Digital Repository Doctoral Projects Fall 2021 Depression Screening for Adolescents in a Rural Community Chelsea Hoopes Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Hoopes, C. (2021) Depression Screening for Adolescents in a Rural Community Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Depression Screening for Adolescents in a Rural Community by Chelsea Hoopes A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Mary Anne Hales Reynolds PhD, ARN, ACNS-BC_(signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: SCREENING FOR DEPRESSION IN ADOLESCENTS 1 Depression Screening for Adolescents in a Rural Community Chelsea Hoopes Annie Taylor Dee School of Nursing, Weber State University December 10, 2021 SCREENING FOR DEPRESSION IN ADOLESCENTS 2 Acknowledgements This DNP-FNP project is dedicated to my husband, Sam as well as my brother Derek. Both are my closest friends and real-life heroes who provide unwavering support in my life and endeavors. It is with genuine gratitude and sincere respect that I thank Dr. Greg Staker, M.D., F.A.A.P. and CMO of Uintah Basin Healthcare for his mentorship, advice, and support through this entire educational experience. I would also like to thank Dr. Mary Anne Reynolds, RN, PhD, ACNS-BC and Dr. Daniel Colver, DBH, LMFT for mentoring and encouraging me through the process. To all the strong women in my life, I appreciate the courage and camaraderie you provide. A big thank you to my parents and parents-in-law for keeping all the parts in my life moving through the chaos. Most importantly I would like to thank my children, Allie, Mitch, and Spencer for their unconditional love and understanding in the past 2+ years and for teaching me that I can do hard things. One last thank you to Sam, the resilient and brilliant man who held things together when I couldn’t and who supports my continued academic and personal growth. SCREENING FOR DEPRESSION IN ADOLESCENTS 3 Abstract In Utah, depression rates have risen annually since 2013 and in Duchesne County, depression rates are among the highest in the state. Adolescent patients at Uintah Basin Medical Center (UBMC) clinic were not regularly screened for depression, and local resources were not well utilized. The purpose of this Doctor of Nursing Practice (DNP) project was to improve the diagnosis and treatment of adolescent depression by implementing a depression screening pathway for adolescents ages 12-17 in a pediatric primary care setting. A mental health pathway was developed using the GLAD-PC guidelines for adolescent depression. Three providers were educated regarding the pathway, including a depression screening tool and referral lists. Adolescent patients presenting to UBMC clinic were screened using the Patient Health Questionaire-9 (PHQ-9). If a patient screened positive, the pathway was initiated, and they were provided with a referral and/or medication, and a 1–4-week follow-up appointment. During the year preceding the implementation of this project, only 3% of adolescent patients were screened for depression in the pediatric clinic. After implementing the depression screening pathway, 48% of adolescent patients were screened for depression. Those who screened positive had a 90% referral and follow-up rate. Adolescent depression is a global crisis with devastating implications if not diagnosed and treated early. Decreasing adolescent depression rates in Duchesne County can be accomplished through routine screening in a primary care setting. This DNP project demonstrated that regular screening for depression could improve diagnosis and treatment rates for depression in adolescents. Keywords: depression, adolescent, screening, rural, mental health SCREENING FOR DEPRESSION IN ADOLESCENTS 4 Depression Screening for Adolescents in a Rural Community Over 264 million people suffer from depression, making it the second leading cause of disability worldwide. Of those affected by depression, an estimated 2.3 million are adolescents ages 12-17 (World Health Organization [WHO], 2020). Depressive disorders are among the most costly and impairing disorders. Major depression is characterized by irritability (in children), loss of interest/pleasure in activities (in adults), and mood changes that last two or more weeks (American Psychiatric Association [APA], 2019). Adults who report experiencing depression in adolescence report more healthcare visits, increased behavioral problems, participation in unsafe sexual activity, increased substance abuse, work impairment, and more suicide attempts in their lifetime (Paschall & Bersamin, 2017). According to Mojtabai, Olfson, and Han (2016), there is a sharp rise in the risk for depression as a child enters adolescence. In recent years there is an uptrend in the prevalence of depression in adolescents (Siu, 2016). Nearly 1 in 11 adolescents have a major depressive episode (MDE) every year, yet from 2005 to 2014, no significant changes in mental health treatment occurred (Mojtabai, Olfson & Han, 2016). If left untreated, the effects of depression are serious, yet nearly 50% of major depressive disorder (MDD) cases are missed due to inconsistent screening in primary care settings. Of the estimated 50% of cases of MDD that are identified, less than 35% of those received treatment (Siu, 2016). Early identification and treatment of mental disorders in adolescents are critical to improving the long term quality of life, mitigating medical and societal costs, and preventing associated health detriments. The purpose of this DNP project is to develop and implement an effective screening and treatment program for adolescents with depression. for primary care providers in Duchesne County, Utah. SCREENING FOR DEPRESSION IN ADOLESCENTS 5 Search An electronic literature search for peer-reviewed articles, both research and non-research, was performed using six databases: CINAHL: Nursing and Allied Health, Cochrane library, PubMed database, Google Scholar, Academic Search Premier, and Stewart Library OneSearch. The search was restricted to articles published after January 2015. It included the search terms depression screening AND adolescents (13-18 years old), depression AND adolescents, depression AND primary care physicians, clinical guidelines, and depression. Next, the search was narrowed to include adolescent depression AND (screening OR diagnosing). Article examination was limited to articles with complete studies published in English and involving children or adolescents specifically. Other inclusion criteria considered reports with measured data and statistics regarding adolescent depression rates, suicide prevalence, and resource availability. Literature Review Depression Depression is diagnosed in the presence of at least three of the following symptoms: severe, persistent feelings of hopelessness, weight loss, appetite changes, sleep disturbances, fatigue, reduced concentration, guilt, suicidal thoughts or ideation, and withdrawal from regular activity (APA, 2019). While there are several types of depression, including bipolar depression, seasonal affective disorder (SAD), and major depressive disorder (MDD), MDD is the most commonly researched and diagnosed type of depression. Depressive symptoms that last greater than two weeks require a diagnosis of MDD, also called clinical depression, classified as mild, moderate, or severe, and goes undiagnosed in approximately 76% of people (Zuckerbrot, Cheung, Jensen, Laraque, & Stein, 2018). Regardless of the type of depression a person is SCREENING FOR DEPRESSION IN ADOLESCENTS 6 experiencing, untreated clinical depression leads to increased morbidity and mortality, interferes with interpersonal function, reduces productivity at work or school, and may ultimately and catastrophically lead to suicide (APA, 2019). Risk factors like socioeconomic status and trauma increase susceptibility to depression, but anyone at any age can be affected. Environmental factors like exposure to violence, abuse, or poverty increase the risk of developing mental health disorders. Genetics, personality, and individual brain chemistry also increase the probability of depression (Mojtabai, Olfson, & Han, 2016). Access to care in rural areas and for individuals in low socioeconomic classes is reduced, putting people at an increased risk for depression, missed diagnoses, and undertreatment of depressive disorders (Steadman, Cole, & Meyers, 2018). Adolescent Depression The World Health Organization (WHO) terms adolescence as the age at which puberty begins until adulthood and includes individuals from ages 10 to 19. Approximately 17% of the world's population are considered adolescents, and mental health conditions make up 16% of the Global Burden of Disease (GBD), which assesses the mortality and disability resulting from major diseases worldwide, for individuals in this age group (World Health Organization [WHO], 2020). The onset of depressive disorders occurs most often in older adolescents, where there is an increased risk, and occurs at a rate two times higher than in younger adolescents. Approximately 20% of adolescents are affected by depression, and if left untreated, depression may lead to significant long-term consequences like substance abuse, poor school outcomes, adult depression, and suicide (Rinke et al., 2019). Depression in adolescents is defined by persistent feelings of hopelessness and diminished interest or pleasure in regular activities and may include weight loss/gain, fatigue, SCREENING FOR DEPRESSION IN ADOLESCENTS 7 sadness, agitation, feelings of worthlessness, recurrent suicidal thoughts, decreased ability to focus and process thoughts, and lack of motivation. For a diagnosis of depression to be made, loss of interest or hopelessness must be present for two or more consecutive weeks and may be accompanied by one or more other symptoms (Zuckerbrot et al., 2018). Nationally, adolescents ages 13-18 reported feelings of sadness or hopelessness during a 12-month period for two or more weeks in a row at a rate of 31.5% (Centers for Disease Control and Prevention [CDC], 2017). In Utah, the reported depression rate in adolescents is below the national average at 27.3%. In addition, teens in Duchesne and Uintah Counties (TriCounty) report these symptoms at a reportedly lower rate of 24.7%, with females reporting a higher prevalence of hopelessness than males. Children and adolescents who are minorities, and those who live in rural or underserved areas, such as the TriCounty area in Utah, are the least likely to receive mental health screening and treatment due to low socioeconomic status, decreased access to providers, and other financial constraints (APA, 2019). Both nationally and in Utah, reported rates of sadness and hopelessness among teenagers had increased every two years since 2013, at roughly a 3-4% rate (CDC, 2017). Because 31.5% of adolescents in the US report depression symptoms and only 25% are appropriately diagnosed, better assessment and the use of evidence-based tools for identifying depression in adolescents are needed (Rinke et al., 2019). Consequences of Adolescent Depression During adolescence, depression is exacerbated by social pressures, hormonal changes, underdeveloped cognitive level, and emotional immaturity (APA, 2019). Early diagnosis of depression is associated with long-term emotional, economic, and social burdens and is considered a significant public health issue (Forman-Hoffman et al., 2018). Major depressive SCREENING FOR DEPRESSION IN ADOLESCENTS 8 disorder, in adolescence, is the second leading cause of disability and decreased productivity worldwide (Steadman et al., 2018). There is sufficient evidence regarding effective treatment of depression, although, reportedly, only 40.9% of adolescents received treatment for their diagnosed depression in 2016 (Forman-Hoffman, & Viswanathan, 2018). Associated consequences of depression include impairment of one's social, emotional, and physical well-being. Depression can affect relationships, inhibit academic performance, lead to adult comorbidities, and, most devastatingly, result in suicide (CDC, 2018). If not identified and treated early, depression has been linked to added risky behaviors like alcohol use and substance abuse in adolescents. Depression affects one's motivation and ability to think, which increases the potential for associated health detriments, decreased work productivity, and poor scholastic performance (US Department of Health and Human Services [HHS], 2017). Any of these outcomes is harmful to the individual, their families, and potentially to society. Adolescent depression is associated with poor school performance and behaviors, adulthood depression/comorbidities, and suicide. The risk of suicide and rates of suicide attempts increases dramatically with a mental health diagnosis, particularly depression (CDC, 2017). Suicide is the most severe outcome of depression, and in 2016 suicide affected over 45,000 people in the United States (CDC, 2018). Depression is linked to increased rates of suicide ideation, suicide attempts, and suicide. According to the CDC (2017), suicide is the 10th leading cause of death in the United States. According to Rinke et al. (2019), in adolescents ages 15-19, suicide is the second leading cause of death. The suicide rate among adolescents in 2018 was almost 15%, with females attempting suicide nearly two times more than males (WHO, 2020). Of those adolescents who attempt or commit suicide, the majority of them have depression. SCREENING FOR DEPRESSION IN ADOLESCENTS 9 Because depression affects a person's ability to think clearly, the impacts on a child's academic performance and citizenship in school can be devastating. Childhood and adolescent depression are associated with poor academic performance (Paschall & Bersamin, 2017). Behavioral problems that inhibit school performance and participation occur at an increased rate in adolescents diagnosed with depression. Additionally, there is a strong correlation between suicide attempts and low GPA compared to students with GPAs in the highest quartile (Wallin et al., 2019). Depression during adolescence doubles the risk of one developing depression into adulthood and increases the presence of comorbidities (APA, 2019). When left untreated, adolescents with depression are more likely to become adults with depression. Approximately 20% of adults with depression were affected by mental health disorders as adolescents. The progression from adolescent depression into adult depression negatively impacts a patient's social outcomes affecting their employment and increasing criminal behaviors and substance abuse. Further, depression can have physiological effects that can exacerbate existing illnesses and lead to other health issues (Driot et al., 2020). Increased risk behaviors lead to increased comorbidities and strain on health resources, also increasing the financial burden on the individual affected. A study by Ghobadzadeh, McMorris, Sieving, Porta, & Brady, S.S. (2018) compared stressful life events with depression in adolescents and coping mechanisms that include risky sexual behavior and substance abuse. The results suggests that higher levels of stress earlier in life resulted in increased risky behaviors, specifically drug and sexual behavior. Stress and depression are bidirectionally related, and stress correlates directly with risky sexual behavior, whereas depression does not. SCREENING FOR DEPRESSION IN ADOLESCENTS 10 Barriers Depression in adolescence can be challenging to identify and treat. Family, friends, or school personnel often note changes in behavior and mood, but a diagnosis of depression usually comes from the patient's primary care provider (PCP). Often depression goes unrecognized or is misdiagnosed by the patient's PCP (Radovic et al., 2015). Barriers to the diagnosis and treatment of depression involve inaccurate assessment, limited mental health resources, and social stigmas associated with mental disorders (WHO, 2020). The United States Preventative Services Task Force ([USPSTF], 2016) concluded that basic screening tools are adequate and important in identifying youth at risk for depression and recommend more extensive diagnostic tools, assessment by primary care providers, and utilization of community resources in the presence of a positive depression screening. The first step in remedying depression is diagnosing it, which requires early recognition by a healthcare provider and subsequent referral and treatment. Most healthy adolescent patients only see a primary care provider for their health needs, so regular contact with mental health professionals is uncommon (Harder, Barry, French, Consigli, & Frankowski, 2019). Infrequent healthcare visits create opportunities for misdiagnosis or unrecognized depression. Despite evidence supporting the validity of systematic depression identification methods, few PCPs use them. Instead, most healthcare providers rely on patient presentation and complaints, which leads to underdiagnoses or misdiagnoses of depression (Zuckerbrot et al., 2018). Wissow et al. (2013) found that even when PCPs use depression screening tools, there are inconsistencies in the frequency of use and the referral and follow-up processes. Often, PCPs misdiagnose depression, and there are many barriers to fluent and effective screening, diagnosis, and treatment of SCREENING FOR DEPRESSION IN ADOLESCENTS 11 adolescents with depression. PCPs identify only 25% of depressed adolescents, and only 14% of those diagnosed received a mental health referral (Rinke et al., 2019). Nationally there is a shortage of mental healthcare providers, which quickly overwhelms resources and makes it more difficult for providers to make referrals. In addition to limited mental health resources, costs associated with specialty visits may or may not be covered under insurance, further limiting available resources for those who require mental health treatment, especially in rural areas (Radovic et al., 2015). Prevention programs are costly and add to the total cost of healthcare an individual is expected to pay, which is significantly higher throughout the lifespan in children and adolescents diagnosed with a mental disorder, increasing about $2,631 annually (Suryabanshi & Yang, 2016). That estimate is even higher when considering the cost of prescription drugs. It is also estimated that the economic burden associated with mental disorders in youth is about $11 billion per year in the United States (Suryavanshi & Yang, 2016). Even for those who have insurance and for whom resources are available, costs associated with appropriate treatment may prevent patients from complying with care. Solutions Addressing adolescent depression requires a multifaceted approach, including identifying those at risk by using screening tools followed by appropriate treatment and referrals, teaching positive coping skills, and incorporating counseling into their treatment plan. The guideline for adolescent depression in primary care by Zuckerbrot, Chueng, Jensen, Stein, & Laraque (2018) includes five major recommendations for managing adolescent depression. Recommendations include familiarization of diagnosing and treating depression by PCPs using standardized screening tools, implementing a treatment plan, utilizing expert consultation, and coordinating care. SCREENING FOR DEPRESSION IN ADOLESCENTS 12 Familiarizing PCPs to mental health screening and treatment. The PCP is the primary contact for most adolescents regarding healthcare of any kind, so mental health screening and subsequent mental health care must be an integral part of patient visits (Rinke et al., 2019). Due to the increasing prevalence of depression and suicidal ideation in adolescents, early detection in those at risk or who exhibit depressive behaviors is imperative for appropriate treatment and improvement in overall health (Harder et al., 2019). The PCP's role in treating and managing adolescent depression is to diagnose the patient early using evidence-based screening tools. Once screened, the PCP should initiate a comprehensive plan of care (Zuckerbrot et al., 2018). Zeledon et al. (2018) looked to reduce health risk behaviors (HRBs) and depression in adolescents ages 13-18 by implementing an intervention program in primary care settings. The research suggested that health provider inconsistency and increased health risk behaviors predicted severe depression. For clinical use, these conclusions indicate that provider consistency and increased exposure to intervention are essential to reducing depression. Establishing and maintaining relationships with patients while staying current on best practice guidelines is correlated to decreased internal barriers and successful implementation of mental health preventative measures in primary care (Mahoney et al., 2017). General practitioners must increase their knowledge and involvement in the care and management of depressive disorders in patients at risk or diagnosed with a depressive disorder while also utilizing regular screening and community resources (Driot et al., 2019). Regular screening. Early identification of patients at risk for depression by the PCP or pediatrician is essential in receiving the best care. The American Academy of Pediatrics recommends using a targeted depression screening tool (Zuckerbrot et al., 2018). Despite these SCREENING FOR DEPRESSION IN ADOLESCENTS 13 recommendations, an estimated half of adolescents with depression are not diagnosed due to inconsistent screenings (Siu, 2016). Implementation of a standardized screening tool is essential for every patient as untreated depression can be detrimental to the overall condition, even those who are otherwise healthy. When screening youth for depression, it is essential to realize that even without reports of depression, reports of stressful life events or reports of risky sexual behavior may indicate a risk for depression (Ghobadzadeh et al., 2018). A systematic review by Roseman et al. (2016) assessed the screening tools' accuracy in children and adolescents at risk for MDD. The review concluded that screening tools and use of them differ substantially. However, it is recommended to screen adolescents for depression using a standardized screening tool at least annually (Zuckerbrot et al., 2018). Expert consultation and community referrals. Early identification of depression is the first step in preventing and managing depression, followed by collaboration amongst the patient's healthcare team and referral to mental health experts if necessary. Collaborative care and effective referrals are an integral part of diagnosing and treating patients with depression. This referral could include community programs, mental health counselors, or even school personnel. Additionally, perceived barriers/support and attitudes toward mental health are essential to depression screening and referrals and successful treatment (APA, 2019). Expert consultation and referrals should be based on standardized care and can be addressed in a clinical pathway. Clinical pathways involve the collaboration of care, a clear sequence of steps in treatment, and documentation. Implementing clinical pathways into patient care reduces costs and improves care by facilitating the flow of care (Mater, Aldwairi, & Ibrahim, 2018). Mental health prevention is more successful for adolescents at risk for depression than increased screening and treatment alone. Avoidance of behaviors and influences that increase SCREENING FOR DEPRESSION IN ADOLESCENTS 14 depression requires active involvement in patient care by parents, PCPs, and teachers and the formation of support groups and healthy psychosocial habits. A study by Mahoney et al. (2017) found that motivation for communication and compliance with preventative practices was directly related to the dedication shown by PCPs and medical staff throughout treatment. Therefore, these prevention strategies should be incorporated into the patient's care plan or as part of the referral process (Zuckerbrot et al., 2018). In a study by Forman-Hoffman & Viswanathan (2018), it is suggested that clinical training and community partnerships, and family training on monitoring risk factors could alleviate some of the burden resulting from insufficient mental health resources. According to Driot et al. (2020), mild depressive episodes require supportive therapy and monitoring for four to six weeks, whereas moderate to severe depressive episodes should be referred to specialists. Follow-ups should initially be weekly for one month then expand to every two weeks for the second month. Patients should then be seen at least monthly while depressive symptoms are present. Where treatment is indicated, psychotherapy or a combination of psychotherapy and medication should be considered using the minimum effective dose. Multidisciplinary assessment and attention are crucial for depressed adolescent patients (Harder et al., 2019). Summary of Literature Review Adolescent depression affects about 20% of children worldwide and goes undiagnosed in over 50% of patients. Undiagnosed depression affects a person's physical health, emotional well-being, and academic performance. Ultimately, adolescent depression can affect a person into adulthood and may tragically lead to suicide (WHO, 2020). Difficulties in treating mental health disorders in adolescents include inaccurate assessment, inadequate access to care, limited mental health resources, misdiagnosis, and social stigmas surrounding mental health. Regular depression SCREENING FOR DEPRESSION IN ADOLESCENTS 15 screening to identify depression early can improve patient outcomes. Improving PCP education and mental health screenings, collaborating with mental health experts through referrals, and utilizing community resources is essential to successfully diagnose and treat adolescent depression (Zuckerbrot et al., 2018). Practice Change Plan In Duchesne County, a rural community, there was no consistent use of a depression screening tool to identify adolescents at risk for depression. Early identification can lead to early referral and treatment, thus decreasing behaviors that may impact school, work, social interactions, general health, and suicidal behaviors. Creating and applying a mental health pathway in the pediatric clinic at Uintah Basin Medical Center for PCPs and their adolescent patients improved patient outcomes. Implementing a standardized screening pathway was the emphasis of this DNP practice change. The DNP leader acted as a change agent and liaison for the DNP project through effective communication and collaboration (Weber State University [WSU], 2019). Other responsibilities included contacting the implementation site, obtaining Institutional Review Board (IRB) approval, and organizing the project design, implementation, and evaluation (WSU, 2019). Once the implementation site was established, stakeholders were identified and discussions regarding organizational needs were organized. This DNP project was IRB exempt and the project design moved forward with the collaboration of the site medical director, mental health provider, and the DNP student. Implementation and evaluation of this project were completed by the DNP leader in the Spring of 2021. SCREENING FOR DEPRESSION IN ADOLESCENTS 16 Theoretical Framework Practice change should be guided by evidence and theory for program implementation and effective change (Burnes, 2020). Kurt Lewin's three-step model of change was the guide for this DNP project. Lewin's three-step model includes unfreezing, moving, and freezing as the three steps to successful change (Cummings, Bridgman, & Brown, 2016). Unfreezing is the first step and involves the process of identifying the necessity for change. This perceived change could be a product of an individual, a group, or changes in guidelines or recommendations (Burnes, 2020). In this phase of the change process, key stakeholders are identified to brainstorm ideas and organizational needs. Next is the moving process, which requires research, development, implementation, and progress towards change. Freezing is the final step in Lewin's change process and is described as the process that seeks to stabilize the implemented change, solidifying it as the new norm or behavior (Burnes, 2020). This practice change sought to change the process of identifying and treating depression in adolescents by adding a routine screening and referral process. The first step, unfreezing, was where stakeholders and PCPs were identified and informed of the anticipated change and asked for their input—next, moving required implementing a clinical pathway that included regular screening with a standardized screening tool, referrals, and documentation. Finally, freezing was demonstrated by supporting the providers, assessing their satisfaction with the project, addressing their concerns, and the continued regular use of depression screening with proper referrals, which leads to accurate diagnosis and treatment of adolescent depression (Cummings, Bridgman, & Brown, 2016). SCREENING FOR DEPRESSION IN ADOLESCENTS 17 Expected Outcomes The goal of implementing this DNP project was to improve mental health, specifically depression, for adolescents in Duchesne County, Utah. This project established a standardized depression screening schedule and implemented a protocol based on current clinical guidelines. The mental health pathway included resources and a referral list for primary care providers and patients. Finally, the practice change engaged providers by providing education and data on the importance and use of the screening tool and clinical pathway. Provider education ensured accurate diagnoses and treatment for depression in adolescent patients. Setting This project took place in the pediatric clinic at Uintah Basin Medical Center (UBMC) in Roosevelt, Utah, which serves the entire county of Duchesne. The pediatric clinic at the facility has one board-certified pediatrician, one physician's assistant (PA), and one family nurse practitioner (FNP). Office staff included four receptionists, one registered nurse (RN), and four medical assistants (UBH, 2020). The number of pediatricians in Duchesne county per 100,000 children ages 0-18 is 2.9, with 2.9 phycologists and 0 psychiatrists in the area (CDC, 2020). Each provider saw about 24 patients per day, and around 60% of those are well-child checks. Although referral services in the area are limited, Northeastern Counseling Center (NCC) is a mental health center that offers adults, adolescents, and children services. This counseling group provides services for Duchesne, Uintah, and Dagget counties. NCC is the preferred referral service for patients who have Medicaid or Medicare. According to Psychology Today (2020), ten therapists are serving this area currently. Of those mental health providers, five accept most insurances or self-pay, one accepts only five private insurances, and four accept self-SCREENING FOR DEPRESSION IN ADOLESCENTS 18 pay only. These providers are not all specific to adolescent patients, which creates a shortage of resources for the adolescent population. Population According to the US Census Bureau (USCB) (2020), there are approximately 6,800 children and adolescents in Duchesne county, ages 6-18 years old. Recent data from the Utah Department of Health (2017) shows that although Duchesne county ranks below the Utah state average in reported adolescent depression, the increased suicide and suicidal ideation rates indicate that prevention and diagnosis of depression in the county are inadequate. The estimated population of Duchesne county, which is considered a rural area, is 19,938. There is one high school, two high school/junior high schools, one school with students K-12th grade, and one junior high school in Duchesne County. The population is 90.9% White, 8.3% Hispanic or Latino, 4.9% American Indian or Alaska Native, 2.8% two or more races, 0.5% Black or African American, 0.5% Asian, and 0.3% Native Hawaiian or Pacific Islander. Adolescents ages 12-18 make up 33.4% of the population in Duchesne county, and 11.9% of the population lives in poverty (USCB, 2020). Gaps in Care Youth in Utah reported suicidal thoughts/attempts at a 17% rate, and those rates were 5% higher among adolescents in the TriCounty area, as 22% of students reported thoughts of suicide or attempted suicide (Utah Department of Health [UDH], 2017). Despite the apparent lower rates of adolescent depression in Utah and the TriCounty area, the suicide rates/attempts indicate a more severe problem, or underdiagnoses, of depression in this area. In Duchesne County, Utah, there is an increased rate of adolescent suicide than the national rate (UDH, 2017). Although 23 primary care providers practice in the area (Uintah Basin Healthcare [UBH], 2020), standardized SCREENING FOR DEPRESSION IN ADOLESCENTS 19 depression screening tools are currently underused. This gap in care contributes to undiagnosed depression that may cause the increased rates of suicide that are presently seen. Combining adequate screening with appropriate preventative education, referrals, and follow-ups is critical in addressing this trend. Project Planning The Guidelines for Adolescent Depression in Primary Care (GLAD-PC, 2020) was the recommendation used to guide this project. The guideline advocates establishing a screening process to create appropriate referrals and partnerships with mental health resources in the community. According to GLAD-PC guidelines, PCPs should first be trained to screen for and identify depression before managing mental health in patients (Zuckerbrot et al., 2018). At UBMC, a flow chart was established to accompany the pathway to facilitate its ease of use. The American Academy of Pediatrics (AAP) recommends the use of a targeted depression screening tool. It includes the PHQ-9 and PHQ-2 questionnaires as useful tools for identifying adolescents at risk for depression (Zuckerbrot et al., 2018). The PHQ-2 assessment has two questions and was supposed to be administered to every patient; however, it was determined that this screening was more time-consuming and less effective for this office. It was omitted from the screening process on the first day of implementation. These two surveys, which are already established in UBMC's EHR and are not consistently used on every patient, were the risk assessments used in this project. The PHQ-9 assessment proved to be succinct and useful on its own and was used to screen every patient. A PHQ-9 score of 0-5 is negative for depression, 5-9 indicates mild depression, 10-14 shows moderate depression, 15-19 suggests moderately severe depression, and 20-27 implies severe depression. Regarding depression, a negative score required no SCREENING FOR DEPRESSION IN ADOLESCENTS 20 intervention, and those patients will be re-screened at their next well-child visit (Zukerbrot et al., 2018). During fall 2020 a screening schedule, pathway, and resources were established. Since the PHQ-9 survey is recommended for depression screening by the AAP and because of its ease of use, and its incorporation in UBMCs electronic health record (EHR) system it was the standard screening tool used. Providers inconsistently used this tool, and results of patient screenings were challenging to find, and often not used effectively. A pre-assessment of depression screening use and usefulness was given to participating providers to determine gaps in knowledge and weaknesses in the previous screening system. This data was used to construct a curriculum for this project. Making the providers aware of the need for and use of the screening tool was the first step in planning and implementing this project. A pathway was developed to include additional evaluations for adolescents who screen positive for depression, a list of mental health providers in the area, and a statewide psychiatric consult service (CALL-UP) that is designed to improve access to the limited pediatric/adolescent psychiatric services in Utah (Huntsman Mental Health Institute [HMHI], 2021). This annotated list consisted of special interests, accepted insurances, and payment plans accepted by these providers. A follow-up process was necessary since failure to contact a specialist after a referral leaves the disorder unresolved. Every patient who screened positive was scheduled for a follow-up with the assessing provider within 7-10 days of the referral. (Zuckerbrot et al., 2018). The screening process was refined by collaborating with office staff, providers, nurses, and patients. to avoid negatively impacting the regular flow of well-child or health maintenance visits SCREENING FOR DEPRESSION IN ADOLESCENTS 21 Project Implementation The implementation of a depression screening pathway was needed because moderate depression requires watchful waiting and a repeated positive PHQ-9 assessments require a follow-up sooner than an annual appointment. Moderate and moderately severe depression requires a treatment plan, a referral to a mental health professional, and a follow-up with the addition of pharmacotherapy for those who screen moderately severe. Any score that denotes severe depression requires immediate pharmacotherapy initiation, expedited referral to mental health, and collaborative management with a safety plan. Regardless of the patient's score in the PHQ-9 assessment, a positive answer to question nine concerning suicide requires a safety plan (Zuckerbrot et al., 2018). Per the GLAD-PC guideline, providers were reminded of the use and interpretation of PHQ screening scores in the training. Regular use of a mental health pathway for adolescents was implemented for those patients positively identified as at risk for depression and began with patient/family education about depression and care management options. Provider education was essential for this step to provide adequate interventions and follow-up. This mental health pathway included producing a complete referral list, educating patients and families about treatment options, and making a referral while the patient was in the office. GLAD-PC recommended all of these steps for the initial management of depression in adolescents (Zukerbrot et al., 2018). Next, provider education on the use of the clinical pathway and screening schedule was developed. Education occurred via in-person classes and handouts regarding regular use and interpretation of the PHQ-9 screening tool. Each provider and their MA were educated on the CALL-UP consultation process and were pre-registered with the service. The screening tool, SCREENING FOR DEPRESSION IN ADOLESCENTS 22 referral lists, and the pathway were made available in all offices. After this, the staff was educated on project goals and the importance of screening every patient. This collaboration among the team members helped decide who was responsible for what, when, and where. Implementation began in April 2021. At this point, the screening schedule and pathway were implemented throughout the clinic, which includes a pediatrician, a physician's assistant (PA), a family nurse practitioner (FNP), and office staff. Implementation involved distributing screening tools and care pathways in each provider's office to screen every patient and providing patient education handouts, a list of local mental health resources, and mental health provider list with contact and payment information. Patients who screened positive in the office were referred the same day by the PCP and scheduled for a maximum seven-day follow-up appointment before leaving. Additionally, those patients who had recurrent or continuous symptoms despite intervention were consulted on using CALL-UP, a free program provided by the University of Utah, which is an addition to the clinical pathway. The project implementation took place over approximately eight weeks. Evaluation and Analysis At the completion of this project, the use of a standard depression screening process and referral rates were assessed through an EHR chart review. Provider education on the importance and process of screening and referral was evaluated using verbal teach-back methods to assess understanding. The evaluation included a monthly chart review to evaluate the screening tool's use and the rate of referrals. The importance of monthly tracking included reviewing the number of adolescent patients ages 12-18 who were seen in the clinic and screened. Monthly appraisals looked for the number of patients referred as well as those who received follow-up appointments. The data gathered from youth identified with a high-risk positive screen was assessed to track SCREENING FOR DEPRESSION IN ADOLESCENTS 23 and determine if the pathway and referral process was completed. Analysis of the data used descriptive statistics to look for any changes in the number of adolescents screened, the number of positive screens, an increase in mental health referrals, and PCP follow-up visits. These rates were compared to those in the same months in 2019 and 2020. Ultimately the data from 2020 was not used as the number of patients seen from March to May 2020 were vastly decreased compared to 2019 and 2021 which was likely due to the COVID-19 pandemic. In 2019 from the beginning of March until the first week in May, the number of adolescent patients seen in the pediatric clinic was 99 (N=99). The number of patients screened for depression during that time was 3 (n=3) and all screened positive. Mental health referrals were made for all of those patients, and a clinical follow-up was provided for them. This represented 3% of adolescent patients seen in the pediatric clinic at UBMC who were screened for depression using the PHQ-9 screening tool, with all of the positive screens receiving an adequate referral and follow up from their PCP. In contrast, from March 2021 until May 2021, the number of adolescent patients seen in the pediatric clinic at UBMC was 104 (N=104), and 50 (n=50) of those patients were evaluated using a PHQ-9 assessment screener. Of the 50 adolescents screened, 19 of them screened positive, 18 were referred, 1 refused referral, and 1 followed up in the office within 7 to 14 days. Using the PHQ-9 assessment tool, 48% of adolescent patients were screened for depression and 90% of those who screened positive received a referral and follow-up care by their PCP within 14 days. There was a 1,500% increase in the number of adolescents screened after implementation. SCREENING FOR DEPRESSION IN ADOLESCENTS 24 Despite the increase in the number of adolescents screened for depression, there was a 10% decrease in the number of follow-ups for positive screens. The reduction in follow-up rates is likely because before the implementation of a screening tool and pathway, only patients suspected of mental health illnesses were screened. The increases seen in the number of adolescent patients screened, positive screens, referrals, and follow-ups indicated that the DNP project was effective. After this project, providers and office staff were surveyed using a Likert scale (Appendix 2) to determine the perceived effectiveness of both the pre-project education and preparation and the usefulness of the depression screening pathway. Overall, 100% of the staff and providers reported that the screening tool and flow chart were easy to use, 66% felt very comfortable using the PHQ-9 screener, 100% thought that the process was beneficial, and 90% felt that they were very well oriented to the screening process. Staff feedback included concerns 0 20 40 60 80 100 120 Total Patients Patients Screened Positive Screens Referrrals Follow Up Figure 1: Screening Comparisons Pre Intervention Post InterventionSCREENING FOR DEPRESSION IN ADOLESCENTS 25 and suggestions regarding screening adolescents too late, with 75% of the staff reporting that they think screening should be done before 12 years of age and 100% of the office staff and providers feeling that the screening and referral process was well received by patients and parents. The lead pediatrician felt that the increase in the percentage of adolescent patients screened was encouraging and found the referral resources to be exceptionally useful. Discussion The purpose of this DNP quality improvement project was to improve depression screening among adolescent patients in Duchesne County, Utah. The AAP and GLAD-PC guidelines recommend screening adolescent patients at least annually for depression. The PHQ-9 100% 3% 99 Total Visits in 2019 Not Screened (96) Screened (3) 52% 48% 104 Total Visits in 2021 Not Screened (54) Screened (50)SCREENING FOR DEPRESSION IN ADOLESCENTS 26 depression assessment tool is an evidence-based tool recommended for use by the AAP. The primary aim of this project was to increase clinic screenings in a pediatric office at UBMC. The project demonstrated that through implementation of a depression screening pathway that included early screening, referral, and provision of community resources, an improvement in screening rates by 1,500% was appreciated compared to data observed from 2019. Although referral and follow up rates post implementation were lower (90%) than in 2019 (100%), the outcome of the project was significant. In 2021 there were 50 (48%) adolescent patients screened for depression in the pediatric clinic compared to only 3 (3%) in 2019. Given the low-cost and high yield nature of this DNP project no financial barriers to implementation are concerning. Developing an effective and efficient screening system can also eliminate the possibility of provider hesitancy regarding implementing a depression screening pathway in their practice. Implications and Recommendations One barrier in implementing this project was determining whether or not an IRB was necessary. Due to the sensitive nature of mental health issues and the adolescent population involved, IRB approval was needed. Other challenges in the successful implementation of this project included provider buy-in and participation in this quality improvement (QI) project. The sensitive nature of mental health conversations and the availability of referrals and mental health resources were also considered when identifying barriers. Restrictions placed on hospitals and clinics during the COVID-19 pandemic were considered as a possible barrier. Still, they were determined to be minimal as clinic visits and referrals, except for CALL-UP consults, were all done in person. Finally, time constraints on both the project's length and providers regarding regular office visits were considered a possible limit to compliance and, therefore, the success of this SCREENING FOR DEPRESSION IN ADOLESCENTS 27 project. The project implementation time was a little over two months which was a reasonable amount of time to collect useful data. The project received adequate support from the pediatrician in charge of the clinical site. The outcomes of this DNP project offer several practice implications for providers caring for adolescent patients. Adopting evidence-based recommendations regarding adolescent depression screening is imperative given that 20% of adolescents in the United States experience depression (Rinke et al., 2019). Pediatric providers are in an opportune position to identify and manage adolescent mental health issues which can prevent suicide and improve mortality. The results of this project serve as evidence that screening for depression in every pediatric office cna assist in identifying those at risk and expedites the referral and treatment processes. Cost-effective options for supplemental mental health providers and community resources were also identified and made available to all providers at UBMC. Further progress and expansion of mental health screening among adolescent patients in the Uintah Basin should be initiated. Presenting the data and including a cost-benefit analysis may help providers and stakeholders overcome perceived barriers. The financial impact of this project could be further proven if specific billing codes are used to track patients and improve the perceived benefits of screening. For instance, a CPT 96127 can be used for depression screening when a standardized instrument is used, scored, and documented by a provider (Hughes, 2020). The cost-effective nature of this DNP project, its positive impact on patient care and outcomes, and its potential to increase revenue for the practice makes implementation ideal. The perceived difficulties of implementing this DNP project mainly coincided with office staff hesitancy and lack of knowledge regarding discussing mental health with pediatric patients. Further staff education and training could be helpful in improving the rate of screening as well as SCREENING FOR DEPRESSION IN ADOLESCENTS 28 improving patient education. There are several recommendations regarding adolescent depression screening that were highlighted by this project. First the age at which screening is performed should be extended to include children ages 10 and above. Additionally, it was determined that screening patients only during annual exams and episodic visits that included a mental health complaint could avoid excessive or inappropriate screening. Patients who require follow up assessments for medication and counseling effectiveness should also be rescreened four to six weeks following initiation of therapy and this was not done for this project. Conclusion Primary care providers and pediatricians in Duchesne County were not regularly screening for depression in adolescents. A mental health pathway and validated depression screening tool were introduced to the staff and providers at a pediatric clinic at UBMC. A regular screening process was implemented from March 2021 to May 2021. Data were gathered from the implementation period and compared to data from the same months in 2019. There was a 533% increase in the number of adolescent patients screened for depression using the PHQ-9 assessment tool during this time, indicating the effectiveness of this DNP project. Using a validated instrument, early screening was proven to identify depression in adolescents more accurately than relying on the patient or parent report alone. This DNP lead project followed the current clinical guidelines for adolescent depression that recommend that primary care providers use a validated depression screening tool to recognize and diagnose depression in teenagers ages 12 to 18 (Zucketbrot et al., 2018). Research shows that general depression screening among adolescents can increase early identification of depression and at-risk adolescents to facilitate appropriate interventions. The results of this project showed an increase screening, depression, diagnoses, and treatment rates among SCREENING FOR DEPRESSION IN ADOLESCENTS 29 adolescents in Duchesne County while also developing a useable and useful mental health pathway for PCPs. Investment in evidence-based practice changes can generate meaningful improvements in health outcomes. SCREENING FOR DEPRESSION IN ADOLESCENTS 30 References American Psychiatric Association (APA). (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from https://www.apa.org/depression-guideline/guideline.pdf Burnes, B. (2020). The origins of Lewin's three-step model of change. The Journal of Applied Behavioral Science, 56(1), 32-59. doi:10.1177/0021886319892685 Centers for Disease Control and Prevention (CDC). (2018). Anxiety, depression, and children's mental health. Retrieved from https://www.cdc.gov/childrensmental health/depression.html Centers for Disease Control and Prevention (CDCP). (2018). 1991-2017 High school youth risk behavior surveillance system data. Retrieved from https://nccd.cdc.gov/Youthonline/App/Default.aspx Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps: Rethinking Kurt Lewin's legacy for change management. Human Relations, 69(1), 33-60. doi:10.1177/0018726715577707 Driot, D., Nguyen-Soenen, J., Costes, M., Pomier, M., Birebent, J., Oustric, S., & Dupouy, J. (2020). Management of child and adolescent depression in primary care: A systematic meta-review. L'Encephale, 46(1), 41-54. doi: 10.1016/j.encep.2019.07.014 Forman-Hoffman, V. L., & Viswanathan, M. (2018). Screening for depression in pediatric primary care. Current Psychiatry Reports. 20(62), 1-10. doi: https://doi.org/10.1007/s11920-018-0926-7 Ghobadzadeh, M., McMorris, B. J., Sieving, R. E., Porta, C. M., & Brady, S.S. (2018). Relationships between adolescent stress, depressive symptoms, and sexual risk behavior SCREENING FOR DEPRESSION IN ADOLESCENTS 31 in young adulthood: A structural equation modeling analysis. Journal of Pediatric Healthcare. 33(4), 394-403. doi: https://doi.org/10.1016/j.pedhc.2018.11.006. Hankin, B. L. (2006). Adolescent depression: Description, causes, and interventions. Epilepsy and Behavior. 8(1), 102-114. doi: 10.1016/j.yebeh.2005.10.012 Harder, V. S., Barry, S. E., French, S., Consigli, A. B., & Frankowski, B. L. (2019). Improving adolescent depression screening in primary care. Academic Pediatrics. 19(8), 925-933. doi: https://doi.org/10.1016/j.acap.2019.02.014 Hughes, C. (2020). Coding and documentation. Family Practice Management. 27(3), 31–31. Retrieved from https://www.aafp.org/fpm/2020/0500/p31.html Hunstman Mental Health Institute: University of Utah. (2021). CALL-UP. Retrieved on May 27, 2021 from https://healthcare.utah.edu/hmhi/programs/call-up.php Institute for Healthcare Improvement. (2020). How to improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx Lai, E. S., Kwok, C. L., Wong, P. C., Fu, K.W., Law, Y. W., & Yip, P. S. (2016). The effectiveness and sustainability of a universal school-based programme for preventing depression in Chinese adolescents: A follow-up study using quasi-experimental design. PloS ONE. 11(2), 1-17. doi: http://dx.doi.org.hal.weber.edu:2200/10.1371/journal.pone.0149854 Mater, W., Aldwairi, M., & Ibrahim, R. (2018). Enhanced teamwork communication model for electronic clinical pathways in healthcare. The Open Bioinformatics Journal. 11(13), 140-163. doi: 10.2174/1875036201811010140 SCREENING FOR DEPRESSION IN ADOLESCENTS 32 Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics. 138 (6). doi: https://doi.org/10.1542/peds.2016-1878 Mahoney, N., Gladstone, T, DeFrino, D., Stinson, A., Nidetz, J., Canel, J.,…Van Voorehees, B. (2017). Prevention of adolescent depression in primary care: Barriers and relational work solutions. Californian Journal of Health Promotion. 15(2),1-12. doi:10.32398/cjhp.v15i2.1895. Paschall, M.J., & Bersamin, M. (2017). School-based health centers, depression, and suicide risk among adolescents. American Journal of Preventative Medicine. 54(1), 44-50. doi: 10.1016/j.amepre.2017.08.022 Psychology Today. (2020). Therapists in Duchesne county, UT Retrieved from https://www.psychologytoday.com/us/therapists/ut/duchesne-county Radovic, A., Reynolds, K., McCauley, H. L., Sucato, G. S., Stein, B. D., & Miller, E. (2015). Parents' role in adolescent depression care: Primary care provider perspectives. The Journal of Pediatrics. 167(4), 911-918. doi: https://doi.org/10.1016/j.jpeds.2015.05.049 Rinke, M. L., German, M., Azera, B., Heo, M., Brown, N. M., Gross, R. S., Bundy, D. G., Racine, A. D., Duonnolo, C., & Briggs, R. D. (2019). Effect of mental health screening and integrated mental health on adolescent depression—Coded visits. Clinical Pediatrics. 58(4), 437-445. doi: 10.1177/0009922818821889 Roseman, M., Kloda, L. A., Saadat, N., Riehm, K. E., Ickoqicz, A., Baltzer, F.,…Thombs, B. D. (2016). Accuracy of depression screening tools to detect major depression in children and adolescents: A systematic review. The Canadian Journal of Psychiatry. 61(12), 746-757. doi: 10.1177/0706743716651833 SCREENING FOR DEPRESSION IN ADOLESCENTS 33 Silke, C., Swords, L., & Heary, C. (2016). The development of an empirical model of mental health stigma in adolescents. Psychiatry Research. 242, 262-270. doi: https://doi.org/10.1016/j.psychres.2016.05.033 Siu, A. L. (2016). Screening for depression in children and adolescents: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 164(5), 360-366. Steadman, L., Coles, K. M., & Myers, L. W. (2018). Adolescent Depression. Pediatric Nursing. 44(6), 308-310. Retrieved from https://link-gale-com.hal.weber.edu/apps/doc/A568148328/AONE?u=ogde72764&sid=AONE&xid=edab235d Suryavanshi, M. S., & Yang, Y. (2016). Clinical and economic burden of mental health disorders among children with chronic physical conditions, United States, 2008-2013. Public Health Research. 13(71), 1-10. doi: http://dx.doi.org/10.5888/ped13.150535 Uintah Basin Healthcare. (2020). Find a provider. Retrieved from https://ubh.org/find-a-provider/ US Census Bureau. (2020). QuickFacts. Retrieved from https://www.census.gov/quickfacts/fact/table/utahcountyutah,duchesnecountyutah,UT/AGE295218#AGE295218 US Department of Health and Human Services (HHS). (2017). United States adolescent mental health facts. Retrieved from https://www.hhs.gov/ash/oah/facts-and-stats/national-and-state-data-sheets/adolescent-mental-health-fact-sheets/united-states/index.html United States Preventative Services Task Force. (2016). Screening and treatment for major depressive disorder in children and adolescents: USPSTF recommendations statement. Annals of Internal Medicine. 164(5), 360-367. doi: 10.7326/M15-2957 SCREENING FOR DEPRESSION IN ADOLESCENTS 34 Utah Department of Human Services Substance Abuse and Mental Health. (2020). 2019 mental health scorecard for children and youth (age 17 and younger). Retrieved from https://dsamh.utah.gov/pdf/Outcomes/MHE%20FY2019%20Final%20Youth.pdf Utah Department of Health. (2017). 2017 Utah adolescent health report. Retrieved from http://www.health.utah.gov/vipp/pdf/2017UtahAdolescentHealthReport.pdf Wallin, A. S., Koupil, I., Gustafsson, J. E., Sammit, S., Allebeck, P., & Falkstedt, D. (2019). Academic performance, externalizing disorders and depression: 26,000 adolescents followed into adulthood. Social Psychiatry and Psychiatric Epidemiology. 54, 977-986, doi: https:// doi.org/10.1007/s00127-019-01668-z Weber State University (2019). DNP project handbook and DNP practice hours [PDF]. Retrieved from file:///C:/Users/aorad/Downloads/Unit%20A%20DNP%20Project%20Handbook%202019-2020.pdf World Health Organization. (2020). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression Zuckerbrot, R. A., Cheung, R. A., Jensen, P. S., Laraque, D., & Stein, R. E. K. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. American Academy of Pediatrics. 141(3), 1-21. doi: https://doi.org/10.1542/peds.2017-4081 SCREENING FOR DEPRESSION IN ADOLESCENTS 35 Appendix 1: Pediatric Depression Pathway SCREENING FOR DEPRESSION IN ADOLESCENTS 36 Appendix 2: Post Assessment Survey Provider Survey for Adolescent Depression Screening Flow Chart 1. How often would you say you screened your adolescent pediatric patients? a. Never b. Sometimes c. Most of the time d. All of the time 2. How easy are the depression screening tool and flow chart to use? a. Very Difficult b. Difficult c. Easy d. Very Easy 3. How comfortable are you with screening and assessing for depression in your adolescent patients? a. Very Uncomfortable b. Uncomfortable c. Comfortable d. Very Uncomfortable 4. Overall, how helpful has the new screening process been for you? a. Very Difficult b. Difficult c. Easy d. Very Easy 5. Do you have any suggestions, comments, or concerns about screening for depression in adolescents or the depression screening flow chart? SCREENING FOR DEPRESSION IN ADOLESCENTS 37 Date Adolescents Seen Adolescents Screened Positive Screens Referrals Follow Up % Screened % Follow-Up 2019 March 36 1 1 1 1 0.03% 100% April 55 2 2 2 2 0.04% 100% May 8 0 0 0 0 0% N/A Totals N=99 n=3 3 3 3 0.03% 100% 2021 March 47 25 7 6 6 53% 86% April 45 19 10 10 8 42% 80% May 12 6 2 2 3 50% 100% Totals N=104 n=50 19 18 17 48% 90% Table 1: Adolescent Depression Screening Totals and Comparison