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MansourM, etal. BMJ Open Quality 2020;9:e000751. doi:10.1136/bmjoq-2019-000751
Open access
Implementing the Patient Health
Questionnaire Modied for Adolescents
to improve screening for depression
among adolescents in a Federally
Qualied Health Centre
Mohamed Mansour ,1 Dharshana Krishnaprasadh,1,2 Janice Lichtenberger,1
Jonathan Teitelbaum1
To cite: MansourM,
KrishnaprasadhD,
LichtenbergerJ, etal.
Implementing the Patient
Health Questionnaire Modied
for Adolescents to improve
screening for depression
among adolescents in a
Federally Qualied Health
Centre. BMJ Open Quality
2020;9:e000751. doi:10.1136/
bmjoq-2019-000751
Received 16 June 2019
Revised 27 August 2020
Accepted 18 September 2020
1Department of Pediatrics,
Monmouth Medical Center, Long
Branch, New Jersey, USA
2Beaumont Health, Royal Oak,
Michigan, USA
Correspondence to
Dr Mohamed Mansour;
mmansour. md@ outlook. com
Quality improvement programme
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Background Depression, which is a serious medical
illness, is prevalent worldwide and it negatively impacts
the adolescent lifestyle. Adolescent depression is
associated with adverse emotional and functional
outcomes and suboptimal physical health. Over the
last decade, it has been found that approximately 9%
of teenagers meet the criteria for depression at any
given time, and one in ve teenagers have a history
of depression during adolescence. Ninety per cent of
paediatricians believe that recognition of child and
adolescent depression is their responsibility; however, it
has been reported that 46% lacked condence that they
could recognise depression.
Methods In this study, adolescents between 12 and
17 years of age were screened during their well- child
visits using the Patient Health Questionnaire Modied for
Adolescents. A score of 10 or higher warrants a referral to
a social worker and psychiatrist. The goals of this quality
improvement project were to implement a standardised
questionnaire and to improve the screening, diagnosis and
treatment of depression in children from 12 to 17 years of
age.
Results It was found that the adolescent depression
screening rate signicantly improved within 6 months
of implementing this quality improvement project. The
screening rate improved to 50% by mid- cycle (Plan- Do-
Study- Act (PDSA) cycle 3) and up to 70% at the end of the
6- month period (PDSA cycle 5). Improvement was noted
among all providers, across all age groups, and in both
male and female patients by the end of the study period.
Conclusion Standardised screening tests with a scoring
system help providers to identify and monitor depression
symptoms using a common language, especially in the
outpatient clinical setting where the patient may be seen
by different providers.
BACKGROUND
Depression is a serious medical illness that is
prevalent worldwide, and it negatively impacts
the adolescent lifestyle. Major depressive
disorder is defined as depressed mood (eg,
feels sad, empty or hopeless) or loss of interest
that is associated with at least four of the
nine other symptoms that reflect a change in
functioning, such as problems with appetite,
energy, concentration, disturbed sleep–wake
cycles, and self- image that last for a period of
2 weeks or more.1 Adolescent depression is
associated with adverse emotional and func-
tional outcomes and suboptimal physical
health.
According to studies from the last decade,
approximately 9% of teenagers meet the
criteria for depression at any given time, and
one in five teenagers have a history of depres-
sion during adolescence.2–6 Another study
conducted in 2006 showed that the lifetime
prevalence of depression in the adolescent
population was 13%.7 Changes in the social
environment and puberty, along with cogni-
tive maturation, may lead to the increased
prevalence of depression among teenagers.8
In 2009, the US Preventive Services Task
Force (USPSTF) noted that screening tools
for depression can help to identify depres-
sion.9 Such screening tools include the
Patient Health Questionnaire Modified for
Adolescents (PHQ- A) and the primary care
version of the Beck Depression Inventory
(BDI). Adolescent depression may be undi-
agnosed if appropriate screening at periodic
intervals is not performed by the primary care
doctor/paediatrician. The Bright Futures/
American Academy of Paediatrics recom-
mends yearly screening of child and adoles-
cent patients aged 12–18 years for emotional
and behavioural problems.10
Another study showed that implementing
PHQ- A in a paediatric primary care setting
led to increased diagnosis of depression
among adolescents.11 Major depressive
disorder has short- term effects that include
poor school performance, suboptimal growth
2MansourM, etal. BMJ Open Quality 2020;9:e000751. doi:10.1136/bmjoq-2019-000751
Open access
and development, behavioural changes and impairment
in normal interaction with family members and peers.
Some of the long- term consequences include poor educa-
tion rates that lead to low socioeconomic status, aggres-
sive behaviour, the diagnosis of depression and anxiety in
adulthood, increased risk for self- injurious behaviour and
suicidal ideation.
A study conducted in 2001 in New Hampshire, USA,
reported that 90% of paediatricians believe that recogni-
tion of child and adolescent depression is their respon-
sibility; however, 46% lacked confidence that they could
recognise depression.12 Therefore, the goal of this quality
improvement (QI) project was to implement a stan-
dardised questionnaire to improve screening for depres-
sion by 60% in adolescents from 12 to 17 years of age.
MATERIALS AND METHODS
The study was formally reviewed and deemed exempt
from further review according to the Institutional
Review Board at Monmouth Medical Center. This study
was conducted in a Federally Qualified Health Centre
wherein more than 50% of the patients have Medicaid as
their insurance provider and over 20% pay out of pocket.
The study aimed to include all adolescents between 12
and 17 years of age who presented for a well- child visit.
Children younger than 12 years old and adolescents
coming for a visit due to illness were not included as
screening for depression is not recommended in that age
group. Patients aged 18 years or older were not included
in the study as they are typically seen by internal medi-
cine residents. Additionally, adolescents coming for a visit
due to illness were not included. The PHQ- A was used as
the depression screening tool. A score of 10 or higher13
would warrant a referral to a social worker and psychia-
trist. PHQ- A has a sensitivity of 73% for a positive test and
specificity of 94%.14
Adolescent well visit appointments from age 12 to
17 years who presented to the FQHC were retrospec-
tively analysed via electronic medical record. The list of
patients was generated by final diagnosis code Z00.129 in
the International Classification of Diseases, Tenth Revi-
sion, Clinical Modification (ICD-10- CM). All patients
were usually seen by a resident physician and precepted
by an attending physician. Demographic data of patients
including age, gender, race and language spoken were
studied. The baseline data regarding the percentage of
patients screened and percentage of referrals to mental
health services for a well visit 1 month prior to the imple-
mentation phase (Plan- Do- Study- Act (PDSA) cycle) of the
study were obtained.
A fishbone (Ishikawa) diagram (figure 1) of the
possible challenges to the implementation of the PHQ- A
was created. Five PDSA cycles were performed and the
project leaders (MM and DK) met to determine strategies
to improve the screening rates. The primary outcome
of this study was to implement the PHQ- A to improve
screening for depression among adolescents in a Feder-
ally Qualified Health Centre. Observing the rate of
referral to mental health specialists and a social worker
was the secondary outcome of this QI project.
In this QI project, we used the PHQ- A as it is readily
available, easy to download in multiple languages and
free of cost. As the PHQ- A also has fewer questions than
the BDI, it easier for the patients to answer and is less
time- consuming for the medical staff.
During our study, we followed the Institute of Health-
care Improvement’s model for QI projects; that is, the
PDSA cycles.
RESULTS
The adolescent depression screening rate significantly
improved within 6 months of implementing this QI
project. After the intervention, we reviewed a total of 109
well- child visit charts of the adolescents (12–17 years)
between February 2017 and June 2017 through five
PDSA cycles. The demographics for the study population
(table 1) showed that the mean age was 14.74±1.65 years
(range 12–17 years), and that it included 59 boys and 50
girls. Fifty per cent of the adolescent females who present
to our clinic for well visit were screened for depression;
Figure 1 Fishbone (Ishikawa) diagram depicting challenges to the implementation of the Patient Health Questionnaire Modied
for Adolescents.
3
MansourM, etal. BMJ Open Quality 2020;9:e000751. doi:10.1136/bmjoq-2019-000751
Open access
53% of the males in this population were screened for
depression. The ethnicity of the population was varied,
including adolescents who were African–American (8),
Native American (1), Asian (1), Caucasian (17), Hispanic
(77) and other (5).
The baseline data showed that no standardised
screening tool was used and the referral rate to mental
health services was 0% as the symptoms of depression
were not identified.
By the end of the study period, screening rate had
increased to 70% (figure 2). The overall rate of referral
to mental health services had also increased to 5.8%
(figure 2). The patients who scored 10 or higher on the
questionnaire had a 100% referral rate to social and
mental health services.
PDSA cycle 1
An email was sent to the residents with the instructions for
using the screening tool. The method of calculating the
scores, and the cut- off values for referral, were outlined.
After this cycle, screening rate was 31%.
Plan: Start educating residents on using depression
screening tool using email and assess the response. Elec-
tronic communication via electronic mail (email) was
noted to be effective with all residency/research- related
communication in the past with other studies in our
institute. Residents were also able to refer to the existing
email if needed.
Do: Sending emails to residents with instructions on
how to use the depression screening questionnaire.
Study: Depression screening rate increased from 0% to
31%. Ten patients out of the 32 adolescent patients who
presented for a well visit were screened for depression
using the PHQ- A tool.
Act: It was clear that we were moving in the right direc-
tion, however, new interventions were needed, and we
started PDSA 2.
PDSA cycle 2
We determined that lack of resident education about
the problem was a possible cause of poor adherence. To
improve this, Microsoft PowerPoint was used to create
educational lectures regarding depression screening,
and the need for implementing the PHQ- A was high-
lighted. Literature supporting the use of a standardised
tool was reviewed during the presentation. In addition,
after analysing the data of cycle 1, it was found that some
patients could not be referred to psychiatry due to lack
of insurance. With the assistance of a social worker,
resources were identified and information about psychi-
atrists who accept uninsured patients was included in the
Table 1 Demographics of the study population
Demographics
Age (in years)
Mean 14.74±1.65
Median 15
Range 11–17
Sex
Male 59
Female 50
Race
African–American 8 (7.4%)
Hispanic 77 (70.6%)
White 17 (15.6%)
Other 7 (6.4%)
Language
English 27 (24.8%)
Spanish 66 (60.5%)
Portuguese 13 (12%)
Other 3 (2.7%)
Figure 2 Screening and referrals for depression in adolescents.
4MansourM, etal. BMJ Open Quality 2020;9:e000751. doi:10.1136/bmjoq-2019-000751
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educational lectures. After this cycle, screening rate was
81%.
Plan: Increase screening by increasing residents’ educa-
tion not only about how to use the questionnaire, but also
about why we use it. Physicians and residents are analyt-
ical thinkers at baseline. Education regarding the use of
questionnaire, the importance of screening for process,
lack of adequate screening added to value to the impor-
tance of tackling the inadequate screening process. Also,
it was noticed that some patients were not able to see a
psychiatrist because of lack of insurance.
Do: PowerPoint presentation discussing prevalence of
depression and the social and emotional impact it has on
children and that residents are in a position to help in
early diagnosis of depression among adolescents by using
the depression screening questionnaire. Thirteen out of
the 16 paediatric residents attended this lecture. We also
worked on helping patients who did not have insurance
by connecting them with the social worker and providing
information about psychiatrists who accept uninsured
patients.
Study: Screening rate increased from 31% to 81%.
During the second PDSA cycle, 13 out of the 16 adoles-
cent patients were screened for depression during their
well visit.
Act: Although screening and referral rates were
increasing, we noticed that the depression question-
naire was available in the clinic only in English and
Spanish. We worked on addressing this problem in
PDSA 3.
PDSA cycle 3
A meeting was conducted, and residents were asked to
express their opinions and concerns regarding the use
of the PHQ- A screening tool. Initially, copies of the
questionnaire were given only in English and Spanish;
however, there were concerns that some patients spoke
Portuguese, Vietnamese or Creole, which prevented the
use of the screening tool. As a result, copies of the ques-
tionnaire were provided in all these languages, and a link
to a website where the questionnaire can be downloaded
was given to each resident physician. After this cycle,
screening rate was 50%.
Plan: Feedback from residents regarding their concerns
and opinion helped us improve our subsequent PDSA
cycles as we started providing depression screening ques-
tionnaires in multiple languages.
Do: Print screening questionnaires in English, Spanish
and Portuguese, as well as provide the web address to
download the questionnaire in more languages if needed.
Study: Screening rate dropped from 81% to 50%.
Nine of 18 adolescents were screened for depression.
We found that a specific group of patients who were
self- pay was missed and not screened during the well
visit.
Act: Identify the patients that needed to be screened
through PDSA 4.
PDSA cycle 4
A significant number of patients were missed, we printed
the list of patients that each resident has every day and
manually marked the patients who are registered for a
well- child visit who are 12–17 years old. This served as
a reminder to perform the screening. After this cycle,
screening rate was 65%.
Plan: Highlighting patients between 12 and 17 years
of age on the printed patient schedule for each resident
daily was a visual reminder for adolescents to be screened
for depression. Identify patients that need to be screened
to increase screening rate.
Do: Print the patient list for each resident and mark the
patients 12–17 years of age who have a well visit that day.
Study: Screening rate increased from 50% to 65%.
Seventeen out of the 26 adolescent patients were screened
for depression.
Act: Rates were improving, and we were looking at
keeping the screening going and we started the last cycle
PDSA 5.
PDSA cycle 5
The results of the previous four cycles were shared with
other residents via email to provide positive feedback and
reinforcement and to promote the idea that providing
quality patient care involves team work and that the
contribution of every member of the team is necessary.
After this cycle, screening rate was 70%.
Plan: Continue depression screening practices by
showing the residents the impact of the screening
tool they use. We thought that sharing the screening
percentage (including the graph) which showed the
incremental improvement may aid to motivate the resi-
dents to continue their screening during well visits.
Do: Share results of the previous four PDSA cycles
and showing the increased rate of diagnosis of depres-
sion cases that could have been missed without using the
screening tool. Using standardised depression screening
tools help identify patients with depressive symptoms that
could have otherwise been missed.
Study: Screening rate increased to 70%. Twelve of 17
patients were screened for depression during their well-
child visit.
Act: Residents were encouraged to continue using the
screening tool even after the conclusion of the QI study.
DISCUSSION
Our baseline data showed that no systematic screening
tool was used for screening adolescents for depression.
The USPSTF makes recommendations about the effec-
tiveness of specific preventive care services for patients
without related signs or symptoms of depression.14 Many
of these patients are at higher risk for depression as they
have additional stressors, including low socioeconomic
status, recent immigration, limited English proficiency,
lack of access to subspecialty care due to lack of insur-
ance, and sometimes one or both parents are in their
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home county and the patient is taken care of by another
family member.
The National Institute of Mental Health reports that,
in 2016, the prevalence of major depressive episode
ranged from 19.4% among adolescent females to 6.4%
in males,15 which is close to the data in our study that
showed that the percentage of adolescents who scored
high on the PHQ- A ranged from 5% to 12%. In another
study done from January 2017 to August 2018 including
2107 adolescents, the percentage of positive screening
was 11%.16
We found improvement in the screening rates and
documentation rates along with an increase in the rate
of referral to mental health services. The screening rate
improved to 50% by mid- cycle (PDSA cycle 3), and up
to 70% at the end of the 5- month period (PDSA cycle
5). There was an initial good spike in screening to 81%
after two PDSA cycles. However, this dropped by 31%,
and screening rate was half of the entire adolescent popu-
lation mid- cycle. The initial spike is likely to have been
due to the Hawthorne effect, and the initial increase in
screening was due to the residents’ excitement about
the project that gradually waned over time. Residents
needed to be re- engaged through monthly meetings, and
although the screening rates have increased, we were not
able to reach 80% again. A similar study done in a rural
clinic in South Carolina showed a compliance rate of
88% for administering depression screen in the adoles-
cent population.11 A study done in Michigan showed
screening rate of 82%. Researchers were able to integrate
the depression screening questionnaire into the clinic’s
EHR which made the screening process easier and also
served as a reminder for the physicians.17 We recognised
that having the questionnaire built into the visit’s template
in the EHR would increase the screening rate. However,
after consulting IT department, we were not able to have
the questionnaire added to the clinic’s EHR. Another
contributing factor for the decline in screening rates was
availability of the PHQ- A only in English and Spanish.
Residents were educated regarding online access for
other languages and were provided with the website link
which resulted in better compliance.
Other potential challenges were identified and repre-
sented in the fishbone diagram. One of the challenges
was to arrange mental health services for those who score
high on the screening test but have no insurance. Prior
studies on screening adolescent for depression did not
mention this particular challenge wherein a subset of
patients without insurance had difficulty to obtain mental
healthcare services/follow- up. Fortunately, in our FQHC
with the help of the clinic’s physicians and social worker,
we were able to arrange such services, even for patients
with other mental health diseases.
This study shows that screening in primary care can
help physicians to identify patients. Initiation of appro-
priate mental health treatment may in turn improve
the quality of life of patients. This was evident from a
Cochrane review done in the UK which showed significant
improvement of short- term and long- term outcomes in
adults with depression.18
Limitations
One of the limitations of this study is the use of a single
centre study with a relatively small sample size.
Another limitation of this study was our inability to add
a reminder prompt into the well- child visit template. As
a result, the screening was missed during some of the
visits in the teenage population. A gap in the systematic
follow- up of the patients, after referral to psychiatric facil-
ities, was noted. Although the follow- up may have been
performed by the clinic’s physicians, reviewing it was not
in the scope of the study. Referral rates to psychiatry are
not equivalent to cases diagnosed with depression since
some patients would have had a false- positive screening
test. However, a limitation of this study is the lack of
follow- up with psychiatry offices to see the percentage of
patients diagnosed with depression in relation to the total
number of patients screened.
Future initiatives
Currently, depression screening for adolescents has been
included as a part of the well- child visits in the clinic.
The screening process is under direct supervision of
the attending physician supervising the residents who
ensures administration of the questionnaire as well as
training new residents on using it. There will be another
PDSA cycle conducted 12 months later to assess ongoing
compliance and to examine the rates of admission to the
hospital’s inpatient psychiatric unit with depressive symp-
toms before and after implementation of the screening
using the PHQ- A. We will look at the admission rates for
the patients who received their routine medical care at
our clinic.
We also hope to be able to do a multicentre study
involving multiple outpatient clinics.
Conclusion
Improvement in screening for depression among adoles-
cents using a standardised and validated screening tool
led to improvement in the rate of referral to mental health
services. Standardised screening tests with a scoring
system help providers to identify and monitor depression
symptoms using a common language, especially in the
outpatient clinical setting where the patient may be seen
by different providers. This study also showed that, during
the preparation of QI projects, potential challenges can
lead to solutions that can then benefit the study popula-
tion even after the project is over. In this QI project, we
were able to arrange mental health services for uninsured
or underinsured patients and these patients continued
to use these services for other mental health problems
that were not related to depression. This project is an
example of a combination of child advocacy, practice-
based learning and system- based practice.
Acknowledgements The authors acknowledge the IT team at Monmouth Family
Health Center for their support in this project.
6MansourM, etal. BMJ Open Quality 2020;9:e000751. doi:10.1136/bmjoq-2019-000751
Open access
Contributors MM designed the study, did substantial work in the analysis
and interpretation of the data, revised the work, approved the nal version to
be published and agreed to be accountable for all aspects of the work. DK did
substantial work in the analysis and interpretation of the data, revised the work,
approved the nal version to be published and agreed to be accountable for all
aspects of the work. JL designed the study, did substantial work in the analysis
and interpretation of the data, revised the work, approved the nal version to
be published and agreed to be accountable for all aspects of the work. JT did
substantial work in the analysis and interpretation of the data, revised the work,
approved the nal version to be published and agreed to be accountable for all
aspects of the work.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to this study are included in the
article.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iD
MohamedMansour http:// orcid. org/ 0000- 0001- 8960- 6882
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