Pre-visit screening may not lead to faster mental health diagnosis

BOSTON — Primary screening of young people was not associated with increased detection and prevention of mental health and substance abuse diagnoses, according to researchers.

Perspective from Meera Beharry, MD

Anne Gadomski, MD, MPH, and colleagues from the Bassett Research Institute in New York examined the effectiveness of the American Medical Association’s guidelines for adolescent preventive services (GAPS) in a rural population. Their findings were presented here at the 2012 Pediatric Academic Societies Annual Meeting.

In a historical cohort study, the researchers compared the incidence of mental health or substance abuse diagnoses of patients aged 11 to 18 years who did not use GAPS before their annual visits from May 1994 to April 1998 (before GAPS was established) with patients who did use the pre-visit screener from May 1999 to April 2003. For those patients who had annual visits, researchers used administrative data to enumerate their subsequent visits that included ICD-9 codes for mental health and substance abuse disorders. In order to obtain population-based rates, researchers analyzed the enrollment data of schools whose districts shared the ZIP codes of the patients seen at the clinic. The Chow test was used to compare pre- and post- GAPS trends in diagnoses.

To compare the time to diagnosis between the two time periods, researchers examined another group of patients aged 13 to 15 years, excluding patients with pre-existing mental health or substance abuse diagnoses in the 5 months leading up to each respective time period. Using the Kaplan-Meier analysis, the researchers compared the median time to diagnosis between the pre- and post-GAPS periods.

Results show that the use of GAPS was not associated with a significant change in the time of diagnosis of mental health or substance abuse disorders, and there were no significant trends in overall mental health and substance abuse diagnoses during the period of time studied, according to researchers. The rate of mental health and substance abuse diagnosis, they wrote, “did not change significantly over the entire pre- and post- GAPS period,” adding that the most common diagnoses were attention-deficit/hyperactivity disorder and adjustment and mood disorders. Researchers also wrote that the proportion of mental health and substance abuse diagnoses on the first annual visits increased slightly after GAPS was introduced in 1998.

“There are many steps between screening at an annual visit and a diagnosis of mental health or substance abuse disorders,” Gadomski told Healio.com. “This study merely scratches at the surface of these processes and begs for more detailed research that is prospective in nature. The bottom-line is we need to figure out how to shorten the time to diagnosis for mental health disorders in order to provide earlier treatment.”

For more information:

Gadomski AM. #1501.86. Presented at: the 2012 Pediatric Academic Societies Annual Meeting; April 28-May 1, 2012; Boston.

Disclosure: Dr. Gadomski reports no relevant financial disclosures.

Perspective

Meera Beharry, MD

The data presents an intriguing question that is relevant to many primary care practices serving adolescents. It suggests that the use of the GAPS tool did not result in earlier diagnosis of mental health or substance abuse problems among the rural adolescent population studied. It raises the question of whether the tool itself was ineffective, or if it was an issue of how the tool was used in practice. Were responses to GAPS items reviewed with the adolescent? Were there additional screening measures used? Did providers use the GAPS in lieu of a discussion with the patient and parents?

Given the rural setting, the findings from this study may not be applicable to urban practices. It would be helpful to know the baseline rate of mental health disorders for this population as this will determine the strength of the findings for this sample size. A retrospective review of the GAPS forms themselves to identify potential red flags that were missed would be helpful in understanding if the lack of earlier diagnosis was a failure of the tool for this population.

The authors have conducted an interesting study that adds to evidence about the usefulness of the GAPS tool. In the years following the completion of this study, additional mental health screening tools have been developed, such as Teen Screen. Further studies of other screening tools in comparison to GAPS may be useful.

Meera Beharry, MD

Pediatric Annals Editorial Board

Disclosures: Dr. Beharry reports no relevant financial disclosures.