Improving routine mental health screening for depression and anxiety in a paediatric lupus clinic: a quality improvement initiative for enhanced mental healthcare

Abstract

Background: Mental health (MH) conditions are prevalent in adolescents with childhood-onset SLE (cSLE). Early identification is crucial in preventing poor patient outcomes; however, MH screening rates remain low.

Local problem: From July 2021-January 2022, only 15% of adolescents in a paediatric tertiary care cSLE clinic were being screened for depression and anxiety. By November 2023, we aimed to increase the percentage of patients with cSLE (≥12-18 years) screened for depression (Patient Health Questionnaire: PHQ-9) and anxiety (Generalised Anxiety Disorder-7: GAD-7) from 15% to 80%.

Methods: This quality improvement project employed the Model for Improvement framework. Stakeholders included the clinic team, patients and families, and MH providers. Statistical process control charts were used to analyse the outcome measure for percentage of screened patients with cSLE. Patient and caregiver satisfaction surveys were conducted at baseline and after screening as a balancing measure.

Interventions: MH screening workflow with a referral algorithm was developed with stakeholders. Additional interventions included two MH training workshops for healthcare providers and a preclinic reminder of eligible patients for screening.

Results: Over 21 months, 146 patients with cSLE completed 270 MH screens, increasing the screening rate from 15%, peaking at 100%, to a median of 56%. Sixty-six individuals (45%) reported symptoms of depression and/or anxiety on their initial screen. Of 270 screens, 44 individuals (17%) reported moderate to severe symptoms meeting the screening workflow criteria for referral to a MH service; 10% of patients screened were referred and seen by the MH service within 2-12 weeks. Patients and caregivers reported satisfaction with the MH screening process and quality of MH follow-up.

Conclusion: Despite not sustainably meeting the target, MH screening rates increased in the cSLE clinic by nearly fourfold, demonstrating feasibility and acceptability. Patients expressed satisfaction with their mental health follow-up, emphasising its importance in their care.

Keywords: Health services research; Lupus Erythematosus, Systemic; Social work.

Figure 1. Driver diagram illustrating the drivers and change ideas contributing to the aim of increasing the percentage of patients with childhood-onset SLE with routine MH screening for depression and anxiety. GAD-7, 7-item Generalised Anxiety Disorder-7; MH, mental health; PHQ-9, 9-item Patient Health Questionnaire.

Figure 2. Swimlane clinic workflow illustrating the movement of a patient with childhood-onset SLE through the clinic and how the mental health (MH) screen is administered. GAD-7, 7-item Generalised Anxiety Disorder; PHQ-9, 9-item Patient Health Questionnaire.

Figure 3. Clinic algorithm for mental health (MH) management based on MH screening results. ED, emergency department; GAD-7, 7-item Generalised Anxiety Disorder-7; PHQ-9, 9-item Patient Health Questionnaire.

Figure 4. SPC chart of percentage of patients with childhood-onset SLE (cSLE) who completed screening for depression (PHQ-9) and anxiety (GAD-7). Annotations denote changes to the process: (A) Clinic algorithm and standardised workflow developed for MH screening scores. (B) First MH educational workshop held for HCPs. (C) Second MH workshop held and preclinic screening email reminders initiated. (D) Lupus MH champion left the institution. (E) Screening frequency changed from annual to every 3 months, and patients with previous psychiatric diagnoses were included in MH screening. (F) MH champion change. New mean of 56% after change ideas were implemented. Target line set at 80%. GAD-7, 7-item Generalised Anxiety Disorder-7; MH, mental health; PHQ-9, 9-item Patient Health Questionnaire; SPC, statistical process control.

Figure 5. Results of the first PHQ-9 and GAD-7 screens for 146 individuals in childhood-onset SLE clinic from January 2022 to November 2023. None–minimal=score less than 5, mild=5–9, moderate=10–14, severe=>15. GAD-7, 7-item Generalised Anxiety Disorder-7; PHQ-9, 9-item Patient Health Questionnaire.