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Pediatric primary care on the front lines of teen mental health crisis
Teen mental health was in crisis before COVID-19. Persistent feelings of hopelessness and sadness almost doubled over a 10-year period ending in 2019, according to a report by the Centers for Disease Control and Prevention. Also during this time, attempted suicide and thoughts about suicide skyrocketed among U.S. high school students.
And then came 2020.
"The urgency regarding adolescent mental health has increased significantly during the pandemic," said Katie Plax, MD, director of the Division of Adolescent Medicine at Washington University School of Medicine in St. Louis. "Our kids are not OK. We're seeing it across the country in our emergency rooms and in our pediatric practices. Many parents and teachers have said they're seeing it."
The CDC saw it, too, in a 2022 data analysis of adolescent mental health during the pandemic.
"We can't just keep on doing the same things," said Plax, the university's Ferring Family Professor of Pediatrics and founder of The SPOT (Supporting Positive Opportunities with Youth), a drop-in health and social services clinic for teens and young adults. "We need to do more."
To that end, Plax has helped lead several studies on depression and pediatric primary care as co-director of the Washington University Pediatric and Adolescent Ambulatory Research Consortium, a network of more than 60 pediatric practices serving demographically diverse patients in the greater St. Louis area. The aim is to help health-care providers develop standardized processes in their practices to diagnose and manage mental health disorders.
One example of Plax's and her team's work involved helping 11 pediatric practices (53 providers) improve follow-up with teens newly diagnosed with depression from October 2018 through April 2019. Such improvements included educating about evidence-based plans for assessing depression, implementing universal depression screening of kids ages 12 and older during annual well visits, teaching providers the best ways to communicate with kids and their parents or guardians about depression, and reviewing the depression treatment guidelines by the American Academy of Pediatrics.
In a study published in 2022 in the journal Pediatrics, Plax's team examined the effectiveness of practice facilitators to develop standard processes such as follow-up phone calls and office visits in the treatment of adolescents with depression. After protocols were established that were feasible within each practice, the researchers reported follow-up care within six weeks after a depression diagnosis had increased from 40% to 81%. Follow-up visits within three months after a patient had stabilized doubled from 30% to 60%, while patients in remission at six months tripled from 7% to 21%.
"Establishing such practice processes with coaching gave clinicians increased confidence to diagnose and manage depression, assess severity, provide medication and educate families," Plax said. "All of these tools are essential to address adolescent mental health disorders."
Plax expounded on the importance of involving pediatric primary care providers in treating teen mental health.
Why was your research focused on pediatric doctors' offices?
Pediatric primary care providers are well-positioned to care for adolescents with depression and other mental health disorders, because they typically have a long-standing, trusting relationship with patients and families.
The problem is that primary care pediatricians have been reluctant to do so, because most have received limited mental health training, and yet pediatricians are the ones who are on the front lines of treating the increasing number of youths struggling with their mental health. They understand the urgency. Even 10 years ago, a lot of pediatrics was mostly about infectious diseases, growth and development, and well-child checkups.
Now, they are doing a lot of care and treatment for anxiety, depression and ADHD. Frankly, they're also confronted with more complex mental health diagnoses beyond even that scope. For example, we know that about 80% of the young people who have died by suicide had been in a pediatric office within the prior year, and a little over 40% had seen a health-care provider within the past few months.
How does this research translate into day-to-day practice in primary care pediatrics?
Our research shows there are opportunities for pediatricians to intervene, and we want to take full advantage of every chance we get. We want to keep all doors open, so if a kid needs help, the pediatric health-care teams know what to do because they have an officewide system in place with assessments, screenings, follow-ups and other tools.
One thing we know is that we don't have enough psychiatrists and therapists. And providing referrals to those specialists has been what most pediatricians do. But we also know that it's likely there will be a three- to six-month wait for an appointment. What happens to the kid from the day they were in their doctor's office until the three to six months it takes to actually see a therapist? We know pediatric primary care practices need to take the lead.
We worked with pediatric practices to help build a system of care that aligns with their office goals. What does that look like? It might mean reassigning roles within the practice. For example, a triage nurse may be fielding calls about acute physical symptoms, but the triage nurse also might need to follow up with families and adolescents with depression. Were you able to get the prescription filled? How are you doing on the medication? Are there any side effects? How have you been feeling emotionally? Consistently following up and asking those sorts of questions helps to ensure that those young people don't fall through the cracks while they're waiting to see a therapist.
What are the factors causing a surge in adolescent depression, suicide and other mental health disorders?
People want to say it's social media. Social media doesn't help sometimes, but it doesn't represent the whole problem. I think we have changed as a country, and our kids perceive it. The divisive politics of the day are difficult for kids. They feel it, and it doesn't feel good. Kids are worried about the future of the planet. They really care about what's going to happen. They feel climate change. It's hotter. And they see things coming across their screens, whether it's social media or just the news, that are deeply disturbing and that involve kids. School shootings are one example. Controversies about gender diversity is another example. Most kids truly don't understand what the adults are arguing about because, really, gender diversity is generally accepted and normalized among young people. Many families also face economic hardship, and we're not done yet, right? And then we have a frightening global pandemic, and we have had, and continue to have, a very tense political environment regarding vaccinations, masking and overall public health. Teens feel it all so deeply.
On top of it, these issues are confusing to figure out when you're a teenager and your brain is programmed to experience emotions more profoundly than adults. The limbic system of the brain is more sensitive in adolescence, meaning your amygdala is quicker to fire when you feel disrespected or dysregulated, and you don't have a developed prefrontal cortex to always think rationally. This is the teenage brain. And it hasn't changed. But what has changed is puberty starting earlier. The hormonal and visible physical changes can change a teen's self-perception as well as how other people treat them. They're not developmentally mature enough yet to process what's going on with their bodies and what they're feeling, and they can't always control it.
I'm not sure that we, as adults, have fully appreciated all those changes and how they affect kids. And the schools, religious organizations, or clubs and athletics that kids are in have not had the chance to always catch up to support kids in the way they need to be supported by trustworthy adults. I wish we had more school counselors. I wish we had more school environments and caring adults who taught wellness and coping skills for the challenging times in their lives. Mental health could be part of a school's curriculum so a kid doesn't have to go to a therapist to learn positive coping skills. It could be the norm because so many kids are facing adversities, and we all will at some point in our lives.
More information: Jane Garbutt et al, Improving Follow-Up for Adolescents With Depression in Primary Care, Pediatrics (2022). DOI: 10.1542/peds.2021-051107