Caroline is an 8-year-old girl who’s been throwing tantrums at home and is refusing to speak at school. Her pregnant mother Teresa brings her in for a checkup with her pediatrician, Dr. Smith. The physician notices that Caroline is exhibiting signs of anxiety and that her mother appears to be detached and possibly depressed.
A girl like Caroline would benefit from behavioral health screening, said Michelle Curtin, DO, associate professor of clinical pediatrics at Wake Forest School of Medicine in Charlotte, North Carolina. Screening is a way to open conversations with patients, to get more information about what behaviors are being seen and how long things have been going on, as well as assess what teachers at school are reporting.
Children 8 or older are recommended for routine, annual anxiety screening by the U.S. Preventive Services Task Force. Screening can help physicians analyze the social context of a person’s behavior, said Dr. Curtin.
“There are resources that exist to look for screening tools that are specific to anxiety, but also tools that are more global and look for more general things,” she added.
Dr. Curtin presented this case study during an AMA webinar on behavioral health screening as a part of ongoing care (watch now; registration required). She and other presenters used case studies to underscore screening pitfalls and practice readiness, focusing specifically on pediatric, ob-gyn and geriatric patient populations.
Mental health care is health care
Screening helps to decrease stigma and normalize mental health as health, said Tiffany Moore Simas, MD, MPH, MEd, who chairs the obstetrics and gynecology department at the University of Massachusetts Chan Medical School.
But it isn’t a silver bullet for mental health care, Dr. Moore Simas and other experts cautioned. These tools don’t provide the whole picture for a patient, said Dr. Moore Simas. “It’s really a snapshot in time.”
It’s also important to remember that screening tools are not diagnostic tools. “They’re the beginning of a process when looking to evaluate mental health and incorporate that as part of all of health,” she added.
That having been said, behavioral health screening does allow for the additional collection of data to make informed decisions regarding patient care, providing a pathway for an initial assessment followed by diagnosis, treatment and follow up, according to Dr. Moore Simas.
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In the case of Caroline, the 8-year-old, screening would also aid her pregnant mother. Upwards of one in five pregnant postpartum people experience a mental health condition. Clinical practice guidelines state that physicians should screen at the initial ob visit, at the 24- to 28-week gestational diabetes screening time, and again in the postpartum period.
Several screening tools such as the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire (PHQ-9) can be applied to pregnant and postpartum women.
“Regarding anxiety, the GAD-7 [Generalized Anxiety Disorder Assessment] can be used in both pregnant and non-pregnant populations,” Dr. Moore Simas said during the webinar, presented by the Behavioral Health Integration Collaborative and the AMA STEPS Forward® Innovation Academy.
Dr. Moore Simas noted that the American College of Obstetricians and Gynecologists also recommends that physicians screen for bipolar disorder before initiating pharmacotherapy for anxiety or depression in perinatal individuals.
“You don't want to be prescribing an unopposed antidepressant to someone with bipolar disorder because you may precipitate mania, psychosis and psychosis is associated with increased risk of both suicide and infanticide,” said Dr. Moore Simas.
Be respectful and nonjudgmental
For older patients, maintaining their sense of dignity is an important part of screening, said David Baron, MSEd, DO, professor of psychiatry at Western University of Health Sciences in Pomona, California.
“A key consideration here is being respectful and nonjudgmental,” said Dr. Baron, who related the case study of Tony, a 65-year-old retiree whose wife recently died. The patient had lost 15 pounds and was reporting a lack of energy and motivation during a physician’s visit.
For patients like Tony, it’s important to avoid assumptions. “We see a particular patient who has had a particular lifestyle, and we sometimes make assumptions that might not fit the data,” he said.
