Integration of Caregiver Depression Screening in a High-Risk Outpatient Asthma Program: Phase 1

Background and Purpose: Asthma morbidity and mortality continue to disproportionately affect under-resourced Black and Latinx children living in urban areas. Caregiver depressive symptoms affect 30-47% of this population and have been associated with suboptimal child medication adherence, higher rates of asthma-related unscheduled child health care utilization, and greater child asthma symptom burden. To mitigate these effects, it is critical to identify caregivers with depressive symptoms and refer them for mental health services. The objective of this quality improvement project was to integrate caregiver depression screening and referral for mental health services into the existing clinical workflow of IMPACT DC, a previously validated program providing NHLBI guidelines-based care to predominately under-resourced and racial minority children with poorly controlled asthma.

Methods: The Model for Improvement with weekly Plan-Do-Study-Act cycles was utilized. A two-item depression screening tool (Patient Health Questionnaire-2; PHQ-2) and an acceptability question ("Is it ok for IMPACT to ask about your mental health?") were added to the existing social needs screening checklist administered to all caregivers at the beginning of the child's in-person clinic visit. Caregivers with a positive PHQ-2 score (≥3) received the PHQ-9. Positive screens on the PHQ-9 (score ≥5) received information and referrals by level of risk. PHQ-9 completers received a follow-up phone call two weeks post-visit to assess connection to support (informal and formal), improvement in depressive symptoms, and satisfaction with resources provided. The initial implementation phase was carried out from August-December 2021.

Results: The expanded social needs checklist with the PHQ-2 and acceptability question was administered to 109 caregivers. The PHQ-2 was completed by 92 caregivers (84%), and the majority (70/92; 76%) found the screening acceptable. Eighteen caregivers triggered and completed the PHQ-9. Two additional caregivers requested mental health assistance despite negative PHQ-2 scores. Of the 92 PHQ-2 completers, 20 caregivers (22%) had depressive symptoms, 16 of whom (17%) had clinically significant symptoms (PHQ-9 score ≥ 10). Two caregivers (2%) reported suicidal thoughts. Fifteen caregivers (75%) participated in the follow-up phone survey. Of these 15 caregivers, 5 (33.3%) sought informal (i.e., family, friends) support for their depressive symptoms, while 2 (13.3%) sought formal support (i.e., therapist, case manager), and 8 (53.3%) did not seek support. At two weeks follow-up, change in depressive symptoms was reported as follows: Much better (2), Somewhat better (5), About the same (6), Somewhat worse (1) and Much worse (0). While most caregivers reported the resources given in clinic were “extremely helpful,” no caregivers reported contacting or using any of those resources.

Implications: Caregiver depression screening was successfully integrated into IMPACT DC asthma clinic visits; however, while caregivers found screening to be acceptable, it did not facilitate connection to formal mental health treatment. The second phase of this project will entail continuing to track screening rates and process measures with a focus on improving rates of completed mental health follow-up. Qualitative interviews with caregivers are being conducted to understand facilitators and barriers to mental health treatment in order to inform changes to the referral process.