Practice Problem: Lack of screening for depression among teenagers admitted to practice site.

Now that you have identified your practicum site, you will identify your practice problem and consider how the problem has been addressed in your organization and beyond. After identifying this practice problem, you will begin exploring the problem in the literature.
For this Discussion, consider the problem, and explore whether this is an issue only in your organization or an issue more broadly in healthcare. Consider how the issue is addressed in the literature and examine how the issue is currently being addressed (or perhaps not addressed) by the management in your organization.

“At the heart of the evidence-based practice is a clinical question” (Twa, 2016). A practice-focused question can serve as a basis to design an evidence-based study.

To Prepare
• Review the Learning Resources provided in the module.
• Connect with your preceptor and consider a gap in practice you can explore for the duration of the course.
• Review Learning Resources related to the practice question.
Post a response detailing your practice-focused question. Describe the practice-focused question that is an issue for your facility or organization. Gather evidence to support the issue, and consider the following:
• Is the issue a common issue in healthcare or nursing practice, or is this issue specific to your organization or facility?
• Is this issue addressed in the literature?
• Has this issue been addressed by management to date? If so, how?
• Construct a practice-focused question.

Resources
Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.
• Chapter 4, “The Practice Question Phase” (pp. 73–98)
Hickey, J. V., & Giardino, E. R. (Eds.). (2021). Evaluation of quality in health care for DNPs (3rd ed.). Springer Publishing.
• Chapter 1, “Evaluation and Advanced Nursing Practice: The Mandate for Evaluation” (pp. 3–36)

Agency for Healthcare Research and Quality. (2017). Action plan for translating research into practice: Gap analysis and tests of change: Facilitator guide.
https://www.ahrq.gov/hai/tools/mvp/modules/cusp/action-plan-trip-fac-guide.html

Chia, R., Pandey, A., & Vongpatanasin, W. (2020). Resistant hypertension—defining the scope of the problem. Progress in Cardiovascular Diseases, 63(1), 46–50. https://doi.org/10.1016/j.pcad.2019.12.006

Gallagher Ford, L., & Melnyk, B. M. (2019). The underappreciated and misunderstood PICOT question: A critical step in the EBP process. Worldviews on Evidence-Based Nursing, 16(6), 422–423. https://doi.org/10.1111/wvn.12408

Shirey, M. R. (2011). Addressing strategy execution challenges to lead sustainable change. JONA: The Journal of Nursing Administration, 41(1), 1–4. https://doi.org/10.1097/NNA.0b013e318200288a

Stannard, D. (2021). Problem identification: The first step in evidence‐based practice. AORN Journal, 113(4), 377–378. https://doi.org/10.1002/aorn.13359

Twa, M. D. (2016). Evidence-based clinical practice: Asking focused questions (PICO). Optometry and Vision Science, 93(10), 1187–1188. https://doi.org/10.1097/OPX.0000000000001006

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Solution

Gaps in Practice

Practice Problem: Lack of screening for depression among teenagers admitted to practice site

Depression in adolescents is a disabling condition associated with long-term physical and mental health problems.  According to Aalsma et al. (2018), recent national data have revealed that the yearly prevalence of depression among adolescents has gone up from 8.7 percent in 2005 to   11.3 percent in 2014. An increasing prevalence of depression among adolescents is an issue of concern since depression can have considerable consequences for this population including suicidal thoughts, comorbid mental health problems, and academic difficulty. Since depression can have serious outcomes,   can reoccur across the lifespan, and is treatable, professional organizations recommend routine screening for depression (Aalsma et al., 2018).

Depression screening involves the utilization of a self-report questionnaire on depression symptoms with a pre-established cut-off score to recognize patients who might have depression but have not sought treatment and have not otherwise been identified as depressed. Screening is different from routine assessment, which involves a health care provider employing thoughtful and careful observation and appropriate and question to evaluate the health of a patient and establish if a more focused assessment is required(Roseman et al., 2017).

Guidelines on depression screening in adolescents

The USPSTF recommends that adolescents between 12 and 18 years should be screened for major depressive disorder (MDD) in the primary care setting.  Screening must be performed with appropriate systems in place to ensure accurate diagnosis, effective treatment, and proper follow-up.  This recommendation is in line with the American Academy of Pediatrics (AAP) guideline which recommends yearly screening for patients between 12 and 21 years of age. The two most commonly utilized screening tools for depression in adolescents are the Patient Health Questionnaire for Adolescents (PHQ-A) and the Beck Depression Inventory for primary care (BDI-PC).  (Maurer et al., 2018).

APP recommends that adolescents who are at least 12 years old should be annually screened for depression by physicians through a formal self-report tool in an effort to timely identify the condition.  Since there is no evidence on the most effective screening instrument, physicians should utilize what works well for their patients and practices. Identification of adolescents with risk factors for depression is crucial to permit for r regular monitoring for depression over time.  These risk factors include family or personal history for depression, substance use, suicide-related behavior, bipolar disorder or other mental disorder; major psychological stressors like sexual or physical abuse; and being adopted or in foster care.

Lack of screening for depression among teenagers admitted to practice site as a practice problem

Screening is a possible solution to improve the management of depression.  However, Screening for depression among adolescents is a practice gap in my organization and across health care facilities. Teenagers who are admitted to the practice site are not screed for depression. Due to time constraints, physicians and nurse practitioners rely more on clinical questioning to screen for depression, which has the potential to not identify might have moderate or mild depression, which might become harmful to their physical and emotional health.

Lack of screening for depression among teens is an issue more broadly in healthcare According to Lewandowski et al. (2016), despite the negative consequences of depression along with the availability of treatments; around 60 to 80 percent of depressed adolescents do not get appropriate care.   Identification of depression is the critical initial step in connecting teens to treatments and pediatric primary care is the main setting where depression among adolescents can be identified. Nevertheless, depression is still poorly identified in pediatric primary care.  There is consensus among experts in psychiatry and pediatrics and professional organizations that recommend adolescents to be routinely screened to improve the identification of cases, however, available evidence shows that adolescent depression screening coverage is very low(Lewandowski et al., 2016).

Is this issue addressed in the literature?

The incidence of youth aged between 12 and 17 years who reported a major depressive episode in the past year rose from 8.3 percent in 2011 to 13 percent in 2016. Despite the steady increase in the need for treatment, treatment for depression is still very low, with merely a third of adolescent patients receiving the needed care Guo and Jhe,  (2021), indicate that the main obstacle to treatment occurs at the problem identification stage. Because it is an internalizing disorder, depression is less likely to be detected by adult caretakers unlike externalizing problems like conduct behaviors and substance use.

Despite recommendations by the APP and the USPSTF, there is rising evidence that there are remarkable barriers to depression screening in primary care settings.   These barriers include unstandardized screening and follow-up procedures due to unavailability of mental health resources, time constraints, and difficulty incorporating screening into existing workflows, and limited clinical training and education. This situation is worrying because the inability to consistently apply universal screening across all groups of patients in primary care with sufficient follow-up care might further worsen existing inequalities in adolescent depression identification and treatment (   Guo & Jhe, 2021).

Factors that contribute to low screening compliance include low screening self-efficacy among physicians and shortened visit times along with concerns over how to perform interpretation and intervention with depression screens that turn out positive(Aalsma et al., 2018).    Parker et al. (2020), many general practitioners report low confidence in the identification, diagnosis and management, and appropriate management of mental illness including depression among young people due to inadequate time with appointments and lack of specialty training. After identification of depression, physicians need to comply with treatment recommendations for adolescent depression including referring adolescents to specialized mental health treatment.

Has this issue been addressed by management to date?The management has recognized the practice has initiated a quality improvement project to enhance adolescents to be screened for depression with a validated questionnaire.  According to Parker et al. (2020), it has been demonstrated t, nevertheless, that the utilization of standardized screening tools validated for adolescents like the PHQ- A  can improve the rates of identification of depression in primary care clinics.    The management has decided to implement the utilization of PHQ-A to all teens aged 13-19. According to Beirão et al., (2020), the PHQ-A comprises nine questions and can be administered by a clinician or self-administered by the patient. It evaluates the symptoms that the patient has experienced in the last two weeks. PHQ-A measures functional impairment and also enquires about suicide attempts and suicidal ideation. A clinical flow protocol has been developed. When a teen patient check-in,  a notification will pop- up on the computer reminding nurses and physicians to administer the PHQ-A. The practitioners will automatically administer the PHQ-A which is embedded in the electronic health record.

Before embarking on screening for teens who are at risk for depression, staff will be trained on appropriate screening tools and how they work, and assessment and diagnostic methods. Staff education and training is aimed at equipping staff with the necessary knowledge and skills to conduct screen adolescents for depression ensure timely and appropriate treatment t and monitor patients to reduce illness deterioration. Screening will equip staff with an effective means to identify symptoms of depression and initiate treatment.

A Practice focused question

Would the development of a practice guideline that offers a systematic approach to screening, using the PHQ-A result in increased guidance and willingness and ability of providers to screen teens for depression in the practice setting?

References

Aalsma, M. C., Zerr, A. M., Etter, D. J., Ouyang, F., Gilbert, A. L., Williams, R. L., Hall, . A., & Downs, S. M. (2018). Physician intervention to positive depression screens among adolescents in primary care.  Journal of  Adolescent Health, 62(2), 212-218. doi: 10.1016/j.jadohealth.2017.08.023

American Academy of Pediatrics (AAP). (2018). Depression in Adolescents: AAP Updates Guidelines on Diagnosis and Treatment. American Family Physician, 98(7), 462-463.

Beirão, D., Monte, H., Amaral, M., Longras, A., Matos, C., & Villas-Boas, F. (2020). Depression in adolescents: a review. Middle East Current Psychiatry, 27, 50. https://doi.org/10.1186/s43045-020-00050-z

Guo, S., & Jhe, G. B. (2021). Universal; Depression Screening in Schools-Promises and Challenges in Addressing Adolescent Mental Health Need. JAMA Network Open, 4(11), e2132858. doi:10.1001/jamanetworkopen.2021.32858

Lewandowski, R. E., O’Connor, B., Bertagnolli, A…..  Horwitz, S. M. (2016).  Screening for and Diagnosis of Depression Among Adolescents in a Large Health Maintenance Organization. Psychiatric Services, 67(6), 636-641.

Maurer, D. M., Raymond, T. J., & Davis, B. N.. (2018). Depression: Screening and Diagnosis. American Family Physician, 98(8), 508-515.

Parker, B. L., Achilles, M. R., Subotic-Kerry, M., & O’Dea, B. (2020). Youth StepCare: a pilot study of an online screening and recommendations service for depression and anxiety among youth patients in general practice.  BMC Family Practice, 21, 2.

Roseman, M., Saasat, N., Riehm, K…..Thombs, B. D. (2017). Depression Screening and health Outcomes in Children and Adolescents: A Systematic Review. Canadian Journal of Psychiatry, 62(12), 813-817. doi: 10.1177/0706743717727243