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Abstract
Background/Purpose Mental health (MH) problems are prevalent in adolescents with childhood-onset lupus (cSLE), with cross-sectional studies estimating prevalences of 20-60% for depression symptoms and 20-40% for anxiety symptoms. Despite this, MH screening rates are low. Identifying and treating MH symptoms early on is crucial as they are known to be associated with poor patient outcomes. A six-month chart audit (July 2021- Dec 2021) revealed a baseline median percentage of 17% of cSLE patients with documented MH screening in paediatric lupus outpatient clinic at The Hospital for Sick Children (Sickkids). In response, we aimed to: 1) increase percentage of cSLE patients (≥ 12-18 yo) with routine MH screening for depression (Patient Health Questionnaire-9 (PHQ-9)) and anxiety (Generalized Anxiety Disorder-7 (GAD-7)) from 17% to 80%, and if positive, 2) increase percentage of documented initial management (psychoeducation and/or referral to appropriate MH service(s)) from 22% to 80% in cSLE outpatient clinic by Sep 2022.
Methods This is a time series study analyzed with run charts. Root cause analysis was performed using fishbone diagram, 5Whys, and pareto chart. Patient and parent satisfaction surveys were conducted to determine their baseline satisfaction. Plan-Do-Study Act (PDSA) method was used to systematically evaluate and adjust process in real time. Family of measures included outcome measure – percentage of positively screened cSLE patients with documented initial MH management, process measure – percentage of eligible cSLE patients screened, and balancing measure – number of referrals to MH services, and time till seen.
Results Root causes identified included limited MH resources, lack of integration into clinic workflow, lack of standardized clinic algorithm for positive screens, lack of MH training of health care providers, and patient/family stigma and misconceptions. A series of site-specific change ideas (figure 1) were developed accordingly and implemented including 1) patients self-screened instead of administered by health care providers, 2) a standardized clinic algorithm, and 3) two 2-hour MH training workshops for health care providers. Over 50% of patients (n= 23) and parents (n=18) surveyed felt comfortable with routine MH screening, preferably in-person, and supported ongoing MH inquiry at future visits (figure 2). Patients emphasized privacy and confidentiality. Over six month period, 42 cSLE patients completed PHQ-9 and GAD-7 screens, increasing screening rate from 17 to 67%, of which 18 (43%) and 15 (36%) had positive screens respectively (figure 3). Of those, 10% (n=4) had moderate to severe scores and suicidal ideation. Six cSLE patients were referred and seen by appropriate MH service within 4-6 weeks. Majority screened (n=41) received psychoeducation and MH handout.
Conclusion Routine formal depression and anxiety screening is feasible in a busy subspecialty clinic. Next steps include ongoing screening, and ensuring appropriate follow-up plan for positive screens.
Driver diagram - lists key drivers, change ideas and family of measures used
Likert Scale Responses of Patients and Parents from Satisfaction Survey at Baseline
– Run chart of percentage of cSLE patients who completed screening for Depression (PHQ- 9) and Anxiety (GAD-7). Pie charts display results of PHQ-9 and GAD-7 screens, along with percentage of suicidal ideation among total of 42 cSLE patients screened.
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