.S. children and adolescents suffer from a serious mental disorder that causes significant functional impairment at home, at school and with peers.1

• In any given year, only 20% of children with mental disorders are identified and receive mental health services.2

• Half of all mood, anxiety, impulse-control and substance-use disorders start by age 14.3

• On average, the symptoms of mental illness present two to four years before the onset of a full-blown disorder, leaving a lengthy window of opportunity for prevention.4

1Mental Health: A Report of the Surgeon General (1999) 2Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda (2000)3Kessler et al., 20054The National Research Council and the Institute of Medicine of the National Academies (2009).

Major Depressive Episode among Youth Aged 12-17 in the U.S. (2004-06)

Major Depressive Episode among 12-17 Year Olds in the U.S. (2007)

• In 2007, 8.2 percent of adolescents (an estimated 2.0 million youths aged 12 to 17) experienced at least one major depressive episode (MDE) in the past year and only two fifths (38.9 percent) of those received treatment for depression in the past year.

Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 08-4343, NSDUH Series H-34). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Adolescent Suicide in the U.S.

•Suicide is the 3rd leading cause of death for 11-18 year-olds.1

•Almost as many teens die by suicide each year as those who die from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined.2

•Approximately 90% of teens who die by suicide suffer from a treatable mental illness at their time of death.3

•Psychiatric symptoms develop more than a year prior to death in 63% of completed teen suicides.3

•In only 4% of cases, psychiatric symptoms develop within the 3 months immediately prior to the suicide.3

1CDC 2008 (WISQARS) (reviewed 4/2/2008)2CDC 2008 (WISQARS) (reviewed 4/2/2008)3Shaffer et al., 1996

Mental Health & Suicide in Rural Areas

•In 15 states, youth suicide rates remain as high as or even higher than the 20-year peak of 9.36 suicides per 100,000; most of these states are western and mountain states.

•Western and mountain states consistently have higher suicide rates than the rest of the country; all states with the highest suicide rates have many counties that meet most definitions of “rural”.

•In many rural communities, economic factors and sparse population density have created shortages of health and mental health professionals.

•In 1997, fewer than 80% of nonmetropolitan U.S. counties had any mental health professional serving their population; 76% of all designated Mental Health Professional Shortage Areas were in rural counties.

Preventing Youth Suicide in Rural America: Recommendations to States (2008)

Mental Illness and Primary Care

• Almost one-quarter (24%) of pediatric primary care visits involve behavioral, emotional or developmental concerns.

• One-third of mental health visits by privately insured children are to a primary care physician rather than to a specialist.

• Pediatricians tend to under identify children with mental health problems, with detection being particularly low for mood and anxiety related symptoms.

• As many as 2 in 3 depressed youth are not identified by their primary care clinicians and do not receive any kind of care.

• Only a minority of children identified as having a mental health problem by their pediatrician will be referred to a mental health provider.

Cooper, S., Valleley, R.J., Polaha, J., Begeny, J., & Evans, J.H. (2006). Rand Corporation Research Highlights: Mental Health Care for Youth (2001)Zuckerbrot et al., 2007; Simonian, 2006; wren et al., 2003; Stancin & Palermo, 1997

Consequences of Untreated Mental Illness in Children and Adolescents

Suicide Approximately 90% of children and adolescents who commit suicide have a mental disorder. States spend nearly $1 billion annually on medical costs associated with completed suicides

and suicide attempts by youth up to 20 years of age.

Higher Health Care Utilization Youth that are experiencing emotional and behavioral problems, or with higher levels of

psychosocial distress, are likely to be more frequent visitors to their primary care provider. When youth go untreated for mental illness, they use more health care services and incur

higher health care costs in their adult years than others their age.

School Failure Approximately 50% of students age 14 and older who suffer from mental illness drop out of

high school; this is the highest dropout rate of any disability group.

Juvenile and Criminal Justice Involvement Many youth with unidentified and untreated mental illness also end up in jails and prisons.

65 % of boys and 75 % of girls in juvenile detention suffer from mental illness.

Long Term Disability Mental illness is the 2nd leading cause of disability and premature mortality in the U.S.

Why Screen for Mental Illness and Suicide Risk?

• Screening tools that effectively and accurately identify at-risk children and teens are available.

• Mental illness is treatable.

• Most mentally ill and suicidal youth aren’t already being helped.

• There is ample time to intervene before symptoms escalate to a full blown disorder and before a teen turns to suicide.

• No one else is asking teens these questions, but they will give us the answers if we ask the questions.

U.S. Preventive Services Task Force (USPSTF) Depression Screening RecommendationThe USPSTF recommends that primary care providers

annually screen adolescent patients (12-18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy, and follow-up.

• USPSTF is an independent, government supported panel of experts in primary care, prevention and research methods whose recommendations are considered the gold standard in clinical preventive services.

• In its recommendation statement, the USPSTF stated that screening questionnaires developed for primary care accurately identify depression in adolescents and that available treatments are effective for this population.

Additional Support for Mental Health Screening•The Institute of Medicine recommends that the federal government

should make preventing mental disorders and promoting mental health in young people a national priority and note primary care settings to be an important location for screening.

•The American Academy of Pediatrics calls for annual confidential screening and referral for behavioral health problems.

•The Society for Adolescent Medicine supports the early identification of mental illness as a critical standard of care.

•The American Academy of Family Physicians stresses the importance of screening patients for suicide risk.

•The early identification of mental illness through screening has been endorsed by both the U.S. Surgeon General and a Presidential Commission on Mental Health.

Overview:TeenScreen Primary Care

&Mental Health Checkups

Mental Health Checkups

• Mental health checkups can be incorporated into regular healthcare visits, sick visits or other visits with adolescent patients.

• Mental health checkups provide medical professionals with evidence-based practices and instruments to routinely screen adolescent patients for mental illness and suicide risk and also meet the federal and state EPSDT regulations.

• Primary focus:

Early identification of mental illness

Suicide prevention in youth

Linking those in need with services

TeenScreen Primary Care

• TeenScreen Primary Care is an initiative offered through the National Center for Mental Health Checkups at Columbia University that aims to integrate routine mental health screening into adolescent primary care.

• Managed care companies, hospitals and health centers in six states are working with the National Center to pilot a system-wide use of TeenScreen Primary Care.

• The Center provides free tools and resources necessary for physicians to offer a mental health checkup to adolescent patients at the annual well-child visit.

Mental Health Checkup Procedures

Implementation of Mental Health Checkups

Implementation Logistics

• Mental health checkups can be conducted during well-child, sports physical and other visits.

• Screening questionnaire is completed by the teen during the office visit and scored by a nurse or medical technician.

• PCPs review screening results and briefly evaluate youth who score positive on the screening questionnaire.

• Youth who require a more complete evaluation or other mental health services are referred by the PCP to a mental health provider.

PSC-Y

Pediatric Symptom Checklist (PSC-Y)

• 35-item youth self-report questionnaire

• Designed to detect behavioral and psychosocial problems

• Questions cover internalizing, attention, externalizing problems

• Takes 5 minutes to complete and score

• Validated and widely used (Murphy et al., 1992, 1996; Gall et al., 2000; Pagano et al., 2000)

Pediatric Symptom Checklist-Youth

Available in English, Spanish, French, Haitian-Creole and Brazilian-American Portuguese

Includes two questions addressing suicide from the Columbia Suicide Screen

PHQ-A

Patient Health Questionnaire Depression Screen (PHQ-A)

• 9-item youth self-report questionnaire

• Designed to detect symptoms of depression in adolescents

• Two additional questions regarding suicidal thinking and behavior have been added to the PHQ-A

• Takes 5 minutes to complete and score

• Validated and widely used; one of the two depression screens recommended by the U.S. Preventive Services Task Force (USPSTF)

Patient Health Questionnaire Depression Screen (PHQ-A)

Two copies of the screening questionnaire are available for use, the version that is provided in the Quick Start Guide and the “What’s on Your Mind?” brochure

Post-Screening Interview

Post-Screening Interview

Look to see if answers cluster by internal (anxiety/ depression); attention (ADHD); and/ or external (conduct/ oppositional defiant disorder)

Explore symptoms that were endorsed on the screening questionnaire

Inquire about suicidal thoughts and behaviors

Assess the level of impairment caused by the symptoms at school, at home and with peers

Determine if further evaluation or treatment would be beneficial

For patients who score negative on the PSC-Y, it is recommended that you briefly review the symptoms endorsed as “sometimes” and “often” with the patient

Resources for Conducting the Post-Screening Interview

Post-Screening Interview Form (symptom specific checklist and reporting form for the post-screening interview)

Suicide Risk Assessment (provides specific information about conducting a suicide risk assessment)

Sample questions for post-screening interview (symptom specific questions commonly suggested to assess for specific problem areas and suicide risk factors uncovered by the questionnaire)

Making a Referral

Making a Referral

Resources provided for making a referral are available in the TeenScreen Primary Care Quick Start Guide.

It is recommended that primary care offices compile a list of referral resources to share with patients and families.

It may be helpful to work with the patient’s existing insurance benefits to determine what types of referral services may be available.

Coding & Reimbursement

Reimbursement Codes

96110: Developmental Screening

96111: Developmental Testing

In 2003, two CPT codes were approved by the Centers for Medicare and Medicaid Services (CMS) specifically related to developmental and behavioral screening in pediatrics:

Coding & Reimbursement

Resources provided for coding and reimbursement are available in the TeenScreen Primary Care Quick Start Guide.

Materials Available Through the National

Center

TeenScreen Primary Care Quick Start Guide

Comprehensive resource for healthcare providers to assist with the implementation of mental health checkups in a primary care setting.

Includes the following:

Overview of TeenScreen Primary Care

Screening Questionnaire Administration & Scoring Instructions

Screening Questionnaire (Pediatric Symptom Checklist-Youth)

Interpreting the Screening Results

Making a Referral

Coding and Reimbursement Information

Preparing Office Staff to Implement Mental Health Checkups

• Helpful tools to help involve and prepare office staff to implement mental health checkups

• Sample staffing roles and responsibilities as they relate to tasks associated with screening

• Screening implementation checklist/ worksheet

Teen Brochure with PSC-Y or PHQ-A

A brochure designed for adolescent patients that contains the PSC-Y screening questionnaire and information about mental health screening. This brochure can be placed in the waiting room so that patients can access the screening questionnaire on their own or it can be handed out to patients as they come in for their appointment. Available in English and Spanish.

Supplemental Materials

TeenScreen Primary Care CME training Course Available on Medscape at:

http://cme.medscape.com/viewarticle/702353

Mental Health Checkup Resource GuideProvides additional materials you may find helpful to your implementation of mental health checkups.

Guide to Referral, Coding and ReimbursementProvides helpful information about establishing a mental health

referral network and suggested codes and reimbursement techniques

Post-Screening Interview ResourcesIncludes post-screening interview checklist, information for conducting

a suicide risk assessment and sample questions by symptom area.

Tips for Integrating Mental Health Checkups into Your Practice A slide presentation is available for providers who are interesting in learning more about the logistics of mental health screening and receiving tips for integrating mental health check-ups into their practices.

Get Involved!

• Visit TeenScreen’s Web site and sign-up to receive free implementation materials: http://www.teenscreen.org/checkups-in-primary-care

• Call the National Center at 800-673-7714 or email: MentalHealthCheckups@childpsych.columbia.edu to request free

implementation materials

• Upon receiving your information, you will be sent a copy of the TeenScreen Primary Care Quick Start Guide and up to 100 teen

brochures

If you are interested in implementing screening in your clinic: