Adolescent Depression Screening Revisited

Jared Capouya, MD
Medical Director Quality, Mary Bridge Children’s Hospital and Health Network

Close to one year ago, we (Mary Bridge Children’s Hospital) described our implementation of screening adolescents for depression using the Patient Health Questionnaire-2 and 9 (PHQ-2 and PHQ-9) in this newsletter. Since then we have had 18 months of screening, which equates to 4800 adolescents at their wellness visits. We recently revisited some of the questions we had initially when we started the screening.

  1. Will we overwhelm our own internal behavioral health/psychology with referrals at MultiCare Health System, because we are now screening?

Several physicians voiced concerns that we might overwhelm the available resources for behavioral health if we implemented universal screening.  What we have found is the following; in 2015, 268 children received a behavioral health referral, in 2016, our first year of formal measurement of screening, it increased to 275 (2.6%) and this year if we annualize to 12 months we could expect 231 (14% decrease from 2015). In an internal survey of our providers, close to 60% felt like they were not referring more since they implemented the screening. The same percent also remarked having a number score for depression made decision making more manageable.

  1. How would implementing a suicide screen into the EMR impact workflow?

One thought around having a suicide screen as part of the screening process was that we would dramatically increase time patients spent in clinic if we found that they screened positive on question 9 of the PHQ 9 or greater than no or low risk on the Columbia Suicide Severity Rating Scale (C-SSRS). What we have found so far in 2017 is that 3.4% of those screened by the PHQ-2 and went on to the PHQ-9 answered question 9 positively. Of these 56 patients 39 (70%) had the additional C-SSRS performed. A majority, 29 of these adolescents had no to low risk noted, not requiring a lot of additional clinical work. In our internal survey, described above, none of the providers remarked they had to send a patient to the Emergency Department and that the estimated additional time spent in clinic for each of these 56 patients screened at potential risk was around 30 minutes.

In conclusion, implementation of adolescent depression screening has not overwhelmed the Behavioral health resources within our system.  In fact it appears so far that utilization has actually decreased.  Providers in general find having a quantifiable score for depression and suicide preferable in terms of linking decision making to a score. In diving deeper into suicidal ideation, intent and planning we will likely find most youth are lower risk.  Anecdotal reports for the small percentage of patients with moderate to severe risk based upon the CSSRS require around 30 minutes of extra time in clinic. We still have a lot of work to do to understand the optimal workflow for screening, improving our rates of C-SSRS screening and what impact integrating behavioral health resources into the clinics will have.

The MBCHHN adolescent depression screening guideline is available at:

C-SSRS link: