The long-term impact of COVID-19 on mental health may not be known for years, but right now it's vital to assess mental health in teenagers to help them get the help they may require.
As a result of COVID-19, isolation, interpersonal tensions, losses of loved ones, barriers to extended family supports, poverty, job insecurity, and lack of socialization with other children and teens have been a cumulative and interactive burden for communities throughout the United States and elsewhere. The bell-shaped curve demonstrating the distribution of psychosocial disorders in our population has shifted to the right, meaning that the prevalence and severity of a wide range of problems have increased.
Anxiety and depression were already common disorders among teenagers and adolescents, who are especially sensitive to the layered consequences of COVID-19. There is growing concern that the pandemic has added to the rising rate of adolescent suicide and that any increase in depression will also increase the number of adolescents with suicidal ideation.1,2
Now that the pandemic is being brought under better control and schools are reopening, the structure of school, activities, and social relationships will likely help some adolescents feel less depressed and anxious. Many psychologists have hypothesized, however, that the byproducts of COVID-19 (ie, persistent isolation during quarantine, financial strain, and sickness or death in the family) will have lasting effects on adolescent mental health. These effects may be further exacerbated by the stresses related to reestablishing social relationships, shifting from remote school to the intensity of a classroom, and facing the burden of “catching up” on their academic work and testing (particularly for students with higher support needs and/or those without adequate access to technology over the past year). Because adolescence is a time of such rapid change, every year marks a further blossoming of identity and concomitant stresses, and this second year of COVID-19 dramatically increases the need to assess the psychosocial functioning of adolescents.
How should pediatricians in primary care approach the recognition and management of psychosocial concerns in adolescents who are facing the usual developmental challenges intensified by COVID-19? How should pediatricians assess severity and whether additional primary care management or referral is appropriate? How should they frame their role in adolescent suicidal ideation and suicide prevention? What is the role of primary care follow-up?
Although parent observations and questions about their child’s mental well-being are always useful in encouraging recognition during a pediatric office visit, parents may not have the awareness or comfort to discuss potential problems in this setting, especially at an early point in adolescent psychosocial disorders. Screening all adolescents for general psychosocial problems and/or depression3 is the recommended and effective approach to recognition and is now a quality standard of the American Academy of Pediatrics, Medicaid, and the US Preventive Services Task Force, paralleling screening for growth and health indicators (eg, hematocrit, urine). Screening has been facilitated by electronic medical record (EMR) systems that allow parents and teenagers to complete screens online or on electronic devices, then automatically score and post the information in the EMR prior to the visit.
For broad psychosocial screening as well as depression screening, the Pediatric Symptom Checklist (PSC) is a validated, approved, and widely used questionnaire.4-6 Available at no cost and in more than 30 languages, it is most often completed by parents (although there is also a youth-completed version), and its simple scoring system can be found on the following website: https://www.massgeneral.org/psychiatry/treatments-and-services/pediatricsymptom-checklist/bibliography. Parents can complete the questionnaire in about 3 minutes, and the EMR will report the results as an overall score reflecting psychosocial functioning at home, in school, with peers, and at activities. In addition, 3 subscale scores note risk of depression/anxiety, attention problems, and difficulties with conduct. The pediatrician can see the scores in the EMR to assess if any are positive and, later, assess trends over time with repeated administrations of the PSC.
Adolescent depression is common and has multiple consequences, including poor school performance, substance use, risk-taking behavior, low self-esteem, and suicide risk.7-9 Preliminary research suggests that the pandemic is substantially affecting youth mental well-being and depression, with 43.7% of Chinese adolescents reporting mild to severe depression,10 46% of young people in Latin America and the Caribbean reporting lower motivation to engage in their favorite activities,11 and 46% of US parents noticing a new or worsened mental health condition in their teenagers since the start of the COVID-19 pandemic.12 Rising percentages of psychosocial distress indicate a pressing need to accurately identify and help adolescents with depression. Given that adolescent depression, especially early in the course, can be very private, with symptoms remaining unexpressed to others, the Patient Health Questionnaire (PHQ-9) is a useful youth-reported screening tool that focuses specifically on depression.
PHQ-9 scores reflect severity of depression, and its ninth question asks about frequency of suicidal ideation.
Pediatricians could use both the parent-reported PSC and the youth-reported PHQ-9 to obtain a broad picture of overall psychosocial functioning and a more detailed view of depression. The use of both screens yields a range of 15% to 20% of teenagers identifying as positive on 1 or both measures. Most adolescents who screen positive would have indications of depression and anxiety, but about two-thirds will also have other issues related to attention, family problems, and relationships.
Some practices have relied on the parent-reported PSC and used the PHQ-9 only if the parents report a high internalizing score on the PSC; however, the PSC alone would miss those adolescents who are functioning well outwardly, but privately feel depressed. Some practices give only the PHQ-9 or the youth-reported PSC, and these will miss the parent’s historical knowledge and more accurate assessment of the teenager’s overall functioning. Based on our recent research, we recommend that primary care practices use both the parent-reported PSC and the youth-reported PHQ-9 for routine psychosocial screening.13
Next steps for patients who screen positive on the PSC and PHQ-9
About 25% of those teenagers scoring positive will be identified only by the overall score of the parent’s PSC and may have positive subscale scores in attention or conduct problems. As with any PSC positive score, most pediatricians look at answers marked “often” (such as “Often does not listen to rules”) to confirm that the parents sense difficulty in daily functioning, and try to define the problem further when talking to the teenager. Some of these problems, such as attention-related or divorce-related issues, will be known to the pediatrician from previous visits and require less time to evaluate.
New issues will need to be assessed for severity and a decision made whether to offer guidance, schedule follow-up visits to track the problem, or, if serious, refer for a full mental health evaluation. Practices are collaborating, or increasingly colocating, with social workers and psychologists who can provide access to mental health services onsite.
Among the teenagers with a positive screen on the parent-reported PSC, approximately 75% will also have a positive internalizing score, and most of these teenagers will also have a positive PHQ-9 score for depression.13 The score on the PHQ-9 defines depression severity: 0 to 4 (none), 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). Most scores are moderate or lower, with only about 3% of teenagers scoring in the moderately severe or severe range. Adolescents have variations in mood and on any given day, their scores may vary from mild to moderate, or moderate to severe. It is meaningful for the pediatrician to review scores and note changes from prior visits.
With these positive indications, the pediatrician should do a brief assessment of the depression and its severity, and the risk of suicide. Teenagers developmentally are often not comfortable being open and forthright with adults. The pediatrician must use clinical skill (tone, posture, taking time, listening) to create a sense of trust and connectedness with the adolescent such that sufficient honest information can be gathered to ascertain the severity and risks of the depression.
Framing an approach to suicide ideation and prevention
Pediatricians are understandably anxious given the rising rates (and the horror) of a teenager dying by suicide or a depressed teenager taking risks, such as drunk driving, that results in a death called an “accident.” The clinical dilemma arises from the rarity of these events and their lack of predictability. Preliminary research has suggested increased rates of youth suicide attempts during the pandemic compared with 2019,2 but it is still too soon to fully assess the impact of the pandemic on adolescent suicide rates.
Among adolescents, deaths by suicide occur at a rate of approximately 10 in 100,000, annually.14 Based on the results of prior research in an older adolescent and adult population, it is likely that these 10 adolescents would have varied responses to question 9 of the PHQ-9, with some endorsing suicidal thoughts frequently but others endorsing no suicidal thoughts.15 Although accidents, some related to risk taking and illnesses, would have contributed to some more deaths, overwhelmingly most of the 100,000 cohort would be alive. We will discuss risk factors, but our current state of knowledge cannot predict which individual will commit a suicidal act or take a harmful risk, or when.
With these statistics and our lack of knowledge, pediatricians cannot (except in unusual circumstances) expect that they will prevent suicide either immediately or over the next 2 years. Suicidal ideation, depression, and positive parent-reported PSC scores are all alerts that a teenager is in emotional distress. They are more vulnerable to problems in school, family, or with peers, and to substance use, psychiatric disorders, and emotional suffering. Rather than focusing on immediate suicide prevention, the PSC and PHQ-9 select a population of teenagers who have “enduring vulnerability.”16 The screening interview is the first step in assessing the severity of this vulnerability and making recommendations.
This vulnerability is chronic, and just as with any chronic condition, the pediatrician provides appropriate follow-up and tracking. It is likely that half of teenagers who are identified as positive by the PSC and PHQ-9 will improve, and on repeat screening over time, will move from the positive to the negative score range or be at much lower risk. The remaining half, approximately 7% to 10% of all teenagers, will have more chronic or enduring vulnerability and will need ongoing follow-up and efforts to optimize helpful interventions.
When to refer and follow up
Pediatricians should base referral decisions on their severity assessment and comfort level. Usually pediatricians are skillful in sensing the scale and complexity of a psychosocial issue and should refer for mental health evaluation. In general, if the PHQ-9 is positive in the range of moderate or above, and thoughts of death and suicide are frequent, timely referral is indicated to an experienced psychologist or psychiatrist. In less severe circumstances, the pediatrician can make recommendations concerning immediate stressors, suggest lifestyle changes17 (exercise, adequate sleep, meditation, activities that support self-esteem, tutoring, summer programs, etc), and offer guidance to both parents and the teenager. If specific depression treatment is indicated, referral for cognitive behavior therapy18 is a sound additional step. An increasing number of pediatricians are comfortable using first-line antidepressants to treat depression and anxiety. The evidence for the use of medication is stronger in more severe cases than in mild ones.19
What will be of help in dealing with mental health requirements at baseline, and with heightened needs post COVID-19? First, psychosocial screening should be a routine process, just like taking vital signs. Second, follow-up should be consistent, to assess the trajectory of any issue, especially depression, and gain a deeper understanding of the patient. Third, have mental health experts accessible and ideally integrated into pediatric practice, working closely with clinicians to improve access and quality. In the near future, the use of artificial intelligence and large data sets derived from EMRs will hopefully facilitate the discovery of history and behavior patterns that provide more specific guidance for treatment, especially medication.
1. Zhang L, Zhang D, Fang J, Wan Y, Tao F, Sun Y. Assessment of mental health of Chinese primary school students before and after school closing and opening during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9):e2021482. doi:10.1001/jamanetworkopen.2020.21482
2. Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, Williams L. Suicide ideation and attempts in a pediatric emergency department before and during COVID-19. 2020;147(3):e2020029280. doi:10.1542/peds.2020-029280
3. Jellinek M, Murphy JM. Screening for psychosocial functioning as the eighth vital sign. JAMA Pediatr. 2021;175(1):13-14. doi:10.1001/jamapediatrics.2020.2005
4. Murphy JM, Reede J, Jellinek MS, Bishop SJ. Screening for psychosocial dysfunction in inner-city children: further validation of the Pediatric Symptom Checklist. J Am Acad Child Psy.1992;31(6):1105-1111. doi:10.1097/00004583-199211000-00019
5. Pagano ME, Cassidy LJ, Little M, Murphy JM, Jellinek MS. Identifying psychosocial dysfunction in school-age children: the Pediatric Symptom Checklist as a self-report measure. Psychol Sch. 2000;37(2):91-106. doi:10.1002/(SICI)1520-6807(200003)37:2%3C91::AID-PITS1%3E3.0.CO;2-3
6. Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher 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;153(3):254-260. doi:10.1001/archpedi.153.3.254
7. Glied S, Pine DS. Consequences and correlates of adolescent depression. Arch Pediatr Adolesc Med. 2002;156(10):1009-1014. doi:10.1001/archpedi.156.10.1009
8. Pang RD, Farrahi L, Glazier S, Sussman S, Leventhal AM. Depressive symptoms, negative urgency and substance use initiation in adolescents. Drug Alcohol Depend. 2014;144:225-230. doi:10.1016/j.drugalcdep.2014.09.771
9. Merikangas KR, He J, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Psy. 2010;49(10):980-989. doi:10.1016/j.jaac.2010.05.017
10. Zhou SJ, Zhang LG, Wang LL, et al. Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19. Eur Child Adolesc Psychiatry. 2020;29(6):749-758. doi:10.1007/s00787-020-01541-4
11. The impact of COVID-19 on the mental health of adolescents and youth. UNICEF: Latin America and the Caribbean. Accessed April 26, 2021. https://www.unicef.org/lac/en/impact-covid-19-mental-health-adolescents-and-youth
12. Mott Poll Report: how the pandemic has impacted teen mental health. C.S. Mott Children’s Hospital. March 15, 2021. Accessed April 26, 2021. https://mottpoll.org/reports/how-pandemic-has-impacted-teen-mental-health
13. Jellinek M, Bergmann P, Holcomb JM, et al. Recognizing adolescent depression with parent- and youth-report screens in pediatric primary care. J Pediatr. 2021;233:220-226.e1. doi:10.1016/j.jpeds.2021.01.069
14. Suicide. National Institute of Mental Health. Updated May 2021. Accessed July 8, 2021. https://www.nimh.nih.gov/health/statistics/suicide.shtml
15. Simon GE, Coleman KJ, Rossom RC, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. J Clin Psychiatry. 2016;77(2):221-227. doi:10.4088/JCP.15m09776
16. Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatr Serv. 2013;64(12):1195-1202. doi:10.1176/appi.ps.201200587
17. Sarris J, O’Neil A. Lifestyle medicine for the prevention and treatment of depression. In: Mechanick JI, Kushner RF, eds. Lifestyle Medicine: A Manual for Clinical Practice. Springer International; 2016:281-289. doi:10.1007/978-3-319-24687-1_25
18. Spirito A, Esposito-Smythers C, Wolff J, Uhl K. Cognitive-behavioral therapy for adolescent depression and suicidality. Child Adolesc Psychiatr Clin N Am. 2011;20(2):191-204. doi:10.1016/j.chc.2011.01.012
19. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303(1):47-53. doi:10.1001/jama.2009.1943
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