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Review Article |

Improving Recognition of Adolescent Depression in Primary Care FREE

Rachel A. Zuckerbrot, MD; Peter S. Jensen, MD
[+] Author Affiliations

Author Affiliations: Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University and Center for the Advancement of Children's Mental Health, Columbia University/New York State Psychiatric Institute, New York.


Arch Pediatr Adolesc Med. 2006;160(7):694-704. doi:10.1001/archpedi.160.7.694.
Text Size: A A A
Published online

Objective  To address the following questions: (1) What evidence (ie, psychometric data collected in pediatric primary care, patient outcome data) exists for the various methods used to identify adolescent depression in primary care? and (2) What identification practices are currently in use?

Data Sources  We systematically searched MEDLINE for English-language articles using specific search terms and examined relevant titles, abstracts, and articles.

Study Selection  We reviewed 1743 MEDLINE abstracts. Seventy-four articles were pulled for examination, with 30 articles meeting full criteria.

Data Extraction  Five studies had adequate psychometric data on various adolescent depression identification methods in primary care. Only 1 compared the diagnostic accuracy of physicians trained to ask depression questions vs physicians trained in the use of a diagnostic aid. Six studies reported on current practice. Evidence regarding sensitivity, specificity, positive predictive value, and negative predictive value was sought for question 1. Frequency of screening was sought for question 2.

Data Synthesis  Review of these articles found that few health care professionals use systematic depression identification methods, despite some growing evidence for their validity, feasibility, and possible efficacy.

Conclusion  Available evidence indicates that primary care professionals would improve their rates of depression diagnosis through training, but even more so by using adolescent symptom rating scales.

Studies have found that 3% to 9% of teenagers meet criteria for depression at any one time, and at the end of adolescence, as many as 20% of teenagers report a lifetime prevalence of depression.14 Adolescent depression may affect the teen's socialization, family relations, and performance at school, often with potentially serious long-term consequences.5 Adolescents with depression are at risk for increased hospitalizations, recurrent depressions, psychosocial impairment, alcohol abuse, and antisocial behaviors as they grow up.68 Of course, the most devastating outcome of concern for adolescent depression is suicide, the third leading cause of death among older adolescents.9

Despite the severe morbidity and mortality associated with adolescent depression, most studies report that only 1 in 4 to 1 in 3 adolescents with depression are receiving treatment for this disorder.10,11 Extant data suggest that depression is relatively common in pediatric settings12,13 and is often unidentified by pediatric professionals.14,15 Pediatricians, however, do feel responsible for identifying adolescent depression16 and most of the major professional organizations have acknowledged the importance of identifying depression and suicidal behavior in youth.1719 To improve the identification and treatment of adolescent depression, primary care health professionals may need to adapt the service delivery models currently used in treating adults with depression. While depression screening and management are now considered to be an essential function of the primary care setting for adults,2022 no definitive recommendations have been made in support of adolescent depression screening in primary care.

In light of the significant morbidity and mortality of adolescent depression; its high prevalence in pediatric primary care; the existence of promising treatments such as cognitive behavioral therapy,23 interpersonal therapy for adolescents,24 and medication25 (despite the current “black box” warning26); and its underrecognition by pediatricians despite their good intentions, it is surprising that no literature, to our knowledge, has systematically reviewed the available evidence regarding the various methods available and in use for the identification of adolescent depression in pediatric primary care. We conducted a literature search to determine (1) What evidence exists for the various methodsused to identify adolescent depression in primary care? and (2) What identification practices are currently in use? Question 1 includes the following: (1) the availability of psychometric data assessing adolescent depression screening and identification methods in pediatric primary care and (2) available evidence regarding the feasibility, acceptability, cost, and benefit to patients of available identification methods.

This search focused on psychometric data comparing the use of general psychosocial screening tools (eg, Child Behavior Checklist27), depression-specific tools (eg, self-reports, health care professional–rated checklists), reliance on chief complaints, and the use of parent and/or adolescent interview techniques to identify adolescent depression in primary care. Psychometric data sought included sensitivity (the proportion of those with the disease or condition, as measured by the gold standard, who have positive results by the test being studied), specificity (the proportion of those without the disease or condition, as measured by the gold standard, who have negative results by the method, criteria, or test being studied), positive predictive value (PPV), and negative predictive value (NPV) of different identification methods. While the gold standard depression diagnosis typically would involve experienced mental health professionals using high-quality assessment techniques and gathering information from multiple informants, the gold standard diagnosis may be a structured interview or other such approximation. We sought studies that clearly defined their gold standard in primary care. In addition, any available evidence regarding the feasibility, acceptability, cost, and outcome for the adolescent patient of any of the various identification methods was sought. Lastly, by identifying methods currently used in pediatric primary care settings, we hoped to find explanations for the current underrecognition.

We searched MEDLINE (English-language articles only) for all years up through December 28, 2004, using the following key words: primary care or pediatric$ ($ indicates a wild-card term) or family med$ or GP or health clinic or health center or teen clinic or teen center or adolescent clinic or adolescent center or family physician$ or family practi$ or adolescent medicine or ambulatory care and depress$ or mood$ and adolesc$ or teen$. Articles targeting populations with specific somatic symptoms, physical illnesses, or other risk factors; studies not focusing on adolescents; or those discussing children generally but not separating out older children (older than 10 years) were eliminated. Articles that dealt with general psychosocial issues, psychological distress, or suicidality, rather than depression, were included only if depression or mood disorders were also mentioned in the abstract and then specifically examined in the study as well. Population surveys and service use assessments were discarded because they did not take place in primary care, as were treatment articles that did not describe the mechanism of identification. Lastly, English-language articles that described screening conducted in non–English-speaking countries were discarded. In addition, a hand search of the references from the relevant articles found in the search was also conducted.

We identified and hand reviewed 1743 titles (most with abstracts). Seventy-four full articles were selected for initial review based on relevance. Twenty-nine articles met criteria for final review: 24 addressed the first question regarding identification methods in primary care (Table 1) and 6 (including 149 from Table 1) focused on health care professional–reported current practices (Table 2). Final results from a previously published study31 were published in January 2005 and that article is included as the 25th article34 in Table 1.

Table Graphic Jump LocationTable 1. Identification Methods for Adolescent Depression Studied in Primary Care (in Alphabetical Order)
Table Graphic Jump LocationTable 2. Health Care Professional–Reported Current Adolescent Depression Identification Practice
IDENTIFICATION DATA IN PRIMARY CARE (QUESTION 1 PART 1)

Of the 25 articles presented in Table 1, only 5 present data on the sensitivity, specificity, PPV, and NPV of a designated identification method in primary care. In the first of the 5 studies, Winter et al82 trained pediatricians to administer the mood module of the Primary Care Evaluation of Mood Disorders45 to 100 consecutive adolescents. Using the Primary Care Evaluation of Mood Disorders interview as the gold standard to validate a self-report (Beck Depression Inventory for Primary Care83), analyses demonstrated a sensitivity and specificity of 91% at a cutoff score of 4 or higher. With their sample prevalence of 11% for major depressive disorder, the PPV for the Beck Depression Inventory for Primary Care was 55.6% and the NPV, 98.7%.

In the second study, Johnson et al43 attempted to validate the Patient Health Questionnaire for Adolescents, which assesses depression, eating disorders, and substance use. Using a mental health professional–administered telephone interview based mostly on the Primary Care Evaluation of Mood Disorders mood module as the gold standard diagnosis, the Patient Health Questionnaire for Adolescents yielded a sensitivity of 73%, specificity of 94%, and PPV of 56% for major depressive disorder, which rose to 62% for “any depressive disorder” (n = 403).

In the third study, Schubiner and colleagues72 examined the accuracy of physician diagnosis aided by a self-report questionnaire, as well as the accuracy of physician diagnosis based on a mnemonic verbal interview, comparing both with a gold standard, semistructured, psychologist-administered interview. Physicians at an urban adolescent clinic were randomized into 2 groups, 1 trained to use the Safe Times Questionnaire73 (a 7-subscale screen with 1 subscale for depression/suicide comprising 5-7 items) vs 1 trained to conduct interviews based on the Safe Times Questionnaire mnemonic verbal interview. This latter group was not as accurate in depression identification as the Safe Times Questionnaire screening tool group, with area under the receiver operating characteristic curves of 88% for the screen vs 50% for the interview (P<.05), sensitivity of 80% vs 18% (P<.05), specificity of 91% vs 93%, PPV of 71% vs 43%, and NPV of 95% vs 80% (P<.05).72 In this study, depression prevalence was 21%.

In the fourth study, Yates et al84 administered the Mood and Feelings Questionnaire40 to 267 adolescent primary care attendees in Great Britain,with the urban subgroup (n = 130) also receiving the Schedule for Affective Disorders and Schizophrenia for School-Age Children42 diagnostic interview. Full details of this study are described elsewhere.15 Based on receiver operating characteristic curve analyses from an earlier study,15 investigators chose a cutoff score of 17, rather than the accepted 26 in clinical samples, to provide optimal sensitivity and specificity in their adolescent population withan estimated depression prevalence of 20%. Total and internalizing parent Child Behavior Checklist27 scores were modestly correlated with adolescent-rated mood symptoms (Spearman ρ = 0.203 and 0.239; P<.002 and <.001, respectively).84 Recalculation of the data by Yates and colleagues, which is presented in Table 1 in a different article (by Gledhill et al39, indicates that the Mood and Feelings Questionnaire yielded a PPV of 38% (n = 82).

The fifth and final study39 is a follow-up to the Yates et al study80 and relied on Mood and Feelings Questionnaire cutoff scores of 17 for first-stage screening. Gledhill et al39 trained 10 London general practitioners (GPs) in identification and management of adolescent depression and use of an unspecified, structured Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition65(DSM-IV)–based depression questionnaire while interviewing the adolescent. Blinded-GP diagnosis was compared with gold standard diagnosis made by positive first-stage Mood and Feelings Questionnaire screens and follow-up Schedule for Affective Disorders and Schizophrenia for School-Age Children42 interviews. Of 184 adolescents seen, physicians improved pretraining sensitivity and PPV (20% and 33%) to 43% and 75% posttraining, respectively. While improved, GPs still failed to identify more than half of adolescents with depression.

While, to our knowledge, these 5 articles represent the best psychometric data available, 2 other studies (3 articles) from Table 1 used a 2-stage screening method to provide some data on PPVs but not sensitivity or specificity. One of these studies is the Youth Partners in Care study,31,34 in which Asarnow et al preliminarily report a PPV lower than 50% for any depressive disorder using the Center for Epidemiological Studies Depression Scale32 (CES-D) and questions from the Composite International Diagnostic Interview.33 In the second study, Logan and King58 administered the Reynolds Adolescent Depression Scale59 in a general pediatric clinic and obtained data suggesting PPVs of 73.3% to 88% for “any DSM-IV depressive disorder.” Among youth identified as having depression based on the second-stage youth report, 79% of parents failed to endorse a single depression symptom.

In addition, another 6 studies provide some limited data about identification methods in primary care. Pfaff et al68 trained primary care professionals to identify youths at risk for suicidality and found that physicians' ability to recognize high scorers on the CES-D (score ≥16) increased from 45.1% to 62.9% after training. No definitive diagnostic assessment was used, limiting firm conclusions about training. Another study, by Adams et al,28 validated a health care professional–rated, general, psychosocial, adolescent risk screen that included 1 depression question, The Perkins Adolescent Risk Screen (PARS). Medical personnel were trained to use the PARS, while adolescents completed the Children's Depression Inventory29 (CDI), a Periodic Adolescent Preventive Services Visit Form of the American Medical Association's Guidelines for Adolescent Preventive Services17 (GAPS), and a PARS self-evaluation.28 The single PARS mood item correlated significantly with total CDI score (r = 0.58; P<.01) and with mood items from the GAPS (r = 0.48; P<.01). The self-reported PARS mood item correlated significantly (r = 0.47; P<.001; n = 188) with the health care professional–rated mood item. In another adolescent medicine clinic study by Smith et al,78 where positive State-Trait Anxiety Inventory79 and CDI screens (n = 205) were reassessed by physicians after their initial interview, screening identified 18 additional patients who were initially missed. Study health care professionals were so impressed by their inability to associate certain medical complaints with psychological issues that they decided to adopt the CDI into routine clinical care.78 Similarly, 3 other studies50,66,70 suggest that self-reports identify more youth at risk for depression than physician interviews alone. However, because these studies did not examine actual depression diagnoses, results are not definitive and may reflect some false-positive results.

Overall, of these 25 studies, only 1 study, the Schubiner et al72 study, directly compared, through a randomized controlled study, physician diagnosis (based on self-report screening tools), physician identification (based on trained interview), and gold standard mental health interviews. Only 4 studies49,50,58,84 collected information from parents about adolescents' mood symptoms, with only 2 of these studies58,84 reporting a comparison of the results, limiting any information about this specific identification question.

Ten36,46,48,50,6668,74,78,84 of the 25 studies explored in different ways how patients' chief complaints could identify patients at risk for depression. All suggest that sole reliance on chief complaint misses many youth with depression. In 1 study of chief complaints in an adolescent clinic,36 while depression and suicidality were more prominent in those initially seen with either psychological complaints or a combination of medical and psychological complaints, depression symptom prevalence in the patients only with medical chief complaints was still high: 21% of those with just medical complaints scored 16 or higher on the Beck Depression Inventory.37 Similar results are described in other studies.6668,74,78,84

CHALLENGES IN INCORPORATION OF IDENTIFICATION METHODS INTO CLINICAL PRACTICE (QUESTION 1 PART 2)

Although researchers screen teenagers for study purposes, this does not necessarily suggest feasibility of screening in routine primary care. Ten studies46,48,49,6669,72,77,78 mention that the clinic or practice staff or receptionist administered the self-report identification tools to the adolescent patients, with an 11th study35 having practice health care professionals administer and rate adolescent risk checklists. Of these 11, only 535,49,69,72,78 had health care professionals use results of the identification tools clinically, with a sixth77 using clinic case managers to follow up on identified problems.

In 1 of these 11 studies, the Schubiner and colleagues72 study of the Safe Times Questionnaire, less health care professional time was spent with patients given the questionnaire vs the interview, despite more sensitive and equally specific diagnosis with the questionnaire. The 23-second difference (75 seconds vs 98 seconds), however, was not found to be significant. In another of the 11 studies, the Burns et al study,35 although the practice incorporated a health care professional–administered psychosocial risk screen (PARS) into routine care, a medical record review showed that only 49% of patients had a completed PARS.

Three39,68,72 of the 11 studies trained physicians in identification methods, thus incorporating these techniques into routine practice as a research component, with 2 studies39,68 showing improved identification after training. Inaddition, the Beck Depression Inventory for Primary Care validation study by Winter et al82 had pediatricians administer the Primary Care Evaluation of Mood Disorders mood module in clinical practice, but unfortunately, no information was given about the feasibility of such endeavors in nonresearch settings.82

Two49,69 of the 11 studies incorporated adolescent general self-reports that included depression questions into practice. In 1,49 5 community health centers implemented the American Medical Association's GAPS into clinical practice. While a medical record review found GAPS screening forms in 76% of the medical records, this study was limited by selection of health centers most likely to succeed, receipt of university-provided technical assistance, and financial support for health center staff. This study did not examine how many adolescents with depression were found, but it demonstrated that the routine protocol significantly increased (1) adolescents' reported receipt of depression and suicide preventive services (pre-GAPS, 16% and 7%; post-GAPS, 34% and 22%, respectively; P<.001), (2) medical record documentation of depression and suicide screening (pre-GAPS, 3% and 2%; post-GAPS, 79% and 78%, respectively; P<.001), and (3) medical record documentation of family history of mental illness (pre-GAPS, 40%; post-GAPS, 53%; P<.001). Sustained feasibility of this protocol was not examined.

In the second study that incorporated general self-reports,69 1012 adolescents attending an inner-city adolescent clinic for routine care completed questionnaires covering several health topics. Health care professionals reviewed questionnaires that were not part of the medical record. Adolescents responded (n = 966) to questions regarding “being down or depressed,” with 127 (22%) endorsing these items “weekly” or more often. Medical record review of 124 of 127 cases found physician documentation of youths' depressive symptoms in 81% (n = 100) of medical records, demonstrating that most physicians examined the questionnaires.

ASSESSMENT OF THE IMPACT OF IDENTIFICATION (QUESTION 1 PART 2)
Patient Outcomes

Merely identifying adolescent depression may not lead to improved patient care or better mental health. Six31,34,35,39,69,80 of the 25 articles in Table 1 did examine the impact of depression identification on patient outcomes. In the Burns et al study,35 patients identified by medical record review as having been given a PARS previously were invited back to the clinic. At follow-up, a repeat PARS, CDI, and questionnaires studying mental health interventions were administered. While only 44% of follow-up youth reported “ever receiving a mental health intervention,” 72% of those scoring “moderate” or higher on a baseline PARS and 50% of those scoring “moderate” or higher on a follow-up PARS reported receiving mental health interventions, although the study did not separate out the timing of the mental health intervention. Though this study did not make formal depression diagnoses, examine pathways to mental health intervention, and standardize the time between PARS scores, it does suggest that youth with previous positive PARS scores had higher rates of mental health intervention.

Only 1 (Asarnow et al Youth Partners in Care study31,34) of the 6 studies attempted to implement a clinical response in primary care to self-report screens and to measure patient impact. As part of their quality improvement research initiative, evidence-based management was initiated in 1 screened arm with usual care in the other; the quality improvement group fared better, with lower CES-D scores at follow-up. Likewise, another 139 of the 6 studies found improvement in Children's Global Assessment Scale89 scores in adolescents receiving GP depression interventions among GPs completing training. Yet another study80 used CES-D for Children81 scores to measure the mental health impact of inviting teenagers to general practice consultations to discuss health behavior concerns and obtain appropriate follow-up care. While the CES-D for Children was not used as a screening tool per se, those with high scores (≥16) who came for the nurse consultation visits and were independently identified as having depression by the nurses had lower CES-D for Children scores on follow-up than those with high scores who never came for visits.

Finally, in another 1 of the 6 patient outcome studies, the Schichor et al69 study, which incorporated general self-reports into clinical practice and did not have a comparison group, a medical record review demonstrated that of 100 adolescents with depression noted in the medical records, physicians counseled 33% (n = 33) and referred 51% (n = 51) for counseling. Follow-up showed that 55% (n = 28) of those referred completed the referral process. In total, 61% of those identified as having depression by the physicians received some form of counseling in the end, suggesting that implementing routine depression identification can yield tangible increases in care actually delivered.

Physician Management Outcomes

Two68,69 of the 25 studies examined physician management outcomes on some level. While 61% of the patients in the Schichor et al69 study received counseling, physicians actively intervened (either through counseling or referral) in 84% of the cases they identified as having depression and in 67.7% of the 124 patients with self-reported depressive symptoms. While there is no gold standard diagnosis and no comparison group in this study, these data suggest that systematic use of “trigger questions” or self-report scales can affect physician behavior.

In contrast, the Pfaff study et al68 found no changes in management strategies despite improved GP identification of suicidal risk factors and high scorers on the CES-D after GP training. However, to truly understand whether there was no impact, studies would need to follow through on patient outcomes.

CURRENT PRACTICE (QUESTION 2)

While the 25 articles from Table 1 provided some answers to our first question concerning the ways to identify adolescent depression in pediatric primary care, Table 2 represents the evidence for the second question concerning current practice. Six studies attempted to identify current depression identification practice by asking physicians directly either about their intentions or their reported activities (Table 2). In 1 study, Halpern-Felsher and colleagues85 mail-surveyed pediatricians (n = 366; response rate, 66.2%) within a health maintenance organization, with only 15% and 17% reporting screening all (defined as at least 80%) of their adolescent patients for suicide and depression, respectively, at preventive services visits. Likewise, in a second study, Olson and colleagues16 surveyed a national sample of randomly selected pediatricians (response rate, 63%), finding that 46% lacked confidence that they could recognize depression, none recalling the use of any screening instrument during their last remembered case of adolescent depression and 17% using interview-based depression questions during their last remembered case of depression. Instead, identification was based mainly on chief complaints and family concerns. In a third study, Klein et al49 reported that prior to GAPS implementation in several practices, health care professionals reported screening 64% and 53% of their patients for depression and suicidal thoughts, but medical record documentation of such practices was found in only 3% and 2%, respectively, rendering such high self-reported rates of questionable validity.

In a fourth study, Middleman et al88 studied physicians' intentions to ask adolescents about high-risk behaviors. Using questionnaires, investigators presented 7 care scenarios to 64 pediatric residents, asking them to rate how likely they were to address 5 specific high-risk issues, including depression/suicide. Results indicated that residents were more likely to ask teens about sexual activity/birth control than any other high-risk behaviors. They were least likely to screen for suicide/depression and fighting/coping with anger.

Finally, 2 additional studies86,87 of pediatric professionals from 1982 and 1990, which are older and may not reflect current practice, reflect lower rates of asking patients about depression (14%)87 and suicide (20.8%),86 suggesting that despite physicians' feelings of responsibility for16 and good intentions to address depression and suicide, it usually does not happen.

Complicating our understanding of comparisons between studies are the different criteria used for defining depression diagnoses. While no large studies randomized both physicians and youth and compared different identification methods against a gold standard, the studies examined suggest that adolescent self-report tools using recommended clinical cutoff scores identify more patients with depression than other methods and that some adolescent depression screening tools have adequate psychometric properties and feasibility characteristics for use in primary care. However, studies also suggest that using liberal screening criteria may result in overidentification and increase the burden of false-positive results.

While several of the reviewed articles used general psychosocial distress screening tools (vs instruments with depression-specific questions), and while others that screened for general adolescent distress were not included in our search specifically focused on depression, none of these articles addressed how well these questionnaires identified depression compared with a gold standard diagnosis. Thus, the use of general distress self-reports (eg, General Health Questionnaire) without depression-specific trigger questions in pediatric primary care to identify adolescent depression cannot be endorsed or repudiated herein.

Interestingly, training physicians improved their ability to identify depression through interview but not to levels as high as when self-report tools were available. While the HEADSS (home, education, activities, drug use and abuse, sexual behavior, suicidality and depression) interview90 assessment is often discussed in adolescent medicine, no studies of its incorporation into routine primary care for depression identification were found. Thus, we do not have any evidence that even physicians who may have adequate training are successfully using their skills in a systematic fashion. The Schubiner et al study72 is unique in that it studied physician diagnosis aided by a self-report tool, which approximates real-world clinical settings much more than just looking at the accuracy of cutoff scores for a screening instrument given in a vacuum with no additional clinical information. Lastly, the available evidence reviewed herein indicates that reliance on chief complaints alone is insufficient, because most patients with depression came in with medical complaints or for routine care.

STUDIES INCORPORATING IDENTIFICATION METHODS INTO CLINICAL PRACTICE

Studies reviewed herein that incorporated identification methods into clinical practice were limited in number and implementation design. A look at the larger literature on psychosocial issues in pediatric primary care can give some practical suggestions for facilitating clinical incorporation9195 and information regarding cost.96,97

A final clinical issue not yet examined is how often adolescents need to be queried about their moods and at which type of visits. A study of psychosocial screening across ages showed that screening only at well-child visits misses a significant amount of psychosocial issues.98 Our review also suggests that even at preventive services visits, physicians are often not screening for depression. Lastly, while self-reports may identify more teens with depression, the potential burden on practices of assessing false-positive results has not been adequately studied.

IMPACT ON PHYSICIAN BEHAVIOR AND YOUTH OUTCOMES

More research is needed on the assessment of impact. While 1 study72 did have physicians use depression self-report results to make diagnostic decisions, no single study combined all 3 necessary components: a screening component, an intervention, and an assessment of patient outcomes at follow-up. However, the Youth Partners in Care study31,34 did show that screening and triaging done by specialized staff in primary care will lead to better outcomes when proper management is put into place.

CURRENT PRACTICE

The studies cited herein suggest that not only is the use of adolescent depression self-reports rare but also that systematic physician inquiry into the moods of teenagers has been difficult to achieve. Failure to use systematic reliance screening tools or depression trigger questions may be a critical component of the problem, particularly if not coupled with increased pediatric training in this area.

More research is needed to inform pediatric professionals about valid and feasible methods to identify adolescent depression and whether such identification will yield improved patient outcomes, but our review suggests that systematic use of adolescent self-reports with depression-specific questions may be a useful diagnostic aid to pediatric professionals. While improved pediatric diagnosis alone is unlikely to significantly change patient outcomes, recognizing teenagers with depression is the first step to improved depression management. The several studies available already suggest that adding primary care interventions for adolescent depression will be useful. With prolonged suffering and suicide as a potential consequence of undiagnosed depression, pediatric professionals may need to be more proactive and systematic in their depression identification methods.

Correspondence: Rachel A. Zuckerbrot, MD, 1051 Riverside Dr, Unit 78, New York, NY 10032 (raz1@columbia.edu).

Accepted for Publication: December 9, 2005.

Author Contributions:Study concept and design: Zuckerbrot and Jensen. Acquisition of data: Zuckerbrot and Jensen. Drafting of the manuscript: Zuckerbrot and Jensen. Critical revision of the manuscript for important intellectual content: Jensen. Administrative, technical, and material support: Zuckerbrot. Study supervision: Jensen.

Funding/Support: Dr Zuckerbrot was supported by research fellowship T-32 MH16434-22 from the National Institute of Mental Health.

Acknowledgment: We would like to acknowledge the support of David Shaffer, MD. We would also like to thank Lauren Zitner, BA, and Dana Pagar, BA, for their invaluable contribution to the current version of this article.

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Achenbach  TM Manual for the Child Behavior Checklist/4-18 and Profile.  Burlington University of Vermont Dept of Psychiatry1991;
Adams  CDPerkins  KCLumley  VHughes  CBurns  JJOmar  HA Validation of the Perkins Adolescent Risk Screen (PARS) J Adolesc Health 2003;33462- 470
PubMed Link to Article
Kovacs  M Children's Depression Inventory.  North Tonawanda, NY Multi-Health System1992;
Prinz  RJFoster  SKent  RNO’Leary  KD Multivariate assessment of conflict in distressed and non-distressed mother-adolescent dyads J Appl Behav Anal 1979;12691- 700
PubMed Link to Article
Asarnow  JRJaycox  LHAnderson  M Depression among youth in primary care models for delivering mental health services Child Adolesc Psychiatr Clin N Am 2002;11477- 497
PubMed Link to Article
Radloff  L The CES-D scale: a self-report depression scale for research in the general population Appl Psychol Meas 1977;1385- 401
Link to Article
 Composite International Diagnostic Interview Core Version 2.1 Interviewer's Manual.  Geneva, Switzerland World Health Organization1997;
Asarnow  JRJaycox  LHDuan  N  et al.  Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial JAMA 2005;293311- 319
PubMed Link to Article
Burns  JJCottrell  LPerkins  K  et al.  Depressive symptoms and health risk among rural adolescents Pediatrics 2004;1131313- 1320
PubMed Link to Article
Cappelli  MClulow  MKGoodman  JT  et al.  Identifying depressed and suicidal adolescents in a teen health clinic J Adolesc Health 1995;1664- 70
PubMed Link to Article
Beck  ATSteer  RA Manual for the Beck Depression Inventory.  San Antonio, Tex The Psychological Corp1987;
Cull  JGGill  WS Suicide Probability Scale—Manual.  Los Angeles, Calif Western Psychological Services1988;
Gledhill  JKramer  TIliffe  SGarralda  ME Training general practitioners in the identification and management of adolescent depression within the consultation: a feasibility study J Adolesc 2003;26245- 250
PubMed Link to Article
Thapar  AMcGuffin  P Validity of the shortened Mood and Feelings Questionnaire in a community sample of children and adolescents: a preliminary research note Psychiatry Res 1998;81259- 268
PubMed Link to Article
Garber  JWalker  LZeman  J Somatization symptoms in a community sample of children and adolescents: further validation of the Children's Somatization Inventory Psychol Assess 1991;3588- 595
Link to Article
Ambrosini  PJ Historical development and present status of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) J Am Acad Child Adolesc Psychiatry 2000;3949- 58
PubMed Link to Article
Johnson  JGHarris  ESSpitzer  RLWilliams  JB The Patient Health Questionnaire for Adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients J Adolesc Health 2002;30196- 204
PubMed Link to Article
Stewart  ALHays  RDWare  JE  Jr The MOS Short-Form General Health Survey: reliability and validity in a patient population Med Care 1988;26724- 735
PubMed Link to Article
Spitzer  RLWilliams  JBKroenke  K  et al.  Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study JAMA 1994;2721749- 1756
PubMed Link to Article
Joiner  TE  JrPfaff  JJAcres  JG A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project Behav Res Ther 2002;40471- 481
PubMed Link to Article
Goldberg  DPGater  RSartorius  N  et al.  The validity of two versions of the GHQ in the WHO study of mental illness in general health care Psychol Med 1997;27191- 197
PubMed Link to Article
Joiner  TE  JrPfaff  JJAcres  JG Characteristics of suicidal adolescents and young adults presenting to primary care with non-suicidal (indeed non-psychological) complaints Eur J Public Health 2002;12177- 179
PubMed Link to Article
Klein  JDAllan  MJElster  AB  et al.  Improving adolescent preventive care in community health centers Pediatrics 2001;107318- 327
PubMed Link to Article
Lipschitz  DSRasmusson  AMAnyan  WCromwell  PSouthwick  SM Clinical and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary care clinic J Am Acad Child Adolesc Psychiatry 2000;391104- 1111
PubMed Link to Article
Amaya-Jackson  L Child Exposure to Violence Checklist (adapted from Richters' Things I’ve Seen and Heard)  Durham, NC Trauma Evaluation: Center for Child and Family Health1998;
Bernstein  DPFink  L Childhood Trauma Questionnaire Manual.  San Antonio, Tex Psychological Corp1998;
Newman  EAmaya-Jackson  L Assessment of trauma instruments for children Paper presented at: the Scientific Proceedings of the 12th International Conference for Traumatic Stress Studies; November 1996; San Francisco, Calif
March  JSParker  JDSullivan  KStallings  PConnors  CK The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity J Am Acad Child Adolesc Psychiatry 1997;36554- 565
PubMed Link to Article
Winters  KC Personal Experience Screening Questionnaire Manual.  Los Angeles, Calif Western Psychological Services1991;
Olson  DHPortner  JLavee  Y FACES III (Family Adaptability and Cohesion Evaluation Scales).  St Paul University of Minnesota Family Social Service1985;
Masten  ASNeemann  JAndenas  S Life events and adjustment in adolescents: the significance of event independence, desirability, and chronicity J Res Adolesc 1994;471- 87
Link to Article
Logan  DEKing  CA Parental identification of depression and mental health service use among depressed adolescents J Am Acad Child Adolesc Psychiatry 2002;41296- 304
PubMed Link to Article
Reynolds  WM Reynolds Adolescent Depression Scale: Professional Manual.  Odessa, Fla Psychological Assessment Resources1987;
Hodges  KWong  MMLatessa  M Use of the Child and Adolescent Functional Assessment Scale (CAFAS) as an outcome measure in clinical settings J Behav Health Serv Res 1998;25325- 336
PubMed Link to Article
Burns  BJAngols  AMagruder-Habib  KCostello  EPatrick  MKS The Child and Adolescent Services Assessment (CASA).  Durham, NC Duke University Medical Center1992;
Armsden  GCGreenberg  MT The Inventory of Parent and Peer Attachment: individual differences and their relationship to psychological well-being in adolescence J Youth Adolesc 1987;16427- 454
Link to Article
First  MBSpitzer  RGibbon  MWilliams  J Structured Clinical Interview for DSM-IV Axis I Disorders.  New York Biometrics Research Unit, New York State Psychiatric Institute1995;
Schwab-Stone  MEShaffer  DDulcan  MK  et al.  Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3) J Am Acad Child Adolesc Psychiatry 1996;35878- 888
PubMed Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition  Washington, DC American Psychiatric Association1994;
McKelvey  RSDavies  LCPfaff  JJAcres  JEdwards  S Psychological distress and suicidal ideation among 15-24-year-olds presenting to general practice: a pilot study Aust N Z J Psychiatry 1998;32344- 348
PubMed Link to Article
McKelvey  RSPfaff  JJAcres  JG The relationship between chief complaints, psychological distress, and suicidal ideation in 15-24-year-old patients presenting to general practitioners Med J Aust 2001;175550- 552
PubMed
Pfaff  JJAcres  JGMcKelvey  RS Training general practitioners to recognise and respond to psychological distress and suicidal ideation in young people Med J Aust 2001;174222- 226
PubMed
Schichor  ABernstein  BKing  S Self-reported depressive symptoms in inner-city adolescents seeking routine health care Adolescence 1994;29379- 388
PubMed
Schubiner  HRobin  A Screening adolescents for depression and parent-teenager conflict in an ambulatory medical setting: a preliminary investigation Pediatrics 1990;85813- 818
PubMed
Foster  SLRobin  ALMash  EJedTerdal  LGed Family conflict and communication in adolescence Behavioral Assessment of Childhood Disorders. 2nd ed. New York, NY Guilford Press1988;
Schubiner  HTzelepis  AWright  KPodany  E The clinical utility of the Safe Times Questionnaire J Adolesc Health 1994;15374- 382
PubMed Link to Article
Schubiner  HTzelpis  APodany  E Development of the Safe Times Questionnaire [abstract] J Adolesc Health Care 1989;10249
Link to Article
Slap  GBVorters  DFKhalid  NMargulies  SRForke  CM Adolescent suicide attempters: do physicians recognize them? J Adolesc Health 1992;13286- 292
PubMed Link to Article
Achenbach  TMEdelbrock  C Manual for the Youth Self-Report and Profile.  Burlington University of Vermont Dept of Psychiatry1987;
Offer  DOstrov  EHoward  KI The Offer Self-Image Questionnaire for Adolescents: A Manual.  Chicago, Ill Michael Reese Hospital and Medical Center Special Publication1977;
Smith  PBBuzi  RSWeinman  ML Mental health problems and symptoms among male adolescents attending a teen health clinic Adolescence 2001;36323- 332
PubMed
Smith  MSMitchell  JMcCauley  EACalderon  R Screening for anxiety and depression in an adolescent clinic Pediatrics 1990;85262- 266
PubMed
Spielberger  CDGorsuch  RLLushene  RE Manual for the State-Trait Anxiety Inventory.  Palo Alto, Calif Consulting Psychologists Press1970;
Walker  ZTownsend  JOakley  L  et al.  Health promotion for adolescents in primary care: randomised controlled trial BMJ 2002;325524
PubMed Link to Article
Fendrich  MWeissman  MMWarner  V Screening for depressive disorder in children and adolescents: validating the Center for Epidemiologic Studies Depression Scale for Children Am J Epidemiol 1990;131538- 551
PubMed
Winter  LBSteer  RAJones-Hicks  LBeck  AT Screening for major depression disorders in adolescent medical outpatients with the Beck Depression Inventory for Primary Care J Adolesc Health 1999;24389- 394
PubMed Link to Article
Beck  ATGuth  DSteer  RABall  R Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care Behav Res Ther 1997;35785- 791
PubMed Link to Article
Yates  PKramer  TGarralda  E Depressive symptoms amongst adolescent primary care attenders: levels and associations Soc Psychiatry Psychiatr Epidemiol 2004;39588- 594
PubMed Link to Article
Halpern-Felsher  BLOzer  EMMillstein  SG  et al.  Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med 2000;154173- 179
PubMed Link to Article
Hodgman  CHRoberts  FN Adolescent suicide and the pediatrician J Pediatr 1982;101118- 123
PubMed Link to Article
Marks  AFisher  MLasker  S Adolescent medicine in pediatric practice J Adolesc Health Care 1990;11149- 153
PubMed Link to Article
Middleman  ABBinns  HJDuRant  RH Factors affecting pediatric residents' intentions to screen for high risk behaviors J Adolesc Health 1995;17106- 112
PubMed Link to Article
Shaffer  DGould  MSBrasic  J  et al.  A children's global assessment scale (CGAS) Arch Gen Psychiatry 1983;401228- 1231
PubMed Link to Article
Cohen  EMackenzie  RGYates  GL HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth J Adolesc Health 1991;12539- 544
PubMed Link to Article
Metz  JRAllen  CMBarr  GShinefield  H A pediatric screening examination for psychosocial problems Pediatrics 1976;58595- 606
PubMed
Jellinek  MSMurphy  JMLittle  MPagano  MEComer  DMKelleher  KJ Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study Arch Pediatr Adolesc Med 1999;153254- 260
PubMed Link to Article
Murphy  JMArnett  HLBishop  SJJellinek  MSReede  JY Screening for psychosocial dysfunction in pediatric practice: a naturalistic study of the Pediatric Symptom Checklist Clin Pediatr (Phila) 1992;31660- 667
PubMed Link to Article
Gardner  WKelleher  KJPajer  KA Multidimensional adaptive testing for mental health problems in primary care Med Care 2002;40812- 823
PubMed Link to Article
Jensen  PSIrwin  RAJosephson  AM  et al.  Data-gathering tools for “real world” clinical settings: a multisite feasibility study J Am Acad Child Adolesc Psychiatry 1996;3555- 66
PubMed Link to Article
Valenstein  MVijan  SZeber  JEBoehm  KButtar  A The cost-utility of screening for depression in primary care Ann Intern Med 2001;134345- 360
PubMed Link to Article
Dobrez  DSasso  ALHoll  JShalowitz  MLeon  SBudetti  P Estimating the cost of developmental and behavioral screening of preschool children in general pediatric practice Pediatrics 2001;108913- 922
PubMed Link to Article
Borowsky  IWMozayeny  SIreland  M Brief psychosocial screening at health supervision and acute care visits Pediatrics 2003;112129- 133
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Identification Methods for Adolescent Depression Studied in Primary Care (in Alphabetical Order)
Table Graphic Jump LocationTable 2. Health Care Professional–Reported Current Adolescent Depression Identification Practice

References

Garrison  CZAddy  CLJackson  KLMcKeown  REWaller  JL Major depressive disorder and dysthymia in young adolescents Am J Epidemiol 1992;135792- 802
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Lewinsohn  PMHops  HRoberts  RESeeley  JRAndrews  JA Adolescent psychopathology, I: prevalence and incidence of depression and other DSM-III-R disorders in high school students J Abnorm Psychol 1993;102133- 144
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Wortman  RNDonovan  DSWoodburn  KE  et al.  Depression and its relationship to somatic complaints in adolescent patients [abstract] J Adolesc Health Care 1986;7295
Chang  GWarner  VWeissman  MM Physicians' recognition of psychiatric disorders in children and adolescents AJDC 1988;142736- 739
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Kramer  TGarralda  ME Psychiatric disorders in adolescents in primary care Br J Psychiatry 1998;173508- 513
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Olson  ALKelleher  KJKemper  KJZuckerman  BSHammond  CSDietrich  AJ Primary care pediatricians' roles and perceived responsibilities in the identification and management of depression in children and adolescents Ambul Pediatr 2001;191- 98
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Elster  ABKuznets  NJ AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale.  Baltimore, Md Williams & Wilkins1994;
American Academy of Family Physicians, Recommended curriculum guidelines: adolescent health http://www.aafp.orgAccessed June 27, 2003
American Academy of Pediatrics,Committee on Psychosocial Aspects of Child and Family Health, Guidelines for Health Supervision III. 3rd ed. Elk Grove Village, Ill American Academy of Pediatrics1997;
Agency for Healthcare Research and Quality, Screening for depression: recommendations and rationale http://www.ahrq.govAccessed June 27, 2003
Kroenke  KTaylor-Vaisey  ADietrich  AJOxman  TE Interventions to improve provider diagnosis and treatment of mental disorders in primary care: a critical review of the literature Psychosomatics 2000;4139- 52
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Pignone  MPGaynes  BNRushton  JL  et al.  Screening for depression in adults: a summary of the evidence for the US Preventive Services Task Force Ann Intern Med 2002;136765- 776
PubMed Link to Article
Brent  DAHolder  DKolko  D  et al.  A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy Arch Gen Psychiatry 1997;54877- 885
PubMed Link to Article
Mufson  LWeissman  MMMoreau  DGarfinkel  R Efficacy of interpersonal psychotherapy for depressed adolescents Arch Gen Psychiatry 1999;56573- 579
PubMed Link to Article
Emslie  GJHeiligenstein  JHWagner  KD  et al.  Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial J Am Acad Child Adolesc Psychiatry 2002;411205- 1215
PubMed Link to Article
US Food and Drug Administration, FDA launches a multi-pronged strategy to strengthen safeguards for children treated with antidepressant medications http://www.fda.gov/bbs/topics/news/2004/NEW01124.htmlAccessed November 2, 2005
Achenbach  TM Manual for the Child Behavior Checklist/4-18 and Profile.  Burlington University of Vermont Dept of Psychiatry1991;
Adams  CDPerkins  KCLumley  VHughes  CBurns  JJOmar  HA Validation of the Perkins Adolescent Risk Screen (PARS) J Adolesc Health 2003;33462- 470
PubMed Link to Article
Kovacs  M Children's Depression Inventory.  North Tonawanda, NY Multi-Health System1992;
Prinz  RJFoster  SKent  RNO’Leary  KD Multivariate assessment of conflict in distressed and non-distressed mother-adolescent dyads J Appl Behav Anal 1979;12691- 700
PubMed Link to Article
Asarnow  JRJaycox  LHAnderson  M Depression among youth in primary care models for delivering mental health services Child Adolesc Psychiatr Clin N Am 2002;11477- 497
PubMed Link to Article
Radloff  L The CES-D scale: a self-report depression scale for research in the general population Appl Psychol Meas 1977;1385- 401
Link to Article
 Composite International Diagnostic Interview Core Version 2.1 Interviewer's Manual.  Geneva, Switzerland World Health Organization1997;
Asarnow  JRJaycox  LHDuan  N  et al.  Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial JAMA 2005;293311- 319
PubMed Link to Article
Burns  JJCottrell  LPerkins  K  et al.  Depressive symptoms and health risk among rural adolescents Pediatrics 2004;1131313- 1320
PubMed Link to Article
Cappelli  MClulow  MKGoodman  JT  et al.  Identifying depressed and suicidal adolescents in a teen health clinic J Adolesc Health 1995;1664- 70
PubMed Link to Article
Beck  ATSteer  RA Manual for the Beck Depression Inventory.  San Antonio, Tex The Psychological Corp1987;
Cull  JGGill  WS Suicide Probability Scale—Manual.  Los Angeles, Calif Western Psychological Services1988;
Gledhill  JKramer  TIliffe  SGarralda  ME Training general practitioners in the identification and management of adolescent depression within the consultation: a feasibility study J Adolesc 2003;26245- 250
PubMed Link to Article
Thapar  AMcGuffin  P Validity of the shortened Mood and Feelings Questionnaire in a community sample of children and adolescents: a preliminary research note Psychiatry Res 1998;81259- 268
PubMed Link to Article
Garber  JWalker  LZeman  J Somatization symptoms in a community sample of children and adolescents: further validation of the Children's Somatization Inventory Psychol Assess 1991;3588- 595
Link to Article
Ambrosini  PJ Historical development and present status of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) J Am Acad Child Adolesc Psychiatry 2000;3949- 58
PubMed Link to Article
Johnson  JGHarris  ESSpitzer  RLWilliams  JB The Patient Health Questionnaire for Adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients J Adolesc Health 2002;30196- 204
PubMed Link to Article
Stewart  ALHays  RDWare  JE  Jr The MOS Short-Form General Health Survey: reliability and validity in a patient population Med Care 1988;26724- 735
PubMed Link to Article
Spitzer  RLWilliams  JBKroenke  K  et al.  Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study JAMA 1994;2721749- 1756
PubMed Link to Article
Joiner  TE  JrPfaff  JJAcres  JG A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project Behav Res Ther 2002;40471- 481
PubMed Link to Article
Goldberg  DPGater  RSartorius  N  et al.  The validity of two versions of the GHQ in the WHO study of mental illness in general health care Psychol Med 1997;27191- 197
PubMed Link to Article
Joiner  TE  JrPfaff  JJAcres  JG Characteristics of suicidal adolescents and young adults presenting to primary care with non-suicidal (indeed non-psychological) complaints Eur J Public Health 2002;12177- 179
PubMed Link to Article
Klein  JDAllan  MJElster  AB  et al.  Improving adolescent preventive care in community health centers Pediatrics 2001;107318- 327
PubMed Link to Article
Lipschitz  DSRasmusson  AMAnyan  WCromwell  PSouthwick  SM Clinical and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary care clinic J Am Acad Child Adolesc Psychiatry 2000;391104- 1111
PubMed Link to Article
Amaya-Jackson  L Child Exposure to Violence Checklist (adapted from Richters' Things I’ve Seen and Heard)  Durham, NC Trauma Evaluation: Center for Child and Family Health1998;
Bernstein  DPFink  L Childhood Trauma Questionnaire Manual.  San Antonio, Tex Psychological Corp1998;
Newman  EAmaya-Jackson  L Assessment of trauma instruments for children Paper presented at: the Scientific Proceedings of the 12th International Conference for Traumatic Stress Studies; November 1996; San Francisco, Calif
March  JSParker  JDSullivan  KStallings  PConnors  CK The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity J Am Acad Child Adolesc Psychiatry 1997;36554- 565
PubMed Link to Article
Winters  KC Personal Experience Screening Questionnaire Manual.  Los Angeles, Calif Western Psychological Services1991;
Olson  DHPortner  JLavee  Y FACES III (Family Adaptability and Cohesion Evaluation Scales).  St Paul University of Minnesota Family Social Service1985;
Masten  ASNeemann  JAndenas  S Life events and adjustment in adolescents: the significance of event independence, desirability, and chronicity J Res Adolesc 1994;471- 87
Link to Article
Logan  DEKing  CA Parental identification of depression and mental health service use among depressed adolescents J Am Acad Child Adolesc Psychiatry 2002;41296- 304
PubMed Link to Article
Reynolds  WM Reynolds Adolescent Depression Scale: Professional Manual.  Odessa, Fla Psychological Assessment Resources1987;
Hodges  KWong  MMLatessa  M Use of the Child and Adolescent Functional Assessment Scale (CAFAS) as an outcome measure in clinical settings J Behav Health Serv Res 1998;25325- 336
PubMed Link to Article
Burns  BJAngols  AMagruder-Habib  KCostello  EPatrick  MKS The Child and Adolescent Services Assessment (CASA).  Durham, NC Duke University Medical Center1992;
Armsden  GCGreenberg  MT The Inventory of Parent and Peer Attachment: individual differences and their relationship to psychological well-being in adolescence J Youth Adolesc 1987;16427- 454
Link to Article
First  MBSpitzer  RGibbon  MWilliams  J Structured Clinical Interview for DSM-IV Axis I Disorders.  New York Biometrics Research Unit, New York State Psychiatric Institute1995;
Schwab-Stone  MEShaffer  DDulcan  MK  et al.  Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3) J Am Acad Child Adolesc Psychiatry 1996;35878- 888
PubMed Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition  Washington, DC American Psychiatric Association1994;
McKelvey  RSDavies  LCPfaff  JJAcres  JEdwards  S Psychological distress and suicidal ideation among 15-24-year-olds presenting to general practice: a pilot study Aust N Z J Psychiatry 1998;32344- 348
PubMed Link to Article
McKelvey  RSPfaff  JJAcres  JG The relationship between chief complaints, psychological distress, and suicidal ideation in 15-24-year-old patients presenting to general practitioners Med J Aust 2001;175550- 552
PubMed
Pfaff  JJAcres  JGMcKelvey  RS Training general practitioners to recognise and respond to psychological distress and suicidal ideation in young people Med J Aust 2001;174222- 226
PubMed
Schichor  ABernstein  BKing  S Self-reported depressive symptoms in inner-city adolescents seeking routine health care Adolescence 1994;29379- 388
PubMed
Schubiner  HRobin  A Screening adolescents for depression and parent-teenager conflict in an ambulatory medical setting: a preliminary investigation Pediatrics 1990;85813- 818
PubMed
Foster  SLRobin  ALMash  EJedTerdal  LGed Family conflict and communication in adolescence Behavioral Assessment of Childhood Disorders. 2nd ed. New York, NY Guilford Press1988;
Schubiner  HTzelepis  AWright  KPodany  E The clinical utility of the Safe Times Questionnaire J Adolesc Health 1994;15374- 382
PubMed Link to Article
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