Screenings reveal depression among caregivers of children with asthma
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Key takeaways:
- 72.3% agreed or strongly agreed that screenings were acceptable.
- 70% said the clinic could share results with their child’s primary care provider.
- None connected with new mental health treatment.
Researchers successfully developed and implemented a workflow for screening caregivers of children with asthma for depression and referring them for mental health care, according to a study published in Journal of Asthma.
But although caregivers found these screenings acceptable, they did not facilitate connection to formal mental health treatment, Rachel H.F. Margolis, PhD, LICSW, research postdoctoral fellow at Center for Translational Research of Children’s National Research Institute, and colleagues found.
“The literature on children with asthma has consistently reported high rates of caregiver depressive symptoms, especially among racially minoritized children living in under-resourced communities,” Margolis told Healio.
Along with the negative impact that these symptoms have on the caregivers themselves, she continued, these symptoms also have been associated with impaired asthma management and greater child asthma morbidity.
“There is evidence that treatment for caregiver depression may improve child asthma outcomes. However, caregivers with depressive symptoms first need to be identified to be connected to treatment,” Margolis said.
The researchers developed and implemented a workflow for caregiver depression screening and referral for treatment in the Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC) asthma clinic, which predominately serves Black and under-resourced children who have frequent ED visits and other markers of poorly controlled asthma.
Study design, results
The researchers administered the Patient Health Questionnaire-2 (PHQ-2), which is a two-item screening tool for depression, to 233 caregivers (mean age, 33.8 years; 86.4% women; 80.4% Black; 78.4% non-Hispanic) at IMPACT DC.
Among 220 patients who responded to a question about whether it was acceptable for IMPACT DC to ask them about their mental health, 36.4% strongly agreed and 35.9% agreed that it was acceptable, 21.4% were neutral, 3.6% disagreed and 2.7% strongly disagreed.
Based on the PHQ-2, 37 caregivers were identified with depressive symptoms. Thirty-five of them, along with three additional caregivers requesting mental health assistance, then completed the Patient Health Questionnaire-9 (PHQ-9).
“There were several surprising and significant findings,” Margolis said. “Most importantly, we found that nearly one in six of the caregivers who completed the screening had depressive symptoms.”
PHQ-9 results included 35 caregivers (15.9%) with depressive symptoms, including 27 (11.6%) with clinically significant depressive symptoms and five (2.1%) who endorsed suicidal ideation but were considered low or moderate risk for suicide.
The caregivers with depressive symptoms also included 59% with a history of depression and 49% who already were seeing a provider at the time of the screening.
“We were surprised to find that almost half of caregivers with depressive symptoms were already engaged in mental health treatment at the time of the screening,” Margolis said.
“We also found that screening was feasible and acceptable,” Margolis continued. “Nearly 85% of caregivers completed the screening.”
Two weeks after the screening, the researchers reached 70% of the caregivers with depressive symptoms via phone to coordinate follow-up mental health care, 56% of whom said they had reached out to others for support because of the screening and 54% of whom
said their symptoms of depression had improved since the screening.
None of the caregivers used provided educational materials to access new mental health services, with qualitative data indicating that many caregivers were busy with competing priorities.
Conclusions, next steps
The researchers were surprised to find a lower rate of caregiver depressive symptoms compared with the existing literature, although they still called 15.9% a substantial proportion.
“We were also surprised that the overwhelming majority of caregivers, most of whom self-identified as Black, found screening to be acceptable despite the literature suggesting that many Black people are concerned about stigma associated with disclosing mental health issues,” Margolis said.
Further, the researchers were surprised and concerned that nearly half of the caregivers with depressive symptoms were already receiving mental health treatment, suggesting that the treatment they were receiving may not be sufficient.
“Lastly, we were also concerned to find that no caregivers with depressive symptoms accessed new mental health services using the referral materials provided in the clinic during the screening process,” Margolis said. “This finding suggests that additional supports are needed to connect caregivers to needed mental health care.”
Solutions may include active mental health referral processes and short-term care coordination, which the researchers called challenging, and integrated care, which the researchers said is promising but requires more research.
Doctors also can play a role in improving these outcomes, Margolis said.
“We encourage other asthma clinics to consider routinely screening caregivers for depressive symptoms and referring them for mental health care,” she said.
Depending on available staffing, this could range from providing written materials to incorporating more intensive assistance such as care coordination.
“Even if routine screening is not possible, doctors can ask how the caregiver is doing and be aware that caregiver mental health problems may be having an impact on asthma management and child asthma morbidity,” she said.
Margolis additionally said that it is important for clinicians to be aware of the many barriers to mental health treatment that caregivers face, including transportation, childcare, competing priorities, lack of providers and cost.
“This is not an exhaustive list, and a caregiver could be experiencing one or multiple barriers,” Margolis said, adding that there are no simple answers.
“It depends on the specific barriers the caregiver is facing and the available resources in the specific practice setting and in the local community,” Margolis said. “I encourage clinicians to become familiar with the mental health resources in their community.”
To expand mental health access, Margolis also encouraged policymakers to continue to enforce and enhance mental health parity laws, support efforts to train more mental health providers, and work toward the integration of mental health care with primary care.
Meanwhile, Margolis and her colleagues will continue their work.
“We are interested in further testing of referral and service delivery strategies for caregiver depression in the pediatric asthma care, including care coordination and integrated care, or delivering mental health care for caregivers in the asthma clinic setting,” she said.
For more information:
Rachel H.F. Margolis, PhD, LICSW, can be reached at rmargolis@childrensnational.org.
Perspective
Back to Top
In this manuscript, Margolis and colleagues describe the development, implementation, feasibility and acceptability, and effectiveness of a caregiver depression screening in an urban, community-based asthma clinic. As accumulating literature highlights the multilevel pathways whereby caregiver depression influences childhood asthma, this is an important area to address.
Aside from asthma morbidity, it is important to recognize that dual exposure to physical illness and caregiver depression may also place these children at particularly elevated risk for mental health symptoms themselves. Targeting caregiver mental health is an innovative approach that is likely to have cascading effects on children’s physical and psychosocial well-being.
One of today’s most pressing mental health questions is how to make care accessible to those who need it most. Margolis and colleagues work toward addressing this question by implementing a thoughtful and thorough screening process, coupled with psychoeducational materials and mental health resource pamphlets that are specific to caregivers of youth with asthma.
When I think about access, I think of barriers including but not limited to cost, time, effort, travel, language and stigma. It is encouraging that culturally and linguistically appropriate resources were developed. In my own experience within health care systems, such resources have been limited.
It is somewhat disappointing, although not entirely surprising, that none of the caregivers reported using the resources provided, suggesting that this screening intervention did not facilitate short-term connection to treatment. In my own experience working with children with chronic medical conditions, it is very common to see caregivers struggling with their own mental health problems.
All too often, highly burdened caregivers, understandably, prioritize taking care of their children over taking care of themselves. Even when the desire for treatment is present and caregivers are provided with community resources, substantial barriers to accessibility remain.
It is critical that future research and clinical initiatives focus on optimizing mental health service delivery among caregivers of children with asthma. As Margolis and colleagues discuss, there is great promise in integrated care, in which mental health care for both the child and the caregiver is co-located in asthma clinics, thus increasing access and reducing stigma. Although not a replacement for therapy, family education days focused on mental health, psychoeducational webinars and virtual caregiver support groups may be promising starting points.
References:
Ferro MA, et al. J Abnorm Child Psychol. 2015;doi:10.1007/s10802-014-9893-6.
Wood BL, et al. Ann Asthma Allergy Immunol. 2018;doi:10.1016/j.anai.2018.06.031.
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