Pediatricians Report Barriers That Impact Depression Screening in Adolescents

Barriers persist in the implementation and success of universal routine screening for major depressive disorder in adolescents, according to results from a qualitative study published in Comprehensive Psychiatry.

“Primary care pediatricians are in a valuable position to identify and treat depression in their adolescent patients,” the study authors wrote. “Adolescents visit their primary care physicians approximately 2 or 3 times a year on average and typically report feeling comfortable discussing mental health diagnoses with their physician.”

Pediatrician Experiences

The researchers recorded the preferences of 14 pediatricians regarding the implementation of routine depression screening guidelines in a primary care setting. Eleven participants identified as female. Ten participants were White and 4 were Asian. Participants were interviewed for 45 minutes.

All 14 pediatricians supported and followed the 2018 American Academy of Pediatrics recommendation on universal screening for depression in adolescents starting at age 12. There was variability among participants in screening at alternative ages (such as starting at ages 11 or 13) and in the frequency of screening more often than annually. Five pediatricians reported a lack of infrastructure and human resources to treat cases of positive screens, such as access to behavioral health resources. Two participants reported the need for additional clinical training regarding depression diagnosis and management.

Factors Affecting Depression Screening 

Based on a thematic analysis of the interviews, 8 qualitative themes arose regarding factors that influenced the implementation of universal depression screening. The 4 most frequent themes were screening modality, screening validity, time considerations, and confidentiality considerations. Less frequent themes were workplace coordination, alternative starting age other than 12 years old, more frequent screenings than annual screenings, and additional clinician training.

Screening Modality and Validity 

Regarding screening modality, most pediatricians reported a preference for electronic screeners to help streamline office workflow and reduce administrative burden, as screeners could be sent to patients ahead of time to be completed at home or on a tablet at the office. All 14 participants found depression screening tools to be helpful in general, and all 14 used the 9-item Patient Health Questionnaire, though some participants reported their offices using additional screeners. There were mixed impressions on the overall accuracy of the tool alone to correctly identify depression among different subgroups. They emphasized that specificity of language was important for detecting depression in girls versus boys and that cultural considerations were also important to address.

Time and Confidentiality 

Time-related barriers were one of the chief constraints to implementation of universal screening, according to all 14 participants. “The most common barrier was a lack of time to complete the recommended screenings, routine well-exam, trust-building between pediatrician, patient, and parent/guardian, and more” during the allotted 20 to 60 minutes for an examination.

Twelve of 14 participants reported challenges regarding confidentiality, such as the presence of the parent while the child fills out the form and maintenance of confidentiality during diagnosis and management, as well as in an electronic health records system, where answers to the screening tools may be uploaded.

In summary, the authors wrote, “it is important for primary health systems to consider pediatrician preferences—including around screening modality, screening validity, time barriers, and confidentiality barriers—to enhance the implementation of universal depression screening during adolescent routine well-child visits. Screening programs should be tailored to the unique contexts of the primary care clinics and engage collaborative decision-making processes alongside pediatricians and other health care professionals to enhance the buy-in and likelihood of successful implementation.”

The authors offered several suggestions for strategies to provide flexibility to pediatricians and address some of the barriers that were reported.