Behavioral Health Issue
Screening and Use of Health
Services
Deena J. Chisolm, PhD
Columbus Children’s Research Institute &
The Ohio State University
The TARAA Research Team
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Kelly J. Kelleher, MD, MPH – Principal Investigator
William Gardner, PhD - Co-Investigator
Jack Stevens, PhD - Co-Investigator
Deena J. Chisolm, PhD - Supplemental Co-Investigator
Lindsay Buchanan
Teresa Julian, CNP, PhD
Jennifer McGeehan, MPH
• Funded by NIDA grant #R01MH078629-01
Background
• Routine screening for behavioral health issues in
primary care is recommended by the AAP.
• Standardized screening is not regularly done
because of:
– Limited time in the clinical encounter
– Limited resources and increased cost for referral and care
• Computerized self-interviews can help with the first
limitation and yield information superior to that in
face-to-face interviews for sensitive topics.
Trial of Automated Risk
Assessment in Adolescents
• Goal: To improve recognition and treatment of
behavioral health problems in adolescents in
primary care through:
– Risk screening in the primary care waiting room
using wireless web-tablets
– Immediate provision of scored screening results to
clinicians (3 day delay as a control condition)
– Motivational Interview follow-up calls for substance
users (phase II)
• Setting nine urban primary care clinics
Preliminary Results
• 95% were satisfied with their experience and
satisfaction did not vary by race, payor,
computer experience, or risk status.
• Clinicians in the immediate results group
were more likely to recognize behavioral
health issues than those who received
delayed results.
Research Question
• Do youth who screen positive for behavioral
health issues in primary care use more
services in the following 6 months than those
who screen negative?
Methods
Independent Variables
• Mutually exclusive behavioral health issue categories:
– None
– depression – score of >=25 on the CES-DC
– suicidal thoughts – serious thought of ending life past 30 days
(PHQ-A)
– violence risk – physical fighting or carrying a weapon (YRBS)
– substance use – alcohol, marijuana, or inhalants (CASI-A)
– multiple risks
• Potential Confounders: age, gender, service use in
previous six months, payor
Methods
Outcome Variables
• Used data warehouse to gather all visits six
months before and six months after screening.
• Service Use Variables
– Any visit
– Mental Health related visit – any visit with a
diagnosis code included in Clinical Classification
Software (CCS) Codes 66-74
Methods
Analysis
• Relationships between behavioral health
issues and probability of use were tested
using chi-squared and logistic regression.
• Multivariate relationship between behavioral
health issues and number of visits were
tested using negative binomial regression.
Sample Characteristics
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1,524 youth ages 11-20
72% under age 16
57% female
65% non-white
76% covered by Medicaid
Positive Screens
50%
Proportion of Youth
Reporting
42%
40%
30%
24%
22%
20%
7%
10%
3%
2%
0%
Violence
(n=363)
Depression Substance
(n=107)
(n=50)
Suicidal
Thts (n=31)
Multiple
(n=341)
None
(n=632)
Probability of Service Use Within 6 Months
By Risk Category
Percent of youth with
visits
70%
60%
50%
40%
30%
20%
10%
0%
No Risk
Suicidal Thts.
Depression
Any Use
Substance
MH Use
Violence
Multiple
Adjusted Odds Ratios for Service Use
(reference=no risk)
Behavioral Health
Any Use*
Mental Health*
Issue
Suicidal Thoughts 2.93 (1.22-6.98) 3.83 (1.38-10.58)
Depression
1.06 (0.66-1.69) 2.76 (1.43-5.35)
Substance
1.02 (0.51-1.04) 0.53 (0.07-4.02)
Violence
1.18 (0.88-1.59) 1.61 (1.01-2.57)
Multiple
1.01 (0.75-1.37) 1.79 (1.12-2.87)
*Odds ratios adjusted for gender, age group, prior use, and study arm
Six Month Visit rate per 100 Youth
Behavioral
Health Issue
Any Visit
Rate
Mental Health Visit
Rate
None
131.6
21.5
Suicidal Thoughts
138.7
38.7
Depression
205.6*
39.2*
Substance
142.0
8.0
Violence
153.4
34.7*
Multiple
162.8
42.5*
*Difference in visit counts (reference=none) tested using negative binomial regression
controlling for age group, gender, use in previous 6 months, and study arm
Conclusions
• Self-reported behavioral health issues factors
are common in adolescents seen in primary
care.
• Youth who screen positive for depression,
violence, or multiple risks have higher mental
health service use after screening than those
with no behavioral issues.
• Mental health services use in those who screen
positive for depression are still below optimal.
Implications
• Primary care screening programs may
increase treatment for behavioral problems
while creating limited additional burden in the
health care system.
• Systems should consider developing case
management approaches for youth with
identified behavioral health problems to
ensure appropriate use of services.
Thank You
Questions?