Into the Blue

By Laura Pratt

The unfortunate reality is that too many teenagers, coming into their doctors’ offices to seek treatment for one ailment or another, are suffering from the most devastating kind of mental illness—and the subject will never even come up.

Dr. Amy Cheung, an associate scientist at SRI, an assistant professor at the University of Toronto and a youth psychiatrist at Sunnybrook Health Sciences Centre, wants it hauled front and centre. What’s more, she wants to help educate physicians on how to respond when they’re confronted with it.

Results from her new study, published in Healthcare Policy in December 2006, show the lifetime prevalence rate for major depressive disorder among 15-to-18-year-old Canadians is 7.6% (and for suicidality—suicidal or self-harm thinking or behaviour, it’s 13.5%). Just the same, says Cheung, pediatricians and family doctors are ill prepared to face the onslaught. Primary care providers, she laments, spend just four or five weeks on psychiatry as a whole in their medical training. “Here, we’re giving them a primer on depression for teenagers.”

They’re doing so in the form of Guidelines for Adolescent Depression and Primary Care (GLAD-PC), a project started by Dr. Anthony Levitt, an SRI scientist and U of T professor who now serves as a mentor to Cheung. Together, the pair devised strategies for physicians to identify and treat depression in this population, and advised them on how to change their practices such that they can accommodate this new focus.

With the guidelines in hand, Cheung developed a toolkit around them that effects transfer of knowledge. She did so in conjunction with researchers from Columbia University, and thanks to liaisons with a collection of associations (including the Canadian Paediatric Society, the College of Family Physicians of Canada and the American Academy of Pediatrics). Cheung was also endorsed by advocacy groups like the National Alliance on Mental Illness and 23 experts from such areas as health economics, mental health, pediatrics and health policy.

The GLAD-PC initiative, which started in 2003, is currently in the piloting stage—first in Massachussetts, soon in Canada. This aspect of the project, says Cheung, is aimed at understanding “which parts of the toolkit are helpful and what strategies need to be adopted so that doctors will actually use the guidelines to change their practice.” Sometimes, says Cheung, stumbling blocks seem surprisingly insignificant.

“You can say to a pediatrician, ‘You should be giving this test to a teenager when he comes in, in your waiting room, because it will give you information about whether he has depressive symptoms.’ But the questions come up: Who distributes the screen? Where does the teenager sit when he’s filling it out? Who does he return it to? What if the parents want to see it? It sounds trivial, but it’s very important in a busy pediatric practice. One of the doctors said to me, ‘We only have one pen.’”

Monitoring the results of a pilot, say the researchers, is critical. Otherwise, says Cheung, how to make sure the knowledge is being adopted? “Guidelines themselves are almost useless, unless you have a way of making sure that they’re incorporated into practice,” says Levitt.

Cheung’s toolkit is “user friendly,” she notes, pointing to its availability for download from the Web, and the fact that it’s contained in a binder, so pages can be removed for photocopying.

Up next are pilot projects with family doctors and pediatricians in Ontario and Nova Scotia, scheduled for July 2007.

Funding for GLAD-PC came from Sunnybrook Health Sciences Centre and Columbia University, along with a number of foundations and public agencies in Canada and the United States. Cheung’s salary training grant is from the Canadian Institutes of Health Research. The Massachusetts study is funded by the American Academy of Child and Adolescent Psychiatry.