RUNNING HEAD: Adolescent Depression Screening

Adolescent Depression Screening

Kristin K. Sedore
University of Michigan-Flint

Adolescent Depression Screening

Adolescent Depression Screening

The third leading cause of death among adolescents is suicide, and over half of
adolescent suicides are related to depression (Santoro, Murphy, 2010). Much of the time
adolescents are overlooked and disregarded when it comes to genuine depression and anxieties.
Instead their emotional behavior is looked upon as moody or some kind of drama that they
are mixed up in. In reality, adolescents seem to have heightened senses due to the hormonal
surges, physical changes and environmental pressures they face during this time of their lives.
They indicate that life is hard to endure at times because of peer pressure, bullying, alcohol or
drug use, and family dynamics (Dahlmann, Buhren, &Remschmich, 2013). Unfortunately, many
go without the help the desperately need to be able to cope with these feelings since incidents
of suicide among this group have increased as a result. The following discussion attempts to
explain why depression in adolescents is a health care priority, how it affects families and society
in general, why current practices are not working as well as evidenced based practice
recommendations, and why an effective secondary prevention measure should be implemented.
According to the World Health Organization (WHO), the leading causes of disability
among Americans are mental health disorders (WHO, 2004, as sited in Healthy People 20/20
objectives, 2013). Adolescents make up twenty-one percent of the United States population, and
according to the Center for Disease Control (CDC) suicide as the third leading cause of death in
adolescents between the ages of 10 to 24 years (CDC, 2014), several factors can place a young
person at risk, one such factor is depression (CDC, 2014). A brief about mental health, released
in February 2010, by the National Institute of Healthcare Management (NIHCM) listed
depression as the most common mental health disorder amongst adolescents, with 25% of those

Adolescent Depression Screening

presenting with at least mild symptoms (Santoro, Murphy, 2010). In a functioning adult,
depression can have detrimental effects on their quality of life. In comparison, adolescents may
have many risk factors that increase their chances of experiencing depression, but may also
amplify its effects, which can lead to suicide. This time in an adolescents life is sometimes
referred to as psychosocial puberty because of the large amount of social and mental
development that takes place during these years (Dahlmann, et al, 2013). Between the increased
demands placed on an adolescent by his or her social environment, and the brain reorganization
by hormones, mental disorders such as depression have become more common (Dahlmann, et al,
2013). As a result of these pressures, many adolescents choose to injure themselves, or take their
own life. An article about depression screening in Contemporary Pediatrics, stated that sixty
percent of adolescents who suffer from depression have suicidal tendencies, and half of them
will commit suicide or attempt it (Lenz, Coderre, & Watanabe, 2009). The National Institute of
Healthcare Management indicates that pertaining to suicide in the United States, ninety percent
of teens that commit suicide were suffering from an identifiable mental disorder, and most often
it was depression (Santoro, Murphy, 2010). A pilot study conducted at a local hospital in
partnership with the National Institute of Mental Health (NIMH), implemented a suicide
screening on 295 adolescents that were seen in their emergency department. Nineteen percent of
these adolescents screened positive for being at risk for suicide, sixty-five percent had been
previously treated for a mental health issue in an outpatient facility within the last year, and
when asked, the adolescents agreed that the screening tool identified problems that they needed
to address, and that they seemed unaware of previously (King, 2011). The doctor that conducted

Adolescent Depression Screening

the study, indicated that teens that screened positive for suicide risk, were more likely to be
depressed, and use alcohol and or other substances in an attempt to cope with the symptoms
(King, 2011). This study presented the reality that a secondary prevention measure, such as a
screening tool to detect suicidal ideation, is effective, and that the same approach to screening for
depression could be just as effective.
An adolescents depression affects every aspect of their lives, from their well-being to
their environment, which includes their family and friends. Parents are left with questions about
their involvement, and what they can do to help. Adolescents deal with intense emotions, such
as irritableness and violence in boys, and introversion and eating disorders in girls (Dahlmann,
2013). Many parents also encounter barriers regarding healthcare costs, and many find that they
must pay out-of-pocket for treatments that insurance does not cover (Santoro, Murphy, 2010).
Typically, undiagnosed, and untreated depression leads to hospitalization which can become
even more expensive to treat. Mental health hospitalizations for adolescents, accounts for 7.5%
of their admissions, and the average cost for these were $13,397 per stay in 2006 (Santoro,
Murphy, 2010). Since total charges for inpatient care for this population in 2006 was
approximately $903 million, and private insurance was charged $374 million, there seems to be a
large savings that could be accrued if effective prevention and management of adolescent
depression is addressed before inpatient care is needed (Santoro, Murphy, 2010).
Many adolescents who are affected with depression are prone to self-mutilation or
harming themselves, hence glorifying the idea that cutting is what to do to let off steam
(Richardson, Russo, Lozano, McCauley, & Katon, 2010). This situation can lead to more risky
behavior, such as drug and/or alcohol abuse that affects not only the adolescent, but also their

Adolescent Depression Screening

immediate social circle by encouraging friends to become involved, which then could lead to
problems with police, becoming a burden to society in general. The statistics are alarming, and it
seems apparent that the steps to correct this must start with some kind of screening to detect
depression.
When an adolescent is experiencing depression symptoms, they must be able to ask for
help, but many do not know what depression is, or refuse to ask for help, citing the negative
stereotyping of mental health issues (Santoro, Murphy, 2010). Healthy People 20/20 set forth an
objective to increase adolescents willingness to talk to someone about major problems such as
their depressive or anxious feelings by 10% (Healthy People 20/20, 2013). Approaching an
adolescent with the intention of talking about serious health issues may not be easy, but some
parents are successful.
Generally, parents who have identified depression as an issue will start by taking their
child to their primary care provider (PCP) in an anticipation of receiving a referral to a mental
health provider. The problem then arises that most insurance companies expect the PCPs to
handle any behavioral issues within their practice (Williams, Klinepeter, Palmes, Pulley, & Foy,
2004). Many physicians have admitted to not having the expertise to handle mental health
issues, and in a study conducted in 2001, ninety percent of the responding pediatricians felt they
were responsible for the recognition and diagnosis of depression in children and adolescents, but
only twenty-seven percent felt responsible for the treatment, and almost half felt they lacked
confidence in their skills to recognize depression, and few (10%-14%) had confidence in their
ability to treat it (Williams, et al, 2004).

Adolescent Depression Screening

When treatment is initiated by the PCP, generally, a prescription for a serotonin reuptake
inhibitor (SSRI) is given, with the hope that the depressive symptoms are alleviated, but since
2007 a black box warning has been issued on these types of medications, alerting physicians and
consumers about suicidal ideation side effects that accompany them when used as treatment for
adolescent depression, and because of this, many PCPs admit to being avoidant when it comes
to treating adolescents for depression symptoms (Friedman & Leon, 2007). This in turn leaves
the adolescent untreated, or undertreated at best, and may account for many of the undiagnosed
cases. On the other end of the spectrum are the adolescent patients, who may not divulge
information about their symptoms, and go untreated completely. These patients are more likely
to be hospitalized, and the cost becomes much higher (NIHCM, 2010). The question becomes:
What can be done to raise awareness of adolescent depression, and how can the numbers of
undiagnosed and untreated be lowered?
Secondary prevention is the ideal in this situation. Since these young people are being
overlooked, either purposely by their PCP, or unintentionally due to awareness issues, they need
a way to detect the depression symptoms before they progress. But to accomplish this, they need
to know what they are trying to prevent. Many adolescents, parents, and PCPs do not
understand what differentiates depression from what seems to be typical teenage drama
(Dahlmann, et al, 2013). This can be accomplished through screenings that identify at-risk
adolescents. If an adolescent was given a list of questions to help clinicians pinpoint his or her
symptoms of depression, and he or she was made to feel that it was part of their healthcare visit,
he or she may feel inclined to answer the questions truthfully, and agree to talk about it further.
The need for nurse involvement is mentioned in an article written by Teresa Carnevale MSN,
RN, screening for adolescent depression may need to be completed by those who have ready

Adolescent Depression Screening

access to the population (Carnevale, 2010, p. 51). Nurses in general, are in such a position to
implement this type of intervention, as a preventative measure. School nurses have access to
adolescent populations on a daily basis, and because ninety percent of all mental health care is
received from primary care, it would be an ideal environment for the school nurse to initiate
these screenings and encourage the PCP to either treat the adolescent for the depressive
symptoms, or refer them to a mental health specialist for treatment (Currid, Turner,
Bellafontaine, Spada, 2011). It has been reported that as many as 50% of the cases of major
depression are missed, because of the absence of screening by family physicians (Corona,
McCarty, Richardson, 2013, p. 24). The nurse could assist the physician in implementing a
system that will not only screen for depression, but will also offer guidance as to how to handle
positive screenings (Corona, et al, 2013). The United States Preventive Services Task Force
(USPSTF) published a clinical summery of their recommendation for the screening and
treatment of major depressive disorders in adolescents. It stresses the importance of the PCP
screening only when systems are in place, for diagnosis, treatment and follow up (USPSTF,
2009). Screening tools are available on the USPSTF website. In an article written about rural
adolescents and depression, K. R. Puskar and colleagues stated that nurses are in a critical
position to screen for depression, and promote mental health teaching (Puskar, Stark, Fertman,
Bernardo, Engberg, & Barton, 2006). Teaching adolescents some simple coping skills such as
meditation, guided imagery, and deep breathing, could give them an advantage in calming
themselves in stressful situations, and at no cost to the family.
Dr. Kemper and her associates conducted a study on 5651 youth ages 7 to 17 years of
age, with one or more mental health concerns, those being three of the more common disorders;
attention deficit hyperactivity disorder (ADHD), depression, and anxiety (Kemper, 2013). It was

Adolescent Depression Screening

found that 28.9% used one or more complementary and alternative medical therapies (CAM) as
their coping mechanism of choice since it can be accessed immediately, and without cost
(Kemper, 2013). The study also found that the mind-body therapies were also utilized the most,
such as meditation, guided imagery, deep breathing, hypnosis, and bio-feedback, stating the ease
of access, and immediate relief of symptoms as reasons for usage (Kemper, 2013). Adding a
teaching session about some of these CAM therapies by the nurse, could help the adolescent
when they thought they needed immediate care, and a way to include the adolescent in their own
care. This kind of change would have to be recognized by the PCPs, to which they may be
inclined to comply with, since it would be low cost, and a time-sensitive way to protect their
young, at-risk patients.
Adolescent depression is, without a doubt, a significant underdiagnosed and undertreated
condition that affects not only the patient, but society in general by the high costs to healthcare.
Early recognition is the key to improving the number of untreated individuals, but it will require
an effort to raise awareness amongst adolescents, their families, and the PCPs. Nurses play a
major role in prevention, teaching, and raising awareness, and can help implement change and
assist with the administration of a depression screening tool to adolescents systematically during
a healthcare visit. This can be accomplished in a local setting, as well as at the state and national
levels, and will require effective communication and an understanding of the inherent tendencies
of people to be resistant to change (Ellis, Hartley, 2012). The statistics previously mentioned,
make it clear, that a system must be standardized and put into action. Research shows that there
are valid screening tools available, however, more research is needed to address actual success
rates (Carnevale, et al, 2010). It stands that if the problem is in fact, that many cases go unnotice
unnoticed, undiagnosed, and untreated, we need a way to rectify the system, and implement the
changes that are needed.

Adolescent Depression Screening

9
References

Carnevale, T. (2011). An integrative review of adolescent depression screening instruments:

Applicability for use by school nurses. Journal of Child and Adolescent Psychiatric
Nursing, 24, 51-57.
Corona, M., McCarty, C.A., & Richardson, L.P. (2013). Depression screening: Screening
adolescents for depression. Contemporary Pediatrics, 7, 24-30.
Currid, T.J., Turner, A., Bellafontaine, N., & Spada, M.M. (2011). Mental health issues in
primary care: implementing policies in practice. British Journal of Community Nursing,
17(1), 21-26.
Dahlmann, B.H., Buhren, K., & Remschmidt, H. (2013). Growing up is hard: Mental disorders
in adolescence. Deutsches Arzteblatt International, 110(25), 432-40.
Ellis, J.R., & Hartley, C.L. (2012). Nursing in todays world: Trends, issues, and management
(10th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Friedman, R.A., & Leon, A.C. (2007). NEJM-Expanding the black box-Depression, antidepressants, and the risk of suicide. New England Journal of Medicine, 356, 2343-2346
Kemper , K. J., Gardiner , P., & Birdee , G. S. (2013). Use of complementary and alternative
therapies among youth with mental health concerns. Academic pediatrics, NOV-DEC(6),
540-545.
King, C. (2011). Adolescent emergency patients: Suicide risk detection and services facilitation.
NIMH Outreach Partnership Program 2011 Annual Meeting. Retrieved on November 22,
2014 from;
http://www.texassuicideprevention.org/wpcontent/uploads/2013/06/AdolescentEmergenc
yPatientsSuicideRiskDetectionandServices Facilitation.pdf

Adolescent Depression Screening

10
References

Lenz, K., Coderre, K., & Watanabe, M.D. (2009). Overview of depression and its management in
children and adolescents. Formulary, 44, 172-180.
Puskar, K.R., Stark, K.H., Fertman, C.I., Bernardo, L.M., Engberg, R.A., & Barton, R.S. (2006).
School based mental health promotion: Nursing interventions for depressive symptoms in
rural adolescents. Californian J Health Promotion, 4(4), 13-20.
Richardson, L.P., Russo, J.E., Lozano, P., McCauley, E., & Katon, W. (2010). Factors associated
with detection and receipt of treatment for youth with depression and anxiety disorders.
Academic Pediatrics, 10(1), 36-40.
Santoro, K., & Murphy, B. (2010). Improving early identification & treatment of adolescent
depression: Considerations & Strategies for health plans. NIHCM foundation issue brief.
Retrieved on November 25, 2014 from:
http://www.nihcm.org/pdf/Adol_MH_Issue_Brief_FINAL.pdf.
U. S. Preventive Services Task Force, (2009). Screening and Treatment for Major Depressive
Disorders in children and Adolescents: Clinical Summary. Retrieved on November 13,
2014 from:
http://www.uspreventiveservicestaskforce.org/uspstf09/depression/chdeprsum.htm
Williams, J., Klinepeter, K., Palmes, G., Pulley, A., & Foy, J.M. (2004). Diagnosis and treatment
of behavioral health disorders in pediatric practice. Pediatrics, 114(3), 601-06.

Student Name:_Kristin Sedore

Date:_11/22/2014_____________

Learner Initials:________A.R.____age: 14 years____________________

PATIENT AND FAMILY EDUCATION
READINESS TO LEARN
[X ] ACCEPTANCE OF DIGNOSIS
[ ] CALM

[ ] MOTIVATED
[ ] ANXIOUS

[X ] COOPERATIVE
[ ] OTHER (Describe in Comments)

BARRIERS TO LEARING
[X ] NO BARRIERS (Physical/Mental)
[ ] FATIQUE/PAIN
[ ] COMMUNICATION BARRIER
[ ] LOW LITERACY
[ ] CULTURAL/RELIGIOUS/SPIRITUAL
[X ] FINANCIAL (Describe in Comments)
[ ] COGNITIVE/SENSORY IMPAIRMENT [ ] OTHER
STEPS TO OVERCOMING BARRIERS
[ ] VERBAL INSTRUCTION
[ ] WRITTEN INSTRUCTION
[ ] EDUCATION SIGNIFICANT OTHER
[ ] INTERPRETER
[ ] REPETITION
[ X ] OTHER (Describe in Comments)
COMMENTS
This adolescent has no physical or mental barriers that would cause any misunderstandings of the teaching presented.
Financially the family is lower income, and does not have insurance. The parents were told about MI Child health
coverage, and forms were given to them to apply for this, for the two children they have.
PATIENT PREFERENCE
LEARNER CODE
METHOD
PLC (PERFORMANCE
LEARNER CODE
[X ] One on One
[ ] Printed Material
[X ] Video
[ ] Class
[ ] No Preference Expressed

TEACHING FOCUS

PT Patient
SP Spouse
P Parent
SO Significant Other

LEARNER
CODE

V Video
T One to One
D Demonstration
H - Handout

TEACHING
METHOD

PLC

DATE

Mindful meditation

PT, P

Explaination
and
performed

11/22

Deep Breathing

PT, P

Explanation
of benefits,
and
performed

11/22

1 Cannot perform skill

Demonstrates no understanding
2 Needs reinforcement /
assistance
3 Independently demonstrates
skill states accurate
understanding

ADDITIONAL
INFORMATION

PT was receptive to this.

After an explanation to
what it was, and it was
performed, A.R. initiated
it on her own before I
left.
Pt liked the idea that this
could be done anywhere,
especially at school,
without anyone knowing
what she was doing.

SIGNATURE

KS

KS

AGE SPECIFIC NEEDS

Age Specific Need Identified

14 yo girls want to fit in, and do not want to be different.

How was it addressed

The coping skills taught were something she could do in

the privacy of her home, and no one else would know.