Multistage Adolescent Depression Screening: A Comparison of 11-Year-Olds to 12-Year-Olds



 

Alan B Cortez, MD1; Julia Wilkins, BS2; Eric Handler, MD3; Marc A Lerner, MD4; Raoul Burchette, MS5; Lawrence S Wissow, MD6

Perm J 2021;25:20.233

https://doi.org/10.7812/TPP/20.233
E-pub: 03/03/2021

ABSTRACT

Introduction: Adolescent depression screening is recommended starting at age 12 years, but younger children experience depression as well. Our objective was to determine whether screening for depression at age 11 years yields similar results to screening at age 12 years.

Methods: We conducted a retrospective chart review of 1000 11- and 12-year-olds in multiple pediatric offices of a large-group practice associated with a health maintenance organization in Southern California. All offices used a multistage depression screening process during well-child visits using the Patient Health Questionnaire for Adolescents, the global depression inquiry within a parent questionnaire, a chart-based review of mental health history, and brief patient/parent interview informed by the first 3 elements.

Results: The 11- and 12-year-old cohorts had similar completion rates for the Patient Health Questionnaire for Adolescents (99.2% vs 97.8%, P = 0.06), with similar mean total Patient Health Questionnaire for Adolescents scores (2.12 vs 2.22, P = 0.48). There was no significant difference for positive screenings determined by the pediatrician (12.0% vs 16.0%, P = 0.07), but parents of 12-year-olds were more likely have concerns for their child’s mood (6.8% vs 10.5%, P = 0.04). There were similar percentages of referrals (6.2% vs 8.8%, P = 0.12), beneficial conversations related to depression and anxiety, (4.5% vs 4.8%, P = 0.85), and new mental health diagnoses (2.0% vs 2.3%, P = 0.79).

Discussion: The process, results, and outcomes of screenings are similar for 11- and 12-year-olds, with a tendency toward more positive findings in 12-year-olds.

Conclusion: Multistage depression screening in 11-year-olds can be applied successfully in clinical practice, with most cases identifying youths without a prior mental health diagnosis.

INTRODUCTION

The prevalence of major depressive episodes increases through adolescence, peaking at 17%, but is already 5% by age 12 years.1 A recent analysis of 5- to 18-year-olds showed that suicidal thoughts or attempts accounted for 3.5% of all their emergency department visits in the US (more than 1 million visits/y). These visits doubled from 2007 to 2015, and more than 40% were in the 5- to 11-year-old subgroup.2 Screening for adolescent depression starting at age 12 years has been recommended by organizations such as the US Preventive Services Task Force,3 the National Committee for Quality Assurance,4 and the American Academy of Pediatrics,5 but it is not known how early-in-life concerns about depression and suicide should inform universal screening strategies.6,7 The US Preventive Services Task Force found insufficient data to make a determination to perform 11-year-old screening, prompting the need to validate tools and perform outcomes research for this age group.3

The medical group in this report (Southern California Permanente Medical Group) is associated with a large health maintenance organization (Kaiser Foundation Health Plan) and has screened thousands of 11- and 12-year-olds for depression since June 2015. The specific aim of this study is to determine whether there are clinically important differences in the process, results, and outcomes of depression screening in 11-year-olds compared to 12-year-olds. We hypothesized that all observed differences in study parameters would be clinically and statistically insignificant.

METHODS

Study Population

We performed chart reviews on patients of 60 pediatricians who practiced in 14 medical offices of a large-group practice. The pediatricians had received brief training and written information on depression screening methods and interpretation of results. There was no expected difference in the content, approach, or documentation for well-visits of 11- and 12-year-olds in the workflow of this medical group. Data were extracted from electronic health records (EHRs) of well-visits of 11- and 12-year-olds occurring from July 1, 2016, through March 28, 2017. Visits were chosen randomly within each age group, aiming for the final study sample with 60% of the charts (n = 600) from 11-year-olds and 40% (n = 400) from 12-year-olds. The total sample size was chosen as a significant but manageable amount given the need for manual chart reviews on all subjects, and the age distribution matched the frequency of well-visits by age in this practice (approximately 3500 well-visits at age 11 years and 2500 well-visits at age 12 years). Twelve-year-olds were excluded if they had a previous screening as an 11-year-old, so only initial screenings were compared.

Clinical Depression Screening Process

The EHRs supported the screening by increasing the visibility of important entries in the medical record, providing templates for documentation, and prompting nurses and providers to enter results prior to closing the chart. The screening process was designed to improve accuracy by using several tools simultaneously and synthesizing the information with human interpretation. With the published sensitivity (75%–90%) and specificity (85%–90%) of the Patient Health Questionnaire for Adolescents (PHQ-A),8-11 the core initial step in the process, and an expected prevalence of depression in the screened population of ≤ 5%,1 there likely would have been a positive predictive value in the range of only 10% to 30% using this test alone. Furthermore, depression screening tools without suicidality and parent assessment, although helpful, miss cases of adolescent depression.12 The screening thus consisted of 4 components:

The PHQ-A tool administered on paper to the adolescent in English or Spanish. The PHQ-A includes the Patient Health Questionnaire-9 plus 4 additional questions related to duration of depression, severity/functionality, and suicide risk (Figure 1).6-11,13 The parent was instructed to avoid giving any assistance and was told that results would be discussed later with the provider.

Question administered to parent: “Does your child often appear sad, depressed, or anxious?” This question (given in parent’s preferred language when available) was part of a larger questionnaire adapted from the American Academy of Pediatrics and administered routinely at well-visits.14

Review of the patient’s mental health history over 3 years (recent history) and evidence of treatment within 6 months (active history). This information came from the EHR and included dates of appointments, mental health diagnoses and problem listings, and prescribed psychotropic medications.

Interview with patient and parent using the previously noted data to clarify potential mental health dysfunction and to develop a plan of action. For example, clarifying a strongly positive response to a single PHQ-A question (especially when it was not associated with a high total PHQ-A score) might provide enhanced information on psychosocial function.9,10

tpj20233f1

Figure 1. English language wording on form used for Patient Health Questionnaire for Adolescents. On questions 1 through 9, “not at all” is scored as 0, “several days” is scored as 1, “more than half the days” is scored as 2, and “nearly every day” is scored as 3. The last 4 questions are referred to in this article as questions 10 through 13, but they are not numbered in the actual questionnaire and do not contribute to the total score. To analyze the data, questions 10, 12, and 13 were scored as 0 for “no” and 1 for “yes”, and the 4 responses to question 11 were scored from 0 to 3.

Data Extraction

Data extraction required manual chart reviews because some steps in screening are not recorded in extractable data fields. Reading notes was necessary to determine whether the provider considered the screening process to be “positive” and developed a treatment plan. To ensure consistent methodology between the 2 reviewers, they extracted data independently from the first 25 charts, then reviewed their results mutually. During subsequent reviews, the primary reviewer for a chart consulted with the other reviewer for all positive or questionable results. Screening steps were only considered “positive” if both reviewers agreed.

After comparing the age groups for demographic similarity, we sought data on frequency of performing each component of the screening process. For the PHQ-A, we also evaluated whether it was performed correctly (specifically, were all questions answered, documented, and scored correctly, and was there evidence the provider addressed the results).

We extracted and compared the 11- and 12-year-old age groups for the total PHQ-A score (range, 0–27), specific answers to each of the 13 PHQ-A questions (scored 0–3), result of the parent question, and whether a recent or active mental health history existed. A positive screen based solely on these objective data was defined as a yes response to any of the following categories:

Total score of the PHQ-A≥ 10, matching the cutoff currently used by the National Committee on Quality Assurance for ages 12 years and older.4

PHQ-A questions 12 or 13 > 0 (suicidal ideation and plan),

PHQ-A responses≥ 2 to questions 1, 2, 9, or 11, or yes on question 10. These questions are more focused on depression than questions 3 through 8, which deal with less-specific adolescent symptoms.10,11

Positive answer to parent question

Active mental health history present

Recent mental health history present

In some cases when the PHQ-A results were not recorded, but the provider note stated it was positive

We also recorded and performed an age group comparison on the provider’s comprehensive determination of possible depression, which could differ from the results of the instruments and chart review, and whether a mental health diagnosis had been assigned at the end of the visit.

Treatment plans extracted from the medical record and compared by age groups included emergency interventions, documentation of potentially beneficial mental health conversations related to both positive and negative screens, and mental health referrals made (and if completed). The finding that a beneficial conversation had occurred required both reviewers to agree and were defined as documentation of conversations resulting in one or more of the following:

A positive determination when the objective data were negative

Mental health referral

Advice or planning related to depression, anxiety, or adjustment disorder diagnoses that did not lead to a referral

Advice or planning for a psychosocial issue that did not meet criteria for a positive determination of depression

Statistical Analysis

Pearson χ2 tests were used for comparisons between groups, and the Mann-Whitney test was used for PHQ-A score totals. High P values indicated a lack of statistical difference between 11- and 12-year-olds.

RESULTS

The mean ages (Table 1) of the 11- and 12-year-old populations were 11.3 and 12.3 years, respectively. There was no significant difference between 11- and 12-year-olds in the other demographic characteristics we studied, although patient gender and pediatrician gender for the whole group tended toward more girls and women, respectively. The study population reflected the ethnic distribution in this practice as a whole, although it differed from the local population, which has more whites (44%) compared with Latinos (28%).15 From the EHR data or interview, 3% of these adolescents were known to be in active treatment for a mental health diagnosis other than Attention Deficit Hyperactivity Disorder or Autism Spectrum Disorder at the time of screening, including 0.8% who were being treated actively for depression.

Table 1. Demographics by age

Characteristic Total (N = 1000) Age 11 (n = 600) Age 12 (n = 400) P value
  n (%) n (%) n (%)
Mean age, y 11.72 (0.58)a 11.32 (0.30)a 12.33 (0.28)a  
Gender       0.06
 Male 466 (46.6) 294 (49.0) 172 (43.0)  
 Female 534 (53.4) 306 (51.0) 228 (57.0)  
Gender of pediatrician       0.22
 Male 340 (34.0) 213 (35.5) 127 (31.8)  
 Female 660 (66.0) 387 (64.5) 273 (68.3)  
Ethnicity       0.91
 White 286 (28.6) 175 (29.2) 111 (27.8)  
 Hispanic 441 (44.1) 259 (43.2) 182 (45.5)  
 Asian 176 (17.6) 109 (18.2) 67 (16.8)  
 African American 19 (1.9) 12 (2.0) 7 (1.8)  
 Other 78 (7.8) 45 (7.5) 33 (8.3)  
Payor       0.36
 Private 688 (68.8) 423 (70.5) 265 (66.3)  
 Affordable Care Act 86 (8.6) 48 (8.0) 38 (9.5)  
 Medicaid 226 (22.6) 129 (21.5) 97 (24.3)  

aMean (standard deviation).

Table 2. Total Patient Health Questionnaire for Adolescents score and positive responses (1, 2, or 3) for the screened population on each Patient Health Questionnaire for Adolescents question compared by age

PHQ-A result Total (N = 888)a Age 11 (n = 537) Age 12 (n = 351) P value
n (%) n (%) n (%)
PHQ-A mean total score 2.16 (2.98)b 2.12 (2.95)b 2.22 (3.02)b 0.48
 Total score of 0 379 (42.7) 239 (44.5) 140 (39.9) 0.44
 Total score range of 1–4 361 (40.7) 209 (38.9) 152 (43.3) 0.09
 Total score range of 5–9 117 (13.2) 73 (13.6) 44 (12.5) 0.21
 Total score range ≥ 10 31 (3.5) 16 (3.0) 15 (4.3) 0.14
All above scoring ranges compared N = 877c n = 528 n = 349 0.35
 PHQ-A question #1 112 (12.8) 62 (11.7) 50 (14.3) 0.26
 PHQ-A question #2 179 (20.4) 104 (19.7) 75 (21.5) 0.52
 PHQ-A question #3 253 (28.8) 140 (26.5) 113 (32.4) 0.06
 PHQ-A question #4 138 (15.7) 79 (15.0) 59 (16.9) 0.44
 PHQ-A question #5 210 (23.9) 116 (22.0) 94 (26.9) 0.09
 PHQ-A question #6 108 (12.3) 59 (11.2) 49 (14.0) 0.21
 PHQ-A question #7 196 (22.3) 127 (24.1) 69 (19.8) 0.14
 PHQ-A question #8 84 (9.6) 51 (9.7) 33 (9.5) 0.92
 PHQ-A question #9 36 (4.1) 24 (4.5) 12 (3.4) 0.42
 PHQ-A question #10 83 (9.5) 42 (8.0) 41 (11.7) 0.06
 PHQ-A question #11 140 (16.0) 81 (15.3) 59 (16.9) 0.54
 PHQ-A question #12 10 (1.1) 5 (0.9) 5 (1.4) 0.51
 PHQ-A question #13 2 (0.2) 2 (0.4) 0 (0.0) 0.25

a. Calculations exclude adolescents with undocumented total scores.

b. Mean (standard deviation).

c. Calculations exclude adolescents with undocumented answers to the questions.

PHQ-A = Patient Health Questionnaire for Adolescents.

The PHQ-A was administered 98.6% of the time. There was only one documented parental refusal (of an 11-year-old). The PHQ-A was also not performed on 13 others because of intellectual disability (5 adolescents) or staff error (8 adolescents). Overall, 76.3% of the time (data not shown) there was documentation the PHQ-A was performed accurately by staff (recording all 13 answers and scoring correctly) and analyzed by the pediatrician. The parent question was performed and documented successfully in both age groups 99.7% of the time. We could not determine the frequency of successful performance of the mental health history and the interview because they were frequently not documented if the results were negative. There was no observed difference (data not shown) between 11- and 12-year-olds for the process of performing the PHQ-A screening (99.2% vs 97.8%, P = 0.06), documenting accurate completion of all PHQ-A elements (76.0% vs 76.8%, P = 0.79), and documenting accurate completion of the entire multistage screening process except for the interview (75.2% vs 75.5%, P = 0.91).

There was no statistical difference between 11- and 12-year-old results on the PHQ-A (Table 2) for the average total score (2.12 vs 2.22, P = 0.48); percent of responses with the total score grouped by ranges of 0, 1 through 4, 5 through 9, or ≥ 10 (P = 0.35); and individual responses to each of the 13 questions (P = 0.06–0.92).

Figure 2 summarizes the information used by the providers to make their determination of a positive or negative screen, and provides data for the combined 11- and 12-year-old screening outcomes. We found that 13.6% of screens (11.5% for adolescents not currently in treatment) were deemed positive, although a smaller percentage of adolescents (7.2%) was referred formally to a mental health specialist. Of note, for 9 of 30 adolescents with an active mental health history in the EHR, the provider did not document its presence and the screen was deemed negative by the provider.

tpj20233  f2

Figure 2. Provider actions within the depression screen at 1000 well-visits for 11- and 12-year-olds.

We also compared by age the various ways the screening process could lead the provider to determine an adolescent had possible depression (Table 3). Only the parent question showed a higher degree of positivity in 12-year-olds (P = 0.04). We also found no age difference with combinations of categories we analyzed and no age difference when looking at those found positive by interview.

Table 3. Results of each component of the depression screen compared by age

Screen components Total (N = 1000) Age 11 (n = 600) Age 12 (n = 400) P value
n (%) n (%) n (%)
Any positive from all 8 screen categories 243 (24.3) 144 (24.0) 99 (24.8) 0.79
Any positive from the 7 objective screen categories 217 (21.7) 128 (21.3) 89 (22.3) 0.73
Any positive from the 4 PHQ-A categories 151 (15.1) 87 (14.5) 64 (16.0) 0.52
PHQ-A score ≥ 10 31 (3.1) 16 (2.7) 15 (3.8) 0.33
PHQ-A by questions 1, 2, 9, 10, or 11 positive 127 (12.7) 74 (12.3) 53 (13.3) 0.67
PHQ-A by questions 12 or 13 positive 11 (1.1) 6 (1.0) 5 (1.3) 0.71
PHQ-A positive by provider but not recorded 16 (1.6) 8 (1.3) 8 (2.0) 0.41
Parent screen positive 83 (8.3) 41 (6.8) 42 (10.5) 0.04
Active mental health history positive 30 (3.0) 18 (3.0) 12 (3.0) 1.00
Recent mental health history positive 53 (5.3) 34 (5.7) 19 (4.8) 0.53
Interview positive when objective screen negative 26 (2.6) 16 (2.7) 10 (2.5) 0.87

PHQ-A = Patient Health Questionnaire for Adolescents.

Table 4 shows data on treatment plans that resulted from the screening. Only 1 of 136 children (a 12-year-old) with a positive screen was sent for an emergency intervention because of suicidal concerns. Most positive screens (115 of 136) represented new findings; active mental health history was not present in 85% of positive screens. There were no age differences in the number of mental health referrals generated, mental health appointments completed, mental health diagnoses, and specific depression diagnoses. Including the cases diagnosed previously, we found a prevalence of 1.7% for depression and 5.1% for mental health diagnoses overall (excluding Attention Deficit Hyperactivity Disorder or Autism Spectrum Disorder). Some adolescents with recent but not active mental health history (8 of 23) were referred back for further treatment, and 1 child in active treatment for an adjustment disorder was referred specifically to evaluate for depression. The 2 age groups had a similar number of beneficial conversations without referrals (8.5% in 11-year-olds, 9.1% in 12-year-olds). The discussions concerned depression, anxiety, and various psychosocial issues that were revealed in both positive and negative screens.

Table 4. Outcomes of the screening program for the entire study population compared by age

Outcome Total (N = 1000) Age 11 (n = 600) Age 12 (n = 400) P value
% (95% CI) % (95% CI) % (95% CI)
Positive screen per pediatrician 136 (13.6) 72 (12.0) 64 (16.0) 0.07
New referrals sent 72 (7.2) 37 (6.2) 35 (8.8) 0.12
Referrals completed successfully 26 (2.6) 13 (2.2) 13 (3.3) 0.29
Beneficial conversation with positive screena 46 (4.6) 27 (4.5) 19 (4.8) 0.85
Beneficial conversation with negative screen 39 (3.9) 22 (3.7) 17 (4.3) 0.64
New mental health diagnosis 21 (2.1) 12 (2.0) 9 (2.3) 0.79
Preexisting mental health diagnosis 30 (3.0) 18 (3.0) 12 (3.0) 1.00
New depression diagnosis 9 (0.9) 6 (1.0) 3 (0.8) 0.68
Preexisting depression diagnosis 8 (0.8) 3 (0.5) 5 (1.3) 0.19

a. Excludes cases with mental health referrals.

CI = confidence interval.

DISCUSSION

Screening 11-year-olds for depression using a multistep approach that included the PHQ-A was feasible in this real-world clinical practice. The processes and outcomes for 11- and 12-year-olds were very similar, although parents of 12-year-olds were more likely to report concerns about their child. We did not investigate potential reasons for this disparity on the parental question. Still, this singular difference did not affect the clinical decision making (provider determinations and interventions) for the parameters we measured. In addition, the PHQ-A questions that were closest to a significant difference involved sleep, fatigue, and depression, all of which are expected to increase with age in adolescence.1,16

The PHQ-A was chosen as the initial step in the screening process because of its extensive use in clinical settings and as a public health quality indicator, its ease of administration in an office setting, and its focus on depression, rather than a wider array of psychosocial issues that were already screened for during well-visits with a comprehensive parent questionnaire and interview.4,6,8-10,11,13 Despite its widespread use, the PHQ-A has not been validated formally for use in children younger than 12 years old.4,6 Based on our expectations of developmental capabilities at age 11,17,18 we were not surprised that this age group performed in an equivalent fashion to 12-year-olds, with similar responses to specific questions, similar mean scores, and similar lack of extreme results (only 3 recorded scores > 14 in both groups combined).

Depression screening for 11-year-olds has been in existence for several years in the study practice and has now expanded to other pediatrics and family medicine offices in this medical group, in which approximately 25,000 11-year-olds are now screened annually with this process throughout Southern California. We did not investigate formally the possible harm to these adolescents or their families from the screening process or from consequences of incorrect screen determinations. Still, we did not come across any evidence of harm within the chart reviews, nor did we learn about evidence of harm from the providers in this medical practice with whom we discussed it.

We found that pediatricians did not refer many of the adolescents they newly identified (44 of 115) via the screening. This proportion did not differ by age. In all these nonreferred cases, the EHR documented a conversation with the family that included psychoeducation, and often plans for follow-up care.

Beneficial conversations (n = 2) and referrals (n = 1) were not commonly seen among the 21 cases with recognized active mental health history, suggesting the providers generally did not invest additional time when they believed the adolescent was already receiving care. The decreased mental health engagement with these adolescents may have also been compounded by an EHR function that blocks content of most notes from mental health professionals.

Conversations with potential benefit also occurred in visits with negative depression screens when the process uncovered other concerns. However, we also found cases in which mental health histories apparently were not noticed by providers and the screening process was considered negative. These cases may represent failures to integrate somatic and mental health care or to support adherence to mental health treatment. It is possible that future modifications to the EHR, such as more visibility of therapist notes and notifications about mental health history during well-visits, could make it less likely that this data type would be missed.

Importantly, when referrals were made, about one-third (36%) were completed, even in this highly integrated system. We do not know the extent to which this reflects real or perceived barriers, or whether families felt the referrals were not necessary either because they doubted the diagnosis or because they found the pediatrician’s counseling sufficiently helpful.

Validations of screening tools have centered on a score for that tool in relation to a depression diagnosis, but not whether a provider has mental health concerns about a particular adolescent.6,8-10,11,13 The concept that a PHQ-A score ≥ 10 by itself is inadequate, because a single screening tool was supported by our data finding a PHQ-A score ≥ 10 in only 3.1% of the study group, whereas providers determined positive screens in 13.6% and referred 7.2%. In addition, of the 31 cases of PHQ-A scores ≥ 10, only 3 patients were diagnosed with depression and 4 were diagnosed with anxiety or an adjustment disorder. A more appropriate paradigm for 11- and 12-year-olds may be to validate the concern of the pediatrician who should “cast a wider net,” rather than seek only depression diagnoses and recognize suicidal ideation.

The lower prevalence of depression and suicidal ideation in younger adolescents compared to older teens was confirmed by the low volumes we found for diagnoses of depression and emergency interventions.1 Along with the high frequency of beneficial conversations, these findings support the concept that a major purpose of screening younger populations is to determine mental health dysfunction at earlier stages, rather than finding only those patients with established depression or suicidal ideation.6 In this regard, positive screens that do not lead to an immediate depression diagnosis, or referrals of patients who do not attend mental health appointments, are not necessarily a failing of depression screening programs and may actually constitute a long-term benefit as these children are followed over time.

These data also demonstrate the success of the screening in identifying young adolescents who were not previously known to have potential mental health problems. In addition, a possible added benefit was the ability to identify patients with past treatment and what now appeared to be persistent or recurring problems, leading to reactivation of their mental health care.

Limitations of this study relate primarily to interpretation of data, obtained in large part by manual chart reviews, from a retrospective, real-world clinical setting not designed prospectively for research. This study population may differ from other regional populations regarding gender of adolescent, gender of pediatrician, distribution of ethnicities, and distribution of payors. It is possible that the parent and child filled out the tool together, and individualized nursing approaches for introducing the PHQ-A may have affected responses. There was absent documentation of some findings we sought; we could not determine all beneficial conversations or whether there may have been an undocumented mental health referral. There was insufficient documentation and power in the sample to allow for the correlation of screening outcomes with known depression risk factors. It is possible that borderline P values may have shown a different level of significance with a larger sample size or a prospective study design.

CONCLUSIONS

Current public health policy supports initiating universal annual depression screening at age 12 years,3-5 but depression and suicidal ideation are prevalent in children younger than 12 years old.1,2 We have shown that an adolescent depression screening protocol for 11-year-olds can be introduced readily into clinical practice, with similar processes, results, and outcomes as for 12-year-olds. Better identification of depression, leading to treatment even 1 year earlier, may be beneficial toward the goal of preventing suicide attempts and emergency department visits at age 11 years. Secondary benefits include making other mental health diagnoses, providing beneficial conversations on a variety of mental health issues, reactivating mental health care, and identifying children for whom closer monitoring may be appropriate. We hope these findings will lead other medical practices to consider adopting a depression screening protocol at 11-year-old well-visits, leading to prospective studies on screening 11-year-olds to delineate benefits and harms further, and eventually leading to public health recommendations to screen all 11-year-olds for depression.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1Department of Pediatrics, Southern California Permanente Medical Group, Inc, Tustin, CA

2School of Medicine, New York Medical College, Valhalla, NY

3Orange County Health Care Agency, Santa Ana, CA

4Department of Pediatrics, University of California at Irvine, Irvine, CA

5Department of Research and Evaluation, Southern California Permanente Medical Group, Inc, Pasadena, CA

6Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA

Corresponding Author

Alan B Cortez, MD ()

Author Contributions

Alan B Cortez, MD, conceptualized and designed the study, created the data collection instruments, reviewed the medical records, collected the data, drafted the initial manuscript, and maintained full control of the database. Julia Wilkins, BS, participated in the design of the study, reviewed the medical records, collected the data, drafted the initial manuscript, and maintained full control of the database. The first two authors performed all chart reviews. Raoul Burchett, MS, participated in the design of the study and the data collection instruments, maintained full control of the database, performed all statistical analyses, and drafted part of the initial manuscript. Eric Handler, MD; Marc A Lerner, MD; and Lawrence S Wissow, MD; participated in the conceptualization and design of the study, interpretation of the data, and revision of the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Funding

No external funding or sponsorship was secured for this study.

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Keywords: adolescent, depression, screening

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