Data Extraction

Data extraction required manual chart reviews because some steps in screening are not recorded in extractable data fields. Reading notes was necessary to determine whether the provider considered the screening process to be “positive” and developed a treatment plan. To ensure consistent methodology between the 2 reviewers, they extracted data independently from the first 25 charts, then reviewed their results mutually. During subsequent reviews, the primary reviewer for a chart consulted with the other reviewer for all positive or questionable results. Screening steps were only considered “positive” if both reviewers agreed.

After comparing the age groups for demographic similarity, we sought data on frequency of performing each component of the screening process. For the PHQ-A, we also evaluated whether it was performed correctly (specifically, were all questions answered, documented, and scored correctly, and was there evidence the provider addressed the results).

We extracted and compared the 11- and 12-year-old age groups for the total PHQ-A score (range, 0–27), specific answers to each of the 13 PHQ-A questions (scored 0–3), result of the parent question, and whether a recent or active mental health history existed. A positive screen based solely on these objective data was defined as a yes response to any of the following categories:

Total score of the PHQ-A≥ 10, matching the cutoff currently used by the National Committee on Quality Assurance for ages 12 years and older.⁴

PHQ-A questions 12 or 13 > 0 (suicidal ideation and plan),

PHQ-A responses≥ 2 to questions 1, 2, 9, or 11, or yes on question 10. These questions are more focused on depression than questions 3 through 8, which deal with less-specific adolescent symptoms.^10,11

Positive answer to parent question

Active mental health history present

Recent mental health history present

In some cases when the PHQ-A results were not recorded, but the provider note stated it was positive

We also recorded and performed an age group comparison on the provider’s comprehensive determination of possible depression, which could differ from the results of the instruments and chart review, and whether a mental health diagnosis had been assigned at the end of the visit.

Treatment plans extracted from the medical record and compared by age groups included emergency interventions, documentation of potentially beneficial mental health conversations related to both positive and negative screens, and mental health referrals made (and if completed). The finding that a beneficial conversation had occurred required both reviewers to agree and were defined as documentation of conversations resulting in one or more of the following:

A positive determination when the objective data were negative

Mental health referral

Advice or planning related to depression, anxiety, or adjustment disorder diagnoses that did not lead to a referral

Advice or planning for a psychosocial issue that did not meet criteria for a positive determination of depression