Literature Collection

IMPORTANCE: Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected. OBJECTIVE: To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023. EXPOSURES: Demographic, diagnostic, treatment, and health care utilization characteristics. MAIN OUTCOME(S) AND MEASURE(S): Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide. RESULTS: The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days. CONCLUSIONS AND RELEVANCE: Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

The World Health Organization reports that more than 390 million children and adolescents have obesity, with the US facing a prevalence of 14 million among this population and incurring an annual medical cost of $1.3 billion. Childhood and adolescent obesity stems from genetic, environmental, and socioecological factors, indicating the need for an evolving approach to pediatric obesity management. The updated 2023 American Academy of Pediatrics guideline for evaluation and treatment of pediatric obesity advocates for a child-centric strategy, considering health equity, racism, weight bias stigmatism, and adverse childhood experiences. Management includes intensive health behavior and lifestyle treatment, partnership with communities to build comprehensive treatment programs, promotion of early intervention, consideration of pharmacotherapy for children age 12 years and older, selective use of bariatric surgery, screening for and treatment of comorbidities, integration of mental health treatment, and use of motivational interviewing to engage patients in their care. Pediatric primary care providers play a key role in identification of obesity and encouragement of obesity treatment. Proactive management of childhood obesity benefits individuals, families, and the nation. Early intervention holds the promise of substantial cost savings on obesity-related healthcare. Healthcare providers wield significant influence in reducing childhood morbidity and enhancing the overall health of US children and adolescents.

National Health Service (NHS) England highlights the need for preventative, specialist support for adults with mild eating difficulties. This evaluation explored the effectiveness of an Adult Eating Disorder Integrated Mental Health Service (AEDimhs) in reducing mild eating difficulties, within primary care. The lived experience of service users (n = 12) and staff (n = 12) was thematically analysed and levels of staff wellbeing and burnout reported. Individual service-level data (N = 363) were gathered; however, 59.6% of outcome data were Missing Not At Random and n = 69 pre-post intervention mental health outcomes were available for analysis. Statistically significant improvements were found in ED-related thoughts and actions (EDE-Q) and psychosocial difficulties (CIA), while overall distress (CORE-OM), depression (PHQ-9) and anxiety significantly reduced (GAD-7; all measures p < .001). Staff reported moderate levels of wellbeing and low burnout. Thematic analysis identified four themes: 'bridging the gap', 'empowering interventions', 'adaptability and flexibility' and 'shaping the future'. Findings suggest that AEDimhs can potentially provide effective, preventative, specialist support within primary care. Research with larger and more diverse populations is required to strengthen the evidence base and enable evaluation of long-term follow-up.

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical Care Surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.7 percent of visits in 2006-07 to 15.9 percent by 2016 and 2018. Black patients were 40 percent less likely than White patients to have a mental health concern addressed during a primary care visit, and Hispanic patients were 40 percent less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. These findings emphasize the need for payment and billing approaches (that is, value-based care models and billing codes for integrated behavioral health) as well as organizational designs and supports (that is, colocated therapy or psychiatry providers, availability of e-consultation, and longer visits) that enable primary care physicians to adequately address mental health needs.