Parental Depression Screening for Pediatric Clinicians Implementation Manual

Project Design
The Parental Well-Being Project was developed by a working group of primary care pediatricians and academic colleagues within the Clinicians Enhancing Child Health (CECH) regional practice-based research network at Dartmouth Medical School. The recent U.S. Preventive Services Task Force recommendation that all adults undergo brief screening for depression, and the accumulating data about the adverse effects of parental depression on child health, development, and behavior, provided the impetus for changing clinical care. The working group collaborated with a regional managed behavioral health plan to develop a realistic approach to primary care screening for parental depression.

Initially, CECH clinical trials tested the use of interview versus paper screening and determined that there was a better yield with a paper screener that had an introduction. This served to explain to parents why their pediatric provider was performing the screen. The PHQ-2 screener used in our project has been well validated and performs as well as longer measures. The screener was pilot tested in two phases: a one-month phase and a six-month phase a year later, in 2004.

From the start of the project, pediatricians expressed concern that they had insufficient resources to assist parents. The Parent Support Line (PSL), a centralized phone service, was therefore established with the behavioral health organization for parents who wished to discuss their symptoms and receive help with referrals to local community, primary care, or mental health resources. Initially, the support line only received calls, but later in the project PSL staff reached out to parents who agreed to a call during the office visit.

The role of the pediatric provider after screening was clarified over the course of the project. Their role was not to diagnose depression but rather to support and motivate the parent to get help if he or she screened positive. The pediatrician's other role was to help the parent address how her or his depression affected their child. During the project, family behavioral issues and communication, the impact of depression on the child's well-being, and the development of parenting skills to promote child resiliency were among the topics discussed during the well-child visit. Pediatricians then referred parents who thought they might be depressed to other services and followed up during routine care.

A key aspect of the program implementation was utilizing an office-wide approach that educated and involved all staff. Staff were educated about the importance of the maternal depression on child outcomes; encouraged to change the office environment to educate parents about the issues; and provided with educational materials to give to parents as appropriate.

Audience
The program implemented screening of all mothers at well-child visits since depression occurs commonly in mothers throughout the childbearing years, not just during the postpartum period. Fathers were screened if they attended well visits without mothers. Regular screening was implemented at well-child visits rather than selected visits because it was easier for staff to have the same routine for health visits.

The Screening Implementation Trial
Routine parental depression screening at well-child visits was implemented with 37 providers in six community pediatric practices in New Hampshire and Vermont communities with town population ranging from 2,000 to 150,000. Parental gender, screening results, and referrals were collected without identifiers. Overall, 9 percent of visits had only fathers attending. When fathers accompanied mothers, only mothers were screened for depression. Detailed data collection determined the amount of time spent on discussion, how mothers responded during discussion of the results, and provider actions for three one-week periods during the screening project. Throughout the project, screening rates were collected weekly and practices received support from the project staff in overcoming barriers to screening.

Over six months, parental depression screening was conducted in nearly half of 16,000 well-child visits. This rate of screening included time periods when screening was on hold. Across all of the practices, there was a total of 10 weeks when a key staff member responsible for organizing the screening was away and screening did not occur. When these weeks are not counted, parental depression screening occurred in 67 percent of the well visits. Parental nonresponse was rare; only 6 percent of parents refused to answer, had recently completed the screener in the same office at a visit for a sibling, or were not in attendance at the child's visit. For 27 percent of parents, the office visit screening routine was disrupted.

Depression Screening Results
In these community private practice settings, about one of seven parents (14%) reveal mood or anhedonia (lack of interest in please in usual activities) symptoms during routine screening. One of 20 parents (5%), both mothers and fathers, screened at-risk for major depression.

In these practices, Medicaid insured 30 percent of families. In clinical settings that serve predominantly low-income rather than middle-class families, we anticipate, based on other depression screening studies, that the rates of parents screening positive for depression are likely to be 50 percent higher than our results.

Parental Responses
Fifty-two percent of mothers in the project who screened positive (score > 3) felt they might be depressed and 85 percent of them wanted to take action. Among mothers with lower screener scores (1–2), 30 percent thought they might be depressed and two-thirds of them wanted to take action. Twenty-seven percent of mothers who screened positive saw themselves as stressed rather than depressed. This information is not known for fathers due to the small numbers of male guardians seen during the weeks of detailed data collection.

Pediatric providers referred 40 percent of mothers and 21 percent of fathers who screened positive to mental health or primary care providers. The strongest predictor of referral was the parent telling the pediatrician they might be depressed. Providers planned follow-up calls with 36 percent of parents who screened positive. Support line referrals occurred in 26 percent of parents.

Pediatrician Time for Discussion of Screening Results
Providers did not see time for discussion as burdensome. The providers' accounts of time spent are below:

• in 69 percent of well-child visits, no discussion occurred;
• in 22 percent of visits, discussion lasted fewer than three minutes;
• in 5 percent of visits, discussions were three to five minutes;
• In 3.5 percent of visits, discussions were five to 10 minutes; and
• in 1.5 percent of visits, discussions were more than 10 minutes

Included in the under-three-minute discussions were brief conversations about why the practice was conducting screening, with parents who screened negative. Pediatric providers reported that longer discussions reflected the magnitude of the parent's issues and their potential to impact the child.

Lessons Learned
Practice characteristics: Practice flow and clinical care are complex and delicately balanced. Introducing even what appears to be a simple screener of less than one minute will shift care burdens. The office administrative staff and clinicians need to be engaged. When there are underlying conflicts—and/or no collaborative decision-making processes in place—minor challenges in implementing screening will be magnified. It is key to interact with a provider leader as well as nursing and administrative staff.

Provider and staff buy-in: During the project, some clinicians and administrative staff were not comfortable dealing with parents' mental health issues. These providers were more likely to see barriers than benefits in the program and less likely to consistently participate. Some providers expressed concern about their liability if they discussed depression with the parent. For these providers, it was not easy to acknowledge that a child could be helped by a parent getting help. Nurse practitioners, however, were especially attuned to parental issues and were more likely than other staff to refer parents to outside help.

Parental acceptance: Parents generally accepted the screening and frequently commented that they were pleased that the pediatrician cared. Still, there are barriers to screening, especially among economically and culturally diverse populations. Parents who are socially disadvantaged need to know the screening is routine for all parents, and that the practice is trying to help rather than judge them. In some settings, the parent may see many different providers and not feel comfortable discussing issues outside of an established relationship.

Use of an outside referral assistance service: While 26 percent of mothers accepted referral information to the Parent Support line (PSL) from the pediatricians, we found that few parents called it. In fact, no fathers used the PSL. When a parent did call, the first step was a confidential 10-item automated depression assessment to give the parent feedback about the likelihood that she was depressed. If desired, the parent was then connected by telephone at that time, or at a later time if desired, to a social worker. Fifteen percent of parents referred used the 10-item screener.

While 60 percent of these mothers were informed by the automated assessment that they were likely or very likely to be depressed, only 35 percent of them chose to connect to the PSL social worker. Therefore, only 5 percent of mothers referred interacted with the PSL social worker. When a subgroup of these mothers who did not use the system was contacted, the mothers gave a variety of reasons for not calling the support line: they lost the number; were feeling better; meant to call but just hadn't yet; or were already getting help. It was not clear whether inertia accompanying depression also played a role in parental inaction.

We also learned that if parents were ready to call they wanted to talk directly with an individual rather than first complete the automated screener. Three of our practices changed their approach as a result. The PSL services in these practices used a proactive format, having the provider obtain the parent's permission for support line staff to call them. After this change, 29 percent of parents agreed to be called by the support line staff and 90 percent were reached and assisted. Based on these results, it is clear that proactive personal contact is needed.

Practice referral preferences: We also learned that providers made more direct referrals to primary care and mental health providers than initially anticipated. Practices that developed strong linkages to local mental health providers preferred sending parents there over using a support line. Primary care providers also frequently referred mothers to their primary care provider for further evaluation. Thirty percent of parents who screened positive were already being treated for depression; in these cases, providers encouraged them to revisit their provider.

Depression Screening Results
In these community private practice settings, about one of seven parents (14%) reveal mood or anhedonia (lack of interest in please in usual activities) symptoms during routine screening. One of 20 parents (5%), both mothers and fathers, screened at-risk for major depression.

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