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  • An Interview with Meghan McAuliffe Lines, Ph.D., on Depression Screening in Primary Care
October 30, 2019

An Interview with Meghan McAuliffe Lines, Ph.D., on Depression Screening in Primary Care

Type: Announcements Tags: Depression, Newsletter, Screening, Primary Care

This month the NCIBH spoke with Meghan McAuliffe Lines, Ph.D., a pediatric psychologist and Clinical Director for Integrated Primary Care Psychology at Nemours Alfred I. duPont's Hospital for Children.

In her current role, Dr. Lines works with physicians and psychologists to expand the role of behavioral health in pediatric primary care throughout Delaware and Southeastern Pennsylvania. She is also involved in training and education, and has been an investigator on several federal grants aimed to expand behavioral health training and workforce development in primary care. She holds an appointment of Assistant Professor of Pediatrics at the Sidney Kimmel Medical College of Thomas Jefferson University, and is a member of the Medical Executive Committee at Nemours AI duPont Hospital for Children.


Could you tell us a little bit about your background and how you became interested in working in the field of integrated behavioral health and depression screening in primary care?

I have been fortunate to receive my training and establish my career at Nemours in Delaware, an institution that has been a leader in integrated pediatric primary care. Nemours has a pediatric multispecialty hospital in Wilmington, Delaware, as well as a number of primary and specialty care clinics throughout the region. In Delaware, Nemours has 12 pediatric primary care clinics that serve as the medical home care for approximately 25-30% of the children in the state. In the early 2000s, the psychology team noticed a troubling trend in which patients referred from primary care clinics even a few miles from the main hospital campus were not following through on referrals to psychology. Barriers identified included transportation, stigma with seeking mental health services, and a lack of trust for providers outside of the medical home. Federal funding was obtained to pilot placing psychologists and psychology interns in the primary care settings in an effort to increase access, decrease stigma and promote opportunities for prevention and early intervention. I was trained in this model and have had the opportunity to witness firsthand the multiple benefits of integrating behavioral health and medical care within the primary care team. Integrated care allows for earlier identification and treatment of social, emotional, and behavioral concerns. 

Our primary care team at Nemours is committed to adhering to best practices for screening in order to increase detection rates and use data to drive referrals. Moreover, several years ago our state experienced an adolescent suicide cluster that drew attention to the importance of screening and providing resources to youth. In following with the American Academy of Pediatrics and the United States Preventive Services Task Force recommendations for annual depression screening as part of well adolescent care, Nemours began routine screening for depression and suicidality in youth at well-visits several years ago. Youth with elevated scores on the screening tool are connected to an on-site behavioral health provider either in real time for risk assessment, or within a week or two for follow up on less acute concerns.


Why is screening for depression so important in primary care? What do you think medical school educators should focus on? 

Screening adolescents for depression and suicidality in primary care is essential. According to the most recent Youth Risk Behavior Survey (YRBS) put out by the Centers for Disease Control and Prevention (CDC), 31.5% of adolescents report symptoms of depression, and 17.2% of adolescents seriously considered attempting suicide (CDC, 2017). However, research suggests that only 50% of adolescents with depression are diagnosed before reaching adulthood (Kessler, Avenevoli & Merikangas, 2001). Moreover, 45% of suicide victims had contact with primary care providers within 1 month of suicide (Luoma, Martin & Pearson, 2002). Since individuals with depression and suicide risk are not routinely receiving necessary mental health care, it is important that healthcare providers ask the right questions every time. 

Given that as many as half of all pediatric office visits involve emotional and behavioral health concerns (American Academy of Child and Adolescent Psychiatry, 2012), medical school educators should focus on providing physicians with the skills and competencies necessary to address the behavioral health of their patients. The American Academy of Pediatrics recently released an updated policy statement that outlines the mental health competencies that are essential to pediatric practice (Foy, Green & Earls, 2019). These include skills in primary and secondary prevention, assessment, and treatment. In particular, they emphasize comanaging patients with mental health care specialists. An increased focus on providing medical students with skills that meet these competencies, participating on an integrated interdisciplinary practice team is recommended.


What do you think are some successful strategies for overcoming the stigma of depression and the perception of mental health in primary care settings?

Integrating behavioral health specialists as part of the primary care team is helpful step towards destigmatizing mental health challenges and promoting access to mental health treatment. When behavioral health providers are integrated within primary care, they become another member of the multidisciplinary care team that is focused on patient wellness rather than a specialty referral. It can be helpful for primary care providers to adjust language that is used, such as saying “I would like you to meet with another member of our team” versus “I am going to refer you to see a therapist.”

One of the best strategies for reducing stigma is to involve behavioral health as part of primary care from the very first visit. This can be accomplished by including screening and anticipatory guidance regarding emotional and behavioral health in all child care. In practices with an integrated behavioral health provider, involving that provider in early screening and psychoeducation can help to prevent behavioral health challenges from occurring and increase patient and family receptivity to seeking mental healthcare when it is needed. 

Programs such as the evidence-based HealthySteps program, which focuses on children 0-3 and their families in primary care, emphasize positive parenting and healthy development in order to promote health and prevent challenges. Research from this program indicates positive outcomes across physical and behavioral health.


Do you know of any depression prevention, education, curricula or training resources that exist for the current primary care training and education workforce that you would like to share? 


Anything additional you would like to add about your work or depression screening and education in the primary care workforce?

It is essential to engage the entire practice team including clerical staff, medical assistants, nurses, medical providers and behavioral health providers in initiatives focused on screening and referral. Moreover, education needs to include knowledge acquisition as well as support for practice change in order to be most successful.


                                                                                                            References

Centers for Disease Control and Prevention (2012). 2017 Youth Risk Behavior Survey Data. Available at: www.cdc.gov/yrbs. Accessed on 10/28/19.

Foy, J. M., Green, C. M., Earls, M. F., & COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH. (2019). Mental Health Competencies for Pediatric Practice. Pediatrics, e20192757. 

Kessler, R. C., Avenevoli, S., & Merikangas, K. R. (2001). Mood disorders in children and adolescents: an epidemiologic perspective. Biological psychiatry, 49(12), 1002-1014.

Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: a review of the evidence. The American journal of psychiatry, 159(6), 909–916. doi:10.1176/appi.ajp.159.6.909

American Academy of Child and Adolescent Psychiatry (2012). Best principles for integration of child psychiatry into the pediatric health home. Available at: https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_ of_care/best_principles_for_integration_of_child_psychiatry_into_the_pediatric_health_ home_2012.pdf. Accessed on 10/28/19.


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