General Practitioners (GPs) are a key point of contact with the healthcare system for young people. Given the bi-directional association between mental and physical health (2-6), GPs are well placed to identify emerging mental health problems among youth and intervene early to provide necessary and timely care (1, 7, 8). This is particularly important for adolescents as their lower mental health literacy and self-awareness means they often rely on others to recognise mental health problems and initiate help-seeking (7-10). However, GPs face several challenges when treating mental health problems among youth. Many GPs report low confidence in identifying, diagnosing, and appropriately managing young peoples’ mental ill-health due to an absence of specialty training and inadequate time within appointments (11-17). When combined with the low rates of proactive help-seeking (18-20), these factors can reduce GPs capacity to engage with and prioritise mental health among their youth patients (11, 16, 18, 19).
A range of clinical treatment guidelines recommend GPs conduct regular screening and monitoring of young peoples’ mental health to reduce illness onset and deterioration, and to ensure appropriate and timely treatment is provided (1, 20, 21). Screening can equip GPs with an effective method to identify symptoms and initiate conversations about mental health, which is particularly important for the detection of suicidal ideation as relying on spontaneous disclosure may lead to underestimations of prevalence and untimely or non-responsive care (22). Technology offers a useful way to enable screening in primary care as results can be generated automatically and made available electronically for GP review. Decision-making support, such as referral options and psychoeducation, can also be easily integrated into these tools to guide GPs’ consultations and treatment decisions. Technology easily allows for repeated screening which improves GPs’ ability to monitor patients’ symptoms over time.
Technology-based screening services have now been implemented in various healthcare settings. Integrating Mental and Physical healthcare: Research Training and Services (IMPARTS) (23) and StepCare (24) are web-based screening services delivered via a mobile tablet in the waiting room prior to patients’ healthcare appointments. IMPARTS is offered in specialist departments within UK hospitals and aims to identify patients experiencing co-morbid physical and mental illnesses (23, 25), while StepCare was developed to assist Australian GPs to identify and manage symptoms of depression, anxiety, and alcohol misuse in adults. These services are integrated into existing medical software with the screening sent to the consulting practitioner for immediate review. Patient symptoms are also monitored over time. The IMPARTS screener is offered at each specialist visit, albeit infrequent and conditional on the patient’s appointment schedule, and StepCare sends symptomatic patients a fortnightly questionnaire with GPs notified of deterioration or no change. These adult services highlight the potential for delivering acceptable screening solutions.
Australian researchers have also trialled screening programs for youth in primary care with promising results. Webb et al (26) examined the acceptability and effectiveness of a screening tool Check Up GP on self-disclosures. The service screened the mental and physical health of young people (14 to 25 years) using a mobile phone application prior to their GP appointment. Initial uptake of the service was low (41%) although users of the service reported higher rates of self-disclosure on nearly all health and lifestyle issues when compared to youth receiving treatment-as-usual. This supports the benefit of technology-based screening tools for increasing the disclosure of sensitive issues. In another Australian randomised controlled trial (N = 114), Reid et al (27) examined the effectiveness of mobiletype - a mobile phone application designed to monitor a range of mental health and wellbeing outcomes – on mental health outcomes when compared to a group who had only their daily activities mentored. Youth patients were prompted to complete four mental health screens each day for a period of four weeks. Mobiletype was found to increase emotional self-awareness and the trial demonstrated that by providing GPs with support and clinical resources, and users with frequent reminders, the sample, as a whole experienced substantially improved mental health outcomes. The findings suggested the positive effects were moderated by increased emotional self-awareness developed by the self-monitoring component of the service. Taken together, these studies have demonstrated the feasibility and acceptability of technology delivered screening services among healthcare practitioners and patients (23, 24, 26, 27).
However, major challenges in the implementation of these services exist. Because GPs face significant time restraints, technology delivered screeners should be easily embedded into existing medical software to counter the barriers that disrupt usual ways-of-working. Both screening services currently available for youth, Check Up GP and mobiletype, use an external website which require GPs to access and then review. This disruption to usual workflow can create barriers to the uptake and use (27-31). In addition, because GPs report lower levels of confidence treating youth patients and their complex presentations, the usefulness of screening services is likely to be enhanced when decision-making support is provided, as demonstrated in the mobiletype trial. Finally, given that young people do not visit their GP as frequently as other age groups, screening services should offer easily accessible, low intensity, and non-intrusive monitoring capabilities that do not rely on young people returning to the practice to continually re-screen.
The Youth StepCare Service
To overcome the limitations of current youth screening tools for primary care, The Black Dog Institute has developed Youth StepCare - a web-based mental health screening service that aims to assist GPs in identifying and managing depression and anxiety among youth patients. The service consists of three components i) screening, ii) treatment recommendations, and iii) patient monitoring (Figure 1). Youth StepCare is delivered to a young person on a mobile tablet while they are awaiting their appointment. Practice staff are instructed to invite all youth patients to use the service regardless of their appointment reason.
After providing consent, the young person registers by providing their mobile number or email, date of birth, and gender. They are then asked to report whether their current or previous appointments were for mental health reasons. The service then delivers two self-report measures including the Patient Health Questionnaire-9 (PHQ-9; 32) for depressive symptoms and the two-item Generalized Anxiety Scale (GAD-7; (33) for anxiety symptoms. Suicidal ideation is assessed during the initial screener only using participants’ responses to item nine on the PHQ-9. Using their highest total score from either scale, the service automatically assigns each patient to one of four treatment steps with treatment recommendations matched to symptom severity (see Table 1). A report with this information is sent to the GP’s medical software within three minutes via a secure health messaging service. Patients receive brief feedback on the mobile tablet and are then instructed to return it to the practice staff. Monitoring surveys are delivered via SMS or email. Patients who report worsening symptoms are advised to schedule an appointment with their GP. GPs also receive notifications for any patient who fails to complete the monitoring or report that their symptoms have deteriorated, improved, or remained unchanged for four consecutive weeks.
Table 1. Youth StepCare Treatment Model
Step
|
Symptom Severity
|
PHQ-9
(GAD-7) score range
|
Suicidal
Ideation
|
Treatment Recommendation
|
Monitoring
|
0
|
Nil-Minimal
|
0 – 4
(0 – 4)
|
0
|
No action required
|
Not required
|
1
|
Mild
|
5 – 9
(5 – 9)
|
1
|
Referral to a Web-based psychoeducation program
|
Fortnightly for 12 weeks
|
2
|
Moderate
|
10 – 19
(10 – 14)
|
2
|
Referral to a psychologist;
Consider referral to Child and Adolescent psychiatrist;
Referral to web-based psychoeducation program and online cognitive-behaviour therapy (CBT).
|
Fortnightly for 12 weeks
|
3
|
Severe
|
20+
(15+)
|
3
|
Referral to a psychologist or Child and Adolescent psychiatrist;
Referral to Web-based psychoeducation program and online CBT.
|
Fortnightly for 12 weeks
|
Aims
The current study aimed to assess the feasibility and acceptability of delivering the Youth StepCare service in general practices for youth patients aged 14 to 17 years. Specifically, this study assessed the uptake, need, and operational feasibility of delivering the service, the acceptability and perceived effectiveness among GPs and practice staff, and the barriers and facilitators to its implementation in general practice (34-36). These outcomes will guide service modifications and improvements to inform future trials of stepped-care services that integrate digital technology and e-health.