Mental health conditions are a significant source of adolescent morbidity and mortality. According to Gardner (2014), such cases exist because primary care providers lack the ability and tools to screen for mental health conditions in their practices. However, even in states, such as Massachusetts, where screenings are mandatory, the results are only valuable if future interactions lead to the provision of proper care for the adolescents (Gardner, 2014). A study by Hacker et al. (2014) discovered that with an original sample of 227 adolescents, 46% were diagnosed to be positive with a mental condition, of which 54% of them were referred for mental health care where 33% refused. These findings are consistent with earlier studies conducted by other researchers, like Campo et al. (2005). Health care practitioners, especially APNs, therefore, need better systems and tools to not only screen but also follow-up with their patients along the health care continuum and ensure they receive proper health care to achieve better patient outcomes.
POI Significance
To understand the significance of the POI, it is essential to view it from the perspective of an APN or a primary care provider. First, mental health screening is an inefficient practice that is influenced by multiple factors. For instance, the screens lack the desired specificity and sensitivity, while the treatments have low efficacies (Gardner, 2014). Besides, there is a low prevalence of serious mental health conditions, making it a difficult task for the primary care providers because for one adolescent to benefit from the screening and subsequent treatment, the care provider has to screen a lot of youths. Hacker et al. (2014), for instance, discovered that a primary care provider has to screen over five adolescents for one positive patient to get an appointment. Effort aside, the cost of the wasted time lowers the efficiency of the screening process. It is, therefore, factual to conclude that the care providers and APNs will be reluctant to screen the adolescents in outpatient settings (Gardner, 2014). These findings and conclusions highlight the recommendations made by the US Preventive Services Task Force (2009), where screening patients for mental conditions, such as major depressive disorders, should be complemented with proper diagnosis, treatment (like psychotherapy), and follow-ups. The problem, however, apart from screening for mental disorders among adolescents, the other services are not general practice (Forman-Hoffman et al., 2016). Additionally, the screening is only mandatory in Massachusetts, while other states have neither policies nor practices available.
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Before making any recommendations, however, evidence-based practice must play its role. Currently, there is little research being done to provide care beyond mandatory screening for mental health problems among adolescents (Gardner, 2014). Identification is not enough. The research needed is the design of interventions that will coordinate care across the health care continuum, from the screening to treatment and follow-up. APNs can contribute by formulating studies using the PICO framework, assessing the efficacy of tested interventions, and sharing results with hospitals, regulators, and the health care industry as a whole. Such an approach will change practice first because APNs will be contributing solutions apart from providing health care. Secondly, the implementation of effective interventions will change medical practice, especially when delivering the mental health needs of adolescents.
With the implementation of EBP into practice, one outcome measure would be the drop in the number of adolescents who reject referrals after being screened positive for a mental health problem(s). Another outcome measure would be the development of EBP treatment interventions that are lasting or require little follow-up, such as those engage the patient in self-care without putting an unnecessary burden of daily care on the patient, their families, and primary care providers. However, the process measure that is of interest in this position statement paper is the integration of EBP practices that will ensure mental health care delivery for adolescents across the continuum while reducing the burden on the primary care providers and the inefficiencies of the current model.
PICO
P: Adolescents aged between 12 – 18 years of all genders, sexes, and race
I: Mandatory Pediatric Symptom Checklist (PSC) for screening with care coordination (integrated treatment and follow-up)
C: Optional Pediatric Symptom Checklist alone as currently practiced
O: Reducing the number of patients who reject mental health care services, such as referrals, and stick to the recommended treatment regimen.
Clinical Question: For adolescents aged between 12 – 18 years of all genders, sexes, and race (P), is mandatory Pediatric Symptom Checklist (PSC) for screening with care coordination (integrated treatment and follow-up) (I) more effective (O) in reducing the number of patients who reject mental health care services, such as referrals, and stick to the recommended treatment regimen (C) than optional Pediatric Symptom Checklist alone as currently practiced.
Critique of Position Statement
The position statement, as shown in the introduction, is clear, current, and relevant to the population. Hacker et al. (2014) are the most authoritative on the subject matter, and though the study was conducted six years ago, it is considered current. Screening for mental health conditions in adolescents in the outpatient setting has been revealed to be ineffective, and research has yet to pick up and go mainstream on the subject matter (Hacker et al., 2014). Following the lack of EBP guidelines for the vulnerable demographic, the objectives of the statement are clear. EBP interventions need to be implemented across the continuum of care from screening to treatment and follow-up. These EBP implementations are also the key to achieving the previously identified process and outcome measures. For instance, the current screening system needs better technological systems to improve assessments with higher specificity and sensitivity.
On the other hand, the position statement was developed by Hacker et al. (2014), and though it is unclear if they received any funding, the sample size for their study introduces biases, especially when validating their results. However, their information, despite the sample bias, is credible. However, the strength of the results, even when adjusted for the biases, is telling and warrants a second and deeper look with a larger sample. Therefore, using the study by Hacker et al. (2014) as evidence to support the recommendations is strong on the evidence hierarchy. For instance, the results by Hacker et al. (2014) are validated by previous findings by Campo et al. (2005) and the US Preventive Services Task Force (2009). Therefore, the overall quality of that evidence is high and leads any researcher to use it as the foundation for further studies on the subject matter.
Quality Improvement
As stated earlier, the current system is inefficient, even in Massachusetts, where its implementation is mandatory by court order. The recommendations made in this position paper support autonomy and beneficence because the APNs are encouraged to come up with the required EBP interventions to be implemented. No one APN is required to create solutions across the continuum. Instead, desired outcomes will come out of the APNs moral obligation (beneficence) and self-drive (autonomy) to solve problems in screening for mental health conditions in adolescents in the outpatient setting.
Conclusion
In summary, this position statement paper has looked into screening for mental health conditions in adolescents in the outpatient setting with the objective of making sure health care practitioners, especially APNs, have better systems and tools to not only screen but also follow-up with their patients along the health care continuum and ensure they receive proper mental health care to achieve better patient outcomes. The position statement is significant because mental health screening is an inefficient practice that is influenced by multiple factors, such as the lack of the desired specificity and sensitivity, the treatments have low efficacies and a low prevalence of serious mental health conditions. A mandatory Pediatric Symptom Checklist (PSC) for screening with care coordination (integrated treatment and follow-up) is required to reduce the number of patients who reject mental health care services, such as referrals, and stick to the recommended treatment regimen for long-term benefit.
References
Campo, J. V., Bridge, J., & Lucas, A. (2005, October). “Treatment as usual” for pediatric emotional disorders in primary care. In Joint Annual Meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry .
Forman-Hoffman, V., McClure, E., McKeeman, J., Wood, C. T., Middleton, J. C., Skinner, A. C., ... & Viswanathan, M. (2016). Screening for major depressive disorder in children and adolescents: a systematic review for the US Preventive Services Task Force. Annals of internal medicine, 164(5), 342-349.
Gardner, W. (2014). Screening for mental health problems: does it work?. Journal of Adolescent Health , 55 (1), 1-2.
Hacker, K., Arsenault, L., Franco, I., Shaligram, D., Sidor, M., Olfson, M., & Goldstein, J. (2014). Referral and follow-up after mental health screening in commercially insured adolescents. Journal of Adolescent Health , 55 (1), 17-23.
US Preventive Services Task Force. (2009). Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics , 123 (4), 1223-1228.
