1. Florida Mental Health Summit August 2015 Elise Fallucco, MD Child and Adolescent Psychiatrist, Nemours Children’s Specialty Care Physician Scientist, Nemours Center for Health Care Delivery Science

2. Can adolescents get depressed? Symptoms: 2 weeks + Irritability, loss of interest Hopeless, helpless, worthless Changes in sleep, appetite, energy, concentration Suicidal thoughts Over 2 million new cases of adolescent depression each year Depression is often a chronic illness 50% single episode 50% multiple episodes

3. Adolescent Depression 10-20 % teens by age 18 (F>M)  social/academic problems, teen pregnancy, substance abuse 2 ! Shaffer 1996, 1 Garrison 1992, Lewinsohn 1993; 2 Kessler et al. 2001, Fergusson et al. 2002;

4. Youth Suicide SECOND leading cause of death in US 10-24 year olds CDC Youth Risk Behavior Survey 2013 In the past year, have you…US high school students seriously considered suicide17% 1 in 6 attempted suicide8% 1 in 12

5. Aaron, 15 years old Straight-A student at prestigious prep school Varsity athlete Visit to grandfather’s house

6. Opportunities to identify teens Primary care is an ideal setting Primary care providers (PCPs) are trusted health care professionals PCPs see > 70% US adolescents annually (Newachek et al, 1999) Each PCP sees between 200-500 teens each year Many suicide victims (45%) saw PCP in the month before death (Luoma et al, 2002)

7. Case for Primary Care Screening Only 2 strategies proven to reduce suicide rates (JAMA 2005) Educating physicians in depression recognition and management Limiting access to lethal means Screening for depression recommended in primary care United States Preventive Services Task Force (2009) American Academy of Pediatrics (AAP; 2007, 2009, 2010)

8. Missed opportunities Limited primary care screening occurs Only 22% PCPs routinely screen for depression (Fallucco, 2010) PCPs screen few teens at well-visits (34%; Ozer, 2009) Barriers to screening Inadequate PCP training, knowledge regarding depression assessment and treatment (Olson, 2001) Limited access to child psychiatrists (Thomas,2006) 8 child psychiatrists (CAPs) : 100,000 children <18 yo Florida: 7.0 CAPs per 100,000 Delaware: 7.2 CAPs per 100,000

9. Addressing barriers Screening, assessment and treatment of adolescent depression (SATD) workshop for PCPs 2+1/2 hour training developed by a team of child and adolescent psychiatrists, therapists, and pediatricians Involves skill-building seminar and hands-on practice Over 200+ pediatricians and pediatric ARNPs trained 12 STL pediatric residents (Fallucco, 2010) and 15 pediatric gastroenterologists 46 STL PCPs (Fallucco, 2012) 90 Jax PCPs (Fallucco et al, 2015) 70 Nemours PCPs in Delaware and Central Florida

10. Part One: Skill-Building Seminar How to screen for depression 3-step algorithm for evaluating positive screens How to assess patient for suicide risk When/where to refer Treatment strategies Antidepressants referral for therapy Billing and coding for screening

11. Part Two: Practice Skills with Teens PCP practices two x 10- minute mock interviews Case 1: 16 yo with low mood, poor grades Case 2: 17 yo with irritability, drug use PCP receives verbal feedback from teens about communication skills Debriefing with CAP

12. Training among Jax PCPs 32 PCPs (25 pediatricians, 7 ARNPs) Years in pediatric practice: mean 16 yrs (range 1-37 yrs) Weeks of mental health training: Mean 2.9 weeks Adolescent patients (total n= 1315) surveyed at well-visits, “Did your doctor ask you if you have been feeling down?” n=582 baseline n=525 at 2-8 months post-training n=208 at 18-24 months later

13. Adolescent patients (n=1315) Mean age = 14.3 yo, SD 1.8 (range 12-18 yo) Gender Male (45%) Female (55%) Race/Ethnicity: Caucasian (78%) African American (12%) Hispanic/Latino (8%)

14. PCP screening for depression General trends in depression screening Girls more likely to be screened (OR 1.65, 95% CI 1.25- 2.16, p<.0003) Older teens more likely to be screened (18 vs. 12 yo OR 2.0, 95% CI 1.3-3.8) Screening did not differ by adolescent race, ethnicity; provider gender or degree Generalized linear mixed effects logistic regression

15. Billing for Depression Screening

16. Depression Diagnosis and Treatment Baseline2-8 months post-training 18-24 months post- training Newly-diagnosed depression3%5%10%* Discussing evidence-based depression treatment 54%93%*86%*

17. Impact of Training For every pediatrician trained, 200-500 teens screened each year Jacksonville: Over 90 PCPs trained to date 12,000 – 30,000 teens screened each year