Behavioral Health Issue
Screening and Use of Health
Services
The TARAA Research Team
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Deena J. Chisolm, PhD
Columbus Children’
Children’s Research Institute &
The Ohio State University
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 selfself-interviews can help with the first
limitation and yield information superior to that in
faceface-toto-face interviews for sensitive topics.
Kelly J. Kelleher, MD, MPH – Principal Investigator
William Gardner, PhD - CoCo-Investigator
Jack Stevens, PhD - CoCo-Investigator
Deena J. Chisolm, PhD - Supplemental CoCo-Investigator
Lindsay Buchanan
Teresa Julian, CNP, PhD
Jennifer McGeehan, MPH
• Funded by NIDA grant #R01MH078629#R01MH078629-01
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 webweb-tablets
– Immediate provision of scored screening results to
clinicians (3 day delay as a control condition)
– Motivational Interview followfollow-up calls for substance
users (phase II)
• Setting nine urban primary care clinics
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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
Methods
Independent Variables
• Mutually exclusive behavioral health issue categories:
• 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?
– None
– depression – score of >=25 on the CESCES-DC
– suicidal thoughts – serious thought of ending life past 30 days
(PHQ(PHQ-A)
– violence risk – physical fighting or carrying a weapon (YRBS)
– substance use – alcohol, marijuana, or inhalants (CASI(CASI-A)
– multiple risks
• Potential Confounders: age, gender, service use in
previous six months, payor
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Methods
Methods
Outcome Variables
Analysis
• 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 6666-74
• Relationships between behavioral health
issues and probability of use were tested
using chichi-squared and logistic regression.
• Multivariate relationship between behavioral
health issues and number of visits were
tested using negative binomial regression.
Sample Characteristics
50%
1,524 youth ages 1111-20
72% under age 16
57% female
65% nonnon-white
76% covered by Medicaid
42%
Proportion of Youth
Reporting
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Positive Screens
40%
30%
24%
22%
20%
7%
10%
3%
2%
0%
Violence
(n=363)
Probability of Service Use Within 6 Months
By Risk Category
Suicidal
Thts (n=31)
Multiple
(n=341)
None
(n=632)
Adjusted Odds Ratios for Service Use
(reference=no risk)
Behavioral Health
Any Use*
Mental Health*
Issue
Suicidal Thoughts 2.93 (1.22(1.22-6.98) 3.83 (1.38(1.38-10.58)
70%
Percent of youth with
visits
Depression Substance
(n=107)
(n=50)
60%
50%
40%
Depression
30%
20%
1.06 (0.66(0.66-1.69) 2.76 (1.43(1.43-5.35)
Substance
1.02 (0.51(0.51-1.04) 0.53 (0.07(0.07-4.02)
Violence
1.18 (0.88(0.88-1.59) 1.61 (1.01(1.01-2.57)
Multiple
1.01 (0.75(0.75-1.37) 1.79 (1.12(1.12-2.87)
10%
0%
No Risk
Suicidal Thts.
Depression
Any Use
Substance
MH Use
Violence
Multiple
*Odds ratios adjusted for gender, age group, prior use, and study arm
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Six Month Visit rate per 100 Youth
Behavioral
Health Issue
None
Any Visit
Rate
Mental Health Visit
Rate
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
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.
Conclusions
• SelfSelf-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.
Thank You
Questions?
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