"He tried to commit suicide by jumping off a bridge at 14."
Dr. Vincent Valenzuela is reading a hospital report regarding a young patient he saw two years ago at Kaiser Permanente's Santa Ana medical offices. The pediatrician's eyes skim through the report in disbelief.
"At his last physical, there weren't any red flags, but we also didn't have this screening tool," Valenzuela says, referring to a mental-health questionnaire for preteen patients that Kaiser now gives during annual physicals. "Had we had this screening at 11 or 12, maybe we could have gotten him some help before he tried to do something."
In 2014, four Kaiser medical offices in OC—Santa Ana, Brea, Mission Viejo and Huntington Beach—began the practice of screening 11-year-old patients, in addition to teenagers and later 12-year-olds, for signs of depression and suicidal ideation. By doing so, they defied the U.S. Preventative Services Task Force, which cited a lack of evidence on the benefits or harm of mental-health screenings for children younger than 12 in not recommending the practice, a stance that remains today. "There is essentially no evidence involving 11-year-olds directly, so that's why they haven't endorsed it," says Dr. Alan Cortez, who introduced the Kaiser PHQ [Patient Health Questionnaire]-Adolescent survey when serving as chief of the pediatric department. "There's virtually no evidence involving 12-year-olds, either."
But Cortez is hoping that will soon change. "As of three weeks ago, I got approval for a research study at Kaiser Permanente to delve deeply into the work we've done to try to establish that evidence," he says. Though conclusive findings will take time, Cortez is encouraged by what he has already seen. The review of hundreds of charts in the past suggests that 25 percent of the screenings result in a beneficial intervention. Starting and reviving conversations between families and their children about mental-health issues is the most common outcome, but a third of such interventions involve direct referrals to mental-health professionals.
"These numbers are approximations, and we might find different results when the research is done," Cortez says. The findings could propel other health care providers in California and nationwide to follow the Kaiser model.
Over the past three years, the program has been expanded to include all Kaiser facilities in Southern California, which serve 1 million children—120,000 in OC alone.
Receptionists hand out the questionnaire to 11- and 12-year-old patients, who are asked to fill it out away from their parents. The children are asked if they've felt depressed or better off dead in the past two weeks, as well as how often they've felt that way. "People respond so much more in writing, particularly youth," Cortez says. The survey also tries to identify poor sleep patterns and eating habits.
Parents initially met the practice with guarded skepticism but are learning to embrace it. "It has opened up the dialogue about depression between parents and their children," Valenzuela says. "In the Latino community, we don't really talk about that kind of stuff, especially with a lot of the dads and their sons."
According to the 2016 Annual Report on the Conditions of Children in Orange County, the number of children and teens with a serious mental illness leading to hospitalization is up 47 percent from 2008. Major depression and mood disorders account for 64 percent of holds. White youth are the most impacted in the county, with Latinos following second.
Cortez presented his model before CalOptima, the health-care provider for OC Medi-Cal recipients; CalOptima launched an incentivized Screening for Clinical Depression in Adolescents project two weeks ago but kept the earliest age at 12 because of the American Academy of Pediatrics recommendation. "We chose that age for [the] incentive program because of that," says Dr. Donald Sharps, medical director of CalOptima's Behavioral Health Integration, also noting the Task Force's recommendation.
As part of the new incentive program, pediatricians are now eligible to be paid $50 upon each completed screening during annual visits. "It created quite an interest in its first week of release," Sharps says. "We're looking for as many overtures and interventions that we can have, and one of them is to identify people through screening and referral. We do know that our kids will do better if they get out of that depressed mindset as they're growing up."
Doctors gathered at a recent pediatrics department meeting at Kaiser's Santa Ana medical office recounted office talks in which preteens revealed they turn to cutting, but saw it as a normal coping mechanism for stress. "With all the media coverage of kids getting bullied, I think it's hard not to address it," says Dr. Yvonne Bach. "It takes time. When you get a positive screening, it takes a lot longer than 15 minutes."
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The questionnaire also opens up discussions with pediatricians about puberty, dating violence, drug use and sexuality. Last year, Kaiser added in-house social workers to each of its medical offices in Orange County.
"I believe that this should be the national standard so that we can identify mental-health issues early and provide treatment that can potentially prevent long-term [problems]," says Dr. Eric Handler, a county health officer who supports the program.
Cortez anticipates his studies will show the benefits of preventative mental-health care for preteens. "This is not about just medicating youth, as many have said," Cortez says. "We're preventing depression."
For more information and tips on how to talk to teens about depression, please visit this Kaiser fact sheet.