Screening for Mental Health Problems in Primary Care

We understand that as a care provider or patient, it is challenging to keep up with all of the most updated and relevant research related to the care you provide or receive. Accordingly, we will be doing our best to provide you with summaries of recently published peer-reviewed research articles. To be clear, this is not research that we have conducted or produced - rather, these are summaries of research carried out by talented researchers across the world. Our summaries consist of our interpretation of these research studies based on information provided within research articles. These summaries are intended to be educational and full credit regarding the content of each study is to be given to the authors of the study (provided for every article we discuss).

In this post we will be summarizing and briefly discussing the peer-reviewed article “Recognizing the Hurt: Prevalence and Correlates of Elevated PTSD Symptoms Among Adolescents Receiving Mental/Behavioral Health Services in Primary Care” a 2019 article that was published by Selwyn, Schneider, Anderson, and Langhinrichsen-Rohling in the journal Psychological Services. The article aimed to determine how well mental health screening in primary care could identify adolescents who are experiencing problems with post-traumatic stress disorder (PTSD).

What did they do?

The authors of this interesting article set out to examine the prevalence of posttraumatic stress symptoms in adolescents that could be missed by using a behavioral health assessment/screening measure that is often deployed in primary care settings.

Why did they do it?

The authors reference that around one quarter of the 43% of adolescents who experience a potentially traumatic event will continue to show trauma-related symptoms for more than 3 months. The problem is that these trauma symptoms are often either misdiagnosed or completely unrecognized, largely due to a lack of adaptive methods to assess them. Primary care is an ideal setting to screen for behavioral health problems due to the fact that more adolescents are funneling into primary care settings when compared to behavioral care settings.

How did they do it?

The study was carried out in a pediatric clinic that used the Patient Health Questionnaire-9 (PHQ-9) as a primary mental health screening tool. Records from 133 patients who were referred for mental/behavioral health services based on their scores from the PHQ-9 (and other methods, such as broad interviewing) were assessed in further detail. Specifically, PHQ-9 scores were juxtaposed with scores across various other rating scales evaluating internalizing and externalizing behavior problems (including problems specific to PTSD).

What did they find?

58% of included patients screened “positive” for PTSD, being characterized as PTSD-possible or PTSD-likely. 15% of adolescents who screened positive for PTSD did not report elevated PHQ-9 ratings of depression.

What does it all mean (our take)?

The strategies that are being used in many primary care settings to evaluate the mental health of their patients can certainly be improved. It is extremely common for primary care providers to utilize brief screening measures (e.g., PHQ-2, PHQ-9, GAD-7, etc.) to evaluate the mental health of their patients.

Why is this a problem? This article pretty clearly indicated that the use of a depression questionnaire, such as the PHQ-9, as a screen for broad mental health functioning can lead to patients slipping through the cracks. The problem is that the vast majority of mental health screenings completed in primary care settings evaluate singular domains of mental health - for example, the PHQ-9 strictly evaluates depressive symptoms - and fail to broadly evaluate a patient’s overall mental wellbeing.

The challenge is that this quick and efficient system fits nicely with a medical model that does not allow for extended periods of time to be spent face-to-face with patients. On average patients in United States primary care settings spend approximately 15 minutes with their physicians, leaving little time to administer lengthy measures. This is not the fault of physicians by any means, but it is simply an outcome of the payment structure associated with primary care visits.

So what do we do? Based on findings from this article, developing a broader, yet highly streamlined and efficient screening measure could be one solution to the problem. A brief, yet relatively comprehensive screening questionnaire would help physicians more specifically understand what is going on with their patients and allow for a smoother hand off between primary care doctors and behavioral health specialists; ultimately helping to improve integration of primary and behavioral health care.

If the goal of healthcare providers is to evaluate and treat the “whole patient”, then using novel, cutting edge mental health screening measures would be a good start to ensure that we can accomplish this goal.