Adolescent Mental Health Services: Where Are They Now?

Pharmacy Times, November 2016 Cough, Cold, & Flu, Volume 82, Issue 11

Due to the number of patients affected, adolescent mental health issues may be problematic for community pharmacists.

Due to the number of patients affected, adolescent mental health issues may be problematic for community pharmacists. For example, in a cross-sectional study of 10,123 adolescents aged 13 to 18 years in the United States, the incidence of depression or dysthymia was 12%. Higher rates of these mental health issues occurred in an age-dependent manner, and male adolescents were more likely than females to have these conditions.1 Moreover, the annualized crude suicide rate between 2008 and 2010 was 5.22 per 100,000 adolescents aged 13 to 18 years (Figure).2

Greater concerns about adolescent mental health issues arise when discussing how frequently clinicians treat affected adolescents. A study that examined data on 12-month rates of service for adolescent mental health issues found that of those who were given any diagnosis, 45% received treatment, with only about 10% of services received in a primary care setting—even though primary care practitioners may be competent to care for adolescents with mental health issues.3 Richardson et al validated this point through their randomized trial conducted in 9 primary care clinics. Compared with a control group, adolescents with depression who received collaborative care interventions achieved greater reductions on the Child Depression Rating Scale over a 12-month period and improvement in depression symptoms.4

To date, no randomized studies have been conducted to evaluate the impact of integrating adolescent mental health services into community pharmacy practice in the United States. This article reviews the potential barriers and solutions that pharmacists have identified, screening tools for certain mental health conditions in pediatric patients, and recommendations for pharmacologic treatment and patient counseling.

Barriers to Delivering Adolescent Mental Health Services

Community pharmacists have identified barriers as to why they may not properly deliver mental health services to patients. In a survey of 69 community pharmacists in Belgium, regarding delivery of services for depression at their practices, the top 3 barriers to providing care were identified to be lack of mental health education, lack of individual patient time, and limited knowledge of patient history.5 Another survey of 20 Australian community pharmacists identified several barriers to implementing depression screening at their practices, including inadequate compensation for their services, lack of privacy, and a stigma of shame or embarrassment among patients and caregivers (ie, regarding seeking or receiving treatment).6 However, a systematic review in the United Kingdom found that mental-health related stigma has a small to moderate negative effect on seeking help.7

Solutions to Delivering Adolescent Mental Health Services

To overcome the barriers discussed here, community pharmacists have identified solutions to incorporating and delivering mental health services for adolescent patients in their practices. Community pharmacists desire to participate on a multidisciplinary team when they deliver mental health services to adolescent patients and specifically request that general practitioners and caregivers participate.5 The results of a recent Australian study indicated that patients felt their pharmacy was a safe place to discuss mental health issues, as they had developed a trusting relationship with their pharmacist. This shows how important it is for pharmacists to develop a rapport with their patients as they provide mental health services.8 In addition, mental health screening tools may help pharmacists and clinicians properly manage pediatric patients (Table).

Depression Screening

In 2015, about 3 million adolescents aged 12 to 17 years (12.5% of the population) had experienced a major depressive episode within the past year. Of those adolescents, 70.7% experienced a major depressive episode with severe impairment, which hindered their ability to do chores at home, excel in academics, and maintain healthy social relationships.9 For clinicians to properly diagnose depression and manage affected adolescents, several organizations have provided their recommendations for screening depression in adolescents. The American Academy of Child and Adolescent Physicians (AACAP) guidelines recommend thorough evaluation if child or adolescent patients show significant signs of depression in screening to determine depressive or other comorbid psychiatric and medical disorders (AACAP Minimal Standard).10 The US Preventive Services Task Force (USPSTF) recommends screening adolescents aged 12 to 18 years for major depressive disorder and ensuring adequate systems are in place for proper diagnosis, treatment, and follow-up (USPSTF Grade B).11 However, the USPSTF has found insufficient evidence to support screening of adolescents for suicide risk.12 Screening tools for detecting pediatric depression include the Beck Depression Inventory. The various screening tools differ in terms of their ages for use, numbers of items, time to complete, sensitivity, and specificity (Table).13-16

Attention-Deficit/Hyperactivity Disorder Screening

The percentage of children given a diagnosis of attention-deficit/hyperactivity disorder (ADHD) increased from 6.9% from 1998 to 2000 to 9% from 2007 to 2009.17 The current evidence lacks support of universal screening in pediatric patients with ADHD, but caregivers and teachers can complete screening tools to aid clinicians in evaluating ADHD symptoms in adolescent patients.18,19 For example, the Conners Rating Scales-Revised tool requires caregivers and teachers to complete a 28-item questionnaire that addresses oppositional problems, cognitive problems, and hyperactivity, and includes an ADHD index; adolescents can fill out the Conners-Wells Adolescent Self-Report Scale.20

The scale that clinicians most commonly use to evaluate ADHD symptoms in pediatric patients is the Vanderbilt ADHD Rating Scale (VARS), which teachers and caregivers can complete.21 Both versions of the VARS assess symptoms and academic performance impairment; the caregiver version also assesses perceptions of school performance and social skills.22 The ADHD Rating Scale-5, recently updated from criteria established by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, includes screening forms for teachers and caregivers to complete, separate versions for home and school rating scales, and functional impairment items linked to inattention and hyperactive-impulsive symptoms.23

Effect of Medication Adherence on Adolescent Mental Health

Pharmacologic therapy is a mainstay for depression, ADHD, and other mental health conditions in children and adolescents; however, medication nonadherence continues to hinder therapeutic outcomes. Of the pediatric patients who receive medication(s) for chronic therapy, including mental health conditions, 50% to 88% are nonadherent to their prescribed regimens.24-26 If their nonadherence continues, they are likely to remain nonadherent as adults. One study identified that about 50% of adult patients prematurely discontinue antidepressant therapy due to patient- and clinician-related reasons.27 Therefore, to possibly improve medication adherence in adolescent patients with mental health issues, pharmacists should address medication perceptions among this group of patients.

Positive outcomes have been reported as pharmacists address medication adherence. One study found that long-term adherence to stimulant medications was associated with greater improvement in teacher-reported symptoms after 5 years.28 As pharmacists work together with other health care professionals, caregivers, and adolescents to provide mental health services, adolescents are more likely to be adherent to therapy into adulthood, possibly reducing emergency department visits, hospitalizations, and unnecessary health care spending, as well as improving their quality of life.29,30

Brian J. Catton, PharmD, graduated from the Bernard J. Dunn School of Pharmacy at Shenandoah University in Winchester, Virginia, in 2010. He received the Distinguished Young Pharmacist Award from the New Jersey Pharmacists Association in 2014. He currently is a Pharmacist Communicator at Ashfield Healthcare in Ivyland, Pennsylvania. His areas of interest include pediatrics, immunizations, drug-therapy management, social media, patient counseling, and immuno-oncology.

References

  • Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989. doi: 10.1016/j.jaac.2010.05.017.
  • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS), fatal injury reports, 2014, for national, regional, and states (restricted). CDC website. cdc.gov/ncipc/wisqars. Accessed September 21, 2016.
  • Costello EJ, He JP, Sampson NA, Kessler RC, Merikangas KR. Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatr Serv. 2014;65(3):359-366. doi: 10.1176/appi.ps.201100518.
  • Richardson LP, Ludman E, McCauley E, et al. Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA. 2014;312(8):809-816. doi: 10.1001/jama.2014.9259.
  • Scheerder G, De Coster I, Van Audenhove C. Pharmacists’ role in depression care: a survey of attitudes, current practices, and barriers. Psychiatr Serv. 2008;59(10):1155-1160. doi: 10.1176/appi.ps.59.10.1155.
  • O’Reilly CL, Wong E, Chen TF. A feasibility study of community pharmacists performing depression screening services. Res Social Adm Pharm. 2015;11(3):364-381. doi: 10.1016/j.sapharm.2014.08.013.
  • Clement S, Schauman O, Graham T, et al. What is the impact of mental health-related stigma on help-seeking? a systematic review of quantitative and qualitative studies. Psychol Med. 2015;45(1):11-27. doi: 10.1017/S0033291714000129.
  • Mey A, Knox K, Kelly F, et al. Trust and safe spaces: mental health consumers' and carers' relationships with community pharmacy staff. Patient. 2013;6(4):281-289. doi: 10.1007/s40271-013-0032-1.
  • Center for Behavioral Health Statistics and Quality. Key substance use and mental health indicators in the United States: results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Substance Abuse and Mental Health Services Administration website. samhsa.gov/data. Accessed September 21, 2016.
  • Birmaher B, Brent D, Bernet W, et al; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526.
  • Siu AL; US Preventive Services Task Force. Screening for depression in children and adolescents: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(5):360-366. doi: 10.7326/M15-2957.
  • LeFevre ML; US Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;160(10):719-726. doi: 10.7326/M14-0589.
  • Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002;66(6):1001-1008.
  • Richardson LP, McCauley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117-1123. doi: 10.1542/peds.2010-0852.
  • Pignone M, Gaynes BN, Rushton JL, et al. Screening for depression: systematic evidence review. Agency for Healthcare Research and Quality website. ahrq.gov/downloads/pub/prevent/pdfser/depser.pdf. Published April 20012. Published April 2002. Accessed September 18, 2016.
  • Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am Fam Physician. 2012;86(5):442-448.
  • Akinbami LJ, Liu X, Pastor PN, Reuben CA. Attention deficit hyperactivity disorder among children aged 5-17 years in the United States, 1998—2009. NCHS Brief. 2011;Aug(70):1-8.
  • Felt BT, Biermann B, Christner JG, Kochhar P, Harrison RV. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90(7):456-464.
  • Dobie C, Donald WB, Hanson M, et al. Diagnosis and management of attention deficit hyperactivity disorder in primary care for school-age children and adolescents. Institute for Clinical Systems Improvement website. icsi.org/_asset/60nzr5/ADHD-Interactive0312.pdf. Updated March 2012. Accessed September 21, 2016.
  • Conners CK. Development of the CRS-R. In: Conners CK, ed. Conners' Rating Scales-Revised. North Tonawanda, NY: Multi-Health Systems; 2001:83-98.
  • Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.
  • Collett BR, Ohan JL, Myers KM. Ten-year review of rating scales, V: scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003;42(9):1015-1037.
  • DuPaul GJ, Power TJ, Anastopoulos AD, et al. ADHD Rating Scale—5 for Children and Adolescents: Checklists, Norms, and Clinical Interpretation. 1st ed. New York, NY: Guilford Publications, Inc; 2016.
  • Rapoff MA. Adherence to Pediatric Medical Regimens. New York, NY: Springer; 2010.
  • Logan D, Zelikovsky N, Labay L, Spergel J. The Illness Management Survey: identifying adolescents’ perceptions of barriers to adherence. J Pediatr Psychol. 2003;28(6):383-392.
  • Hommel KA, Davis CM, Baldassano RN. Objective versus subjective assessment of oral medication adherence in pediatric inflammatory bowel disease. Inflamm Bowel Dis. 2009;15(4):589-593. doi: 10.1002/ibd.20798.
  • Sansone RA, Sansone LA. Antidepressant adherence: are patients taking their medications? Innov Clin Neurosci. 2012;9(5-6):41-46.
  • Charach A, Ickowicz A, Schachar R. Stimulant treatment over five years: adherence, effectiveness, and adverse effects. J Am Acad Child Adolesc Psychiatry. 2004;43(5):559-567.
  • Koster ES, Heerdink ER, de Vries TW, Bouvy ML. Attitudes towards medication use in a general population of adolescents. Eur J Pediatr. 2014;173(4):483-488. doi: 10.1007/s00431-013-2211-4.
  • Richardson TE, O'Reilly CL, Chen TF. A comprehensive review of the impact of clinical pharmacy services on patient outcomes in mental health. Int J Clin Pharm. 2014;36(2):222-232. doi: 10.1007/s11096-013-9900-y.