Adolescent Depression Curriculum Impact on Pediatric Residents' Knowledge and Confidence to Diagnose and Manage Depression

Adolescent Depression Curriculum Impact on Pediatric Residents' Knowledge and Confidence to Diagnose and Manage Depression

Journal of Adolescent Health xxx (2019) 1e7 www.jahonline.org Original article Adolescent Depression Curriculum Impact on Pediatric Residents’ Knowl...

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Journal of Adolescent Health xxx (2019) 1e7

www.jahonline.org Original article

Adolescent Depression Curriculum Impact on Pediatric Residents’ Knowledge and Confidence to Diagnose and Manage Depression Michael D. Colburn, M.D., M.Ed. a, b, *, Emily Harris, M.D., M.P.H. c, d, Corinne Lehmann, M.D., M.Ed. c, e, Lea E. Widdice, M.D. c, e, and Melissa D. Klein, M.D., M.Ed. c, f a

Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa Division of General Pediatric and Adolescent Medicine, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa c Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio d Division of Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio e Division of Adolescent and Transition Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio f Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio b

Article history: Received July 3, 2019; Accepted August 16, 2019 Keywords: Adolescent health; Depression; Primary care pediatrics; Resident; Adolescent medicine rotation; Medical education; Self-assessment

A B S T R A C T

Purpose: Despite the need for pediatricians to diagnose and manage adolescent depression, few pediatric residency curricula exist. This study evaluated the impact of an adolescent depression curriculum on pediatric residents’ knowledge and confidence to manage depression. Methods: A novel, case-based, adolescent depression curriculum simulating patient-provider continuity was developed and implemented within an adolescent medicine (AM) rotation. The curriculum addressed seven domains critical for diagnosis and management of adolescent depression. Participants were recruited from the pediatric residency at one institution. A survey assessed residents’ demographics, prior training, and self-assessed knowledge and confidence within each domain using a retrospective pre-post evaluation. Wilcoxon signed-rank test evaluated changes in knowledge and confidence. Results: Forty-two of a total 51 residents (82%) completed the curriculum and survey during their AM rotation. Residents reported that within their continuity clinic, 45% (n ¼ 19) had never initiated medication for depression, and 60% (n ¼ 25) did not manage their adolescent patients’ depression medications. Comparisons before and after participation in the curriculum, using the retrospective pre-post survey, demonstrated increased self-assessed knowledge (p < .001, for each domain) and confidence (p < .001, for each domain). Conclusions: In this study, few residents reported experience initiating medication or managing adolescent depression in the continuity clinic. Residents demonstrated increased self-assessed knowledge and confidence to diagnose and manage adolescent depression after participation in a case-based adolescent depression curriculum simulating patient-provider continuity. Incorporation of training on management of adolescent depression into AM rotation may be a feasible option to standardize training within pediatric residency. Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

IMPLICATIONS AND CONTRIBUTION

Training in adolescent depression management has several barriers leading to variable, and at times nonexistent, exposure during pediatric residency. This study demonstrates that using mandatory rotations, such as adolescent medicine, to provide residents with case-based learning, simulating patient-provider continuity, measurably improved residents’ self-assessed knowledge and confidence to manage adolescent depression.

Conflicts of interest: The authors have no conflicts of interest to disclose. Financial Disclosure: The authors have no financial disclosures. * Address correspondence to: Michael D. Colburn, M.D., M.Ed., Division of General Pediatric and Adolescent Medicine, University of Iowa Stead Family Children’s Hospital, 200 Hawkins Dr, Iowa City, IA 52242. E-mail address: [email protected] (M.D. Colburn). 1054-139X/Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. https://doi.org/10.1016/j.jadohealth.2019.08.022

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The prevalence of depression is increasing, with 13.3% of adolescents in the U.S., aged 12e17 years, having had at least one major depressive episode during the past year [1] with a higher prevalence (25%) reported in older adolescent females [2]. Among adolescents with depression, 70% report significant impairment in family, school, work, and interpersonal functioning [1]. Despite the high prevalence and functional impairment, 60% of these youths did not receive treatment [1]. Lack of identification and treatment of depression in adolescents can lead to devastating morbidity [3e5] and mortality [6]. Prompt diagnosis and management lead to improved outcomes [7]. There is a growing recognition that pediatricians must play a critical role in the diagnosis and management of adolescent depression [8,9]. Primary care providers in the U.S. treat approximately 70% of adolescents annually [10], the majority of those providers being pediatricians [11]. Although these encounters provide opportunities for depression screening and diagnosis, pediatricians need to be equipped to manage adolescent depression within the primary care setting, given the limited numbers of child and adolescent psychiatrists [12]. However, pediatric training in mental health is variable and sometimes nonexistent [13]. In 2013, approximately 66% of pediatricians reported that they were not adequately trained to treat adolescents with depression, a finding that had not improved over the past decade [14]. Both the American Academy of Pediatrics [9] and Society for Adolescent Health and Medicine [15] have recognized the importance of diagnosis and management of common mental health conditions. The American Board of Pediatrics has identified mental health education as a necessity in pediatric residency education [16] and established an Entrustable Professional Activity to assess the pediatric residents’ ability to “assess and manage patients with common behavioral/mental health problems” (Entrustable Professional Activity 9) with emphasis on depression identification, treatment initiation, and pharmacotherapy monitoring. Because of the high prevalence of adolescent depression with significant morbidity and mortality and current pediatric residents’ reported interest in adolescent depression training [17,18], it is imperative to answer the national call to action [19] through implementation of curricula on the diagnosis and management of adolescent depression. However, few curricula currently exist. Training pediatric residents to diagnose and manage adolescent depression is challenging for several reasons. First, faculty in continuity clinics may lack competence in this area because of their own lack of training [14,20]. Second, continuity clinics may not provide sufficient exposure to adolescent patients. In one third of nationally surveyed pediatric residencies, adolescents compromised <10% of continuity clinic patients [13]. Third, barriers to patient-provider continuity (i.e., provider accessibility and patient scheduling preference) within a continuity clinic can create difficulty with follow-up. Pediatric residents have reported limited opportunities to treat the same adolescent patient more than once within a given year [13]. Continuity of care provides residents with increased ability to form therapeutic alliances with their patients and observe the effects of their management decisions. When continuity becomes fractured, residents’ ability to learn from their management decisions is impaired [21]. Finally, medical management of depression occurs over months. Noncontinuity resident rotations occur in 2 to 4 weeks blocks, so residents rarely have the opportunity to observe the effects of their treatment plans. Therefore, ideal curricula should be planned to encompass the entire treatment course,

from diagnosis through treatment and recovery in a defined period of time consistent with resident schedules. Case-based learning, a previously proven learning strategy [22], may be a feasible option. A guided inquiry approach depicts real-world scenarios that learners are tasked to solve [23]. Learners are allowed to struggle, define, and resolve the problem alongside experienced facilitators who ensure completion of the learning objectives. Case-based learning provides residents with the opportunity to actively build on prior knowledge, pursue questions in an open dialog, and construct their own treatment plans, which is aligned with the constructivist theory of learning that suggests learners construct knowledge and meaning from their experiences [24]. Incorporating this learning format allows residents to use evolving cases to assess the impact of their interventions and carry out treatment plans. An adolescent medicine (AM) rotation is a logical rotation for an adolescent depression curriculum. As an Accreditation Council for Graduate Medical Education (ACGME) required core educational unit, all pediatric residents have an AM rotation [25]. Given the high prevalence of depression in adolescents, residents may also have more opportunities to apply this knowledge to immediate clinical practice in an AM rotation. Educational interventions have demonstrated improved knowledge and confidence with adolescent depression screening within primary care physicians [10], pediatric residents [26], and medical students [27]. Interventions have led to increased rates of adolescent depression screening within pediatric primary care settings [28]. However, the effect of case-based learning on pediatric residents’ knowledge about and confidence in managing adolescent depression has not been demonstrated. To address this gap, we created a case-based adolescent depression curriculum simulating patient-provider continuity and implemented it during an AM rotation. We evaluated the impact of this curriculum on pediatric residents’ knowledge and confidence in diagnosing and managing adolescent depression. Methods This was a prospective, pre-post educational study. This curriculum was implemented during the AM rotation at Cincinnati Children’s Hospital Medical Center and evaluated during a 1-year period from March 2017 to February 2018. This study received institutional review board approval. Study setting and participants Cincinnati Children’s Hospital Medical Center is a large academic medical center with approximately 185 categorical pediatric and combined residents (i.e., combined medicinepediatrics, triple board, pediatric genetics, pediatric neurology, and pediatric physical medicine and rehabilitation). Participants were postgraduate year 2 or 3 categorical pediatric and combined pediatric residents on their AM rotation. Residents on the AM rotation provide primary care to adolescents at the Teen Health Center, located within Cincinnati Children’s Hospital Medical Center. The Teen Health Center is staffed by 2.0 full-time equivalents of AM boarded attending physicians. It serves approximately 6,700 urban adolescents, with 68% of patients using public insurance. All residents were invited to participate in the curriculum during their AM rotation. Convenience sampling, based on completion of the AM rotation during the study period, was used.

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Before starting their AM rotation, residents received information about the study and consent information via email. Residents were ensured that the decision not to participate in the study would not impact their education or evaluation. Residents were informed that their performance during the curriculum would not be graded and that curriculum facilitators would not be involved in residents’ rotation evaluations. Residents who participated in 75% or more of the educational sessions and completed the voluntary assessment were eligible to be included in the analysis. Residents’ completion of educational sessions was logged using a unique, deidentified code. Curriculum development and implementation The curriculum was developed according to Kern’s six-step model [29]. A needs assessment was performed via interviews with key stakeholders (pediatric residency program director, continuity clinic preceptors, leaders in medical education, child and adolescent psychiatry, and AM providers) and surveys from residency graduates who identified increased need for mental health training. Learning objectives were drawn from the American Board of Pediatrics [16] and ACGME [25] medical knowledge objectives for depression, the American Academy of Pediatrics Mental Health Initiative resources [30], American Academy of Child and Adolescent Psychiatry Practice Parameters [31], and the Guidelines for Adolescent Depression in Primary Care [32]. Seven domains critical for clinicians to master to diagnose and manage adolescent depression within the primary

1. Identification & Risk Assessment

care setting were identified and prioritized. These included the following: (1) identification and risk assessment; (2) diagnostic criteria for depression; (3) safety assessment; (4) nonpharmacologic interventions; (5) medication initiation; (6) medication management; and (7) mental health service collaboration (Figure 1). Based on the learning objectives and principles of case-based learning [23], a case with several scenarios simulating patient-provider continuity was created de novo by members of the study team (M.C. and E.H.) and addressed the seven domains of adolescent depression management. Each month, up to five residents completing their AM rotation participated in four 25-minute facilitated small group teaching sessions that were conducted before clinic to avoid interference with patient care and bedside education. The curriculum was created to simulate an adolescent patient with depression over a year and allowed for variation, through branching content, depending on the interventions chosen by the resident. The case was illustrated through a fictitious adolescent initially presenting with a somatic concern. Residents followed the adolescent from screening through treatment and recovery. In facilitated small group sessions, residents worked together to interpret somatic symptoms and elicit psychosocial risk factors, screened for depression using validated screening tools (domain 1), and applied the DSM-5 diagnostic criteria to diagnose major depressive disorder (domain 2). Residents assessed the adolescent’s suicidal thoughts and carried out safety planning (domain 3). Treatment options were explored, and residents discussed nonpharmacologic interventions through role-play to

4. Nonpharmacologic Interventions

a) Awareness of validated screening tools for adolescent depression and when to implement b) Interpret screening tool results to aid in management decisions

a) Describe role of therapy in the management of depression to an adolescent b) Provide in office interventions to bridge gap in therapy referral

2. Diagnostic Criteria for Depression

5. Medication Initiation

a) Understand the differential diagnosis of depressed mood in adolescents b) Implement the diagnostic criteria for major depressive disorder in adolescents

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a) Determining appropriateness of initiating first-line medications and how to proceed b) Discussing side effects profiles with adolescents and their families (black box warning)

6. Medication Management

Simulated Patient-Provider Continuity 7. Mental Health Service Collaboration

a) Evaluate treatment plans for a) Determine effectiveness of inadequate response medication b) Demonstrate how to a) Understand the spectrum of b) Create treatment plans in collaborate with mental health suicidality response to continued symptoms specialist to improve patient b) Assess for safety in an adolescent (titrating/switching medications) care with depression c) Understand Identify appropriate referrals to Figure 1. The seven of of depression management. Notes: This figure shows how medication residents canduration navigate through the c) seven domains of depression management. c) domains Creation safety plans forbyfirst episode Domains were developed by our study team. Each domain is accompanied their principle objectives. psychiatry

3. Safety Assessment

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hesitant and resistant youth (domain 4) and provided counseling for and initiation of selective serotonin reuptake inhibitor (SSRI) medications (domain 5). During treatment monitoring (domain 6), residents explored dosing and titration of SSRI medications, monitored for and addressed side effects, determined SSRI medications’ success or failure, strategized how and when to switch SSRI medications, and assessed duration of treatment after symptom remission and indications for cessation of pharmacotherapy. Residents also discussed indications for referral to Child and Adolescent Psychiatry (domain 7). At the end of each session, teaching points were reviewed to help foster resident application to patients in subsequent clinics. The curriculum was pilot tested for 3 months with pediatric residents that were not part of the study to assess content, clarity, and feasibility. Curriculum evaluation The curriculum was evaluated following the final teaching session using a retrospective pre-post survey to detect changes in residents’ self-assessed knowledge and confidence within each of the seven domains of adolescent depression management addressed in the curriculum. Residents were asked to self-assess their current knowledge and confidence following the curriculum as well as reflect and retrospectively self-assess their knowledge and confidence before the curriculum. This design minimizes the impact of changes in learners’ self-assessment standards over time as they experience a shift in their frame of reference following an intervention [33,34]. The survey contained 28 questions for residents to self-assess their knowledge and confidence within each of the seven domains identified as critical to diagnose and manage adolescent depression. All response options used a 5-point anchored response scale, in accordance to a Dreyfus scale [35]. Questions related to knowledge ranged from no knowledge/experience (1) to consistent application of evidence-based care (5). Questions related to confidence ranged from no confidence (1) to full confidence (5) to perform the patient care tasks associated with the domain. Self-assessments of knowledge refer to the evaluations learners make about their current knowledge level in a particular domain. These types of evaluations have been used in many disciplines, including education, business, communication, psychology, and medical education [36]. The survey also included items to assess resident demographic information, including residency track, level of training, and prior completion of a Child and Adolescent Psychiatry residency elective. Residents were asked to quantify (from 0 to 10 patients) their exposure to initiating SSRI medications on pediatric patients and to quantify (from 0 to 10 patients) the number of pediatric patients they were actively managing their depression medications (i.e., titrating, switching, and monitoring mood response and side effects) within their pediatric continuity clinic. SSRI medications were singled out from other psychopharmacologic options for depression management because of the consensus that SSRI medications are the first-line medication category for adolescent depression treatment and appropriate for pediatric primary care initiation and management [31,32]. Survey questions and responses were reviewed for content validity and clarity by the study team of AM physicians, psychiatrists, continuity clinic preceptors, and medical educators. The survey was also reviewed for clarity by nonparticipating residents on their AM rotation before curriculum implementation.

Surveys were linked to participant attendance rates via a unique, deidentified code. Residents who completed the survey received a $5 gift card. All deidentified survey data were stored and managed within a password-protected database. Analyses Descriptive statistics were used to analyze residents’ characteristics. Median scores for each domain were calculated. Differences before and after participation in the curriculum in residents’ self-assessed knowledge and confidence within each of the seven domains of adolescent depression management were tested for significance using the Wilcoxon signed-rank test to account for the ordinal, nonparametric nature of the data from the same individuals before and after the curriculum [37]. Stratified analysis of prior SSRI medication exposure within their pediatric continuity clinic was conducted to assess for variation in differences that prior SSRI medication management may have on residents’ self-assessed knowledge and confidence to diagnose and manage adolescent depression. Correction for multiple comparisons of the entire population was via the Bonferroni Correction [37]. All analyses were performed by IBM SPSS Statistical for Windows (version 23.0, Armonk, NY, release 2015). Results Of the 51 residents who completed their AM rotation during the study period, 90% (n ¼ 46) completed 75% or more of the curriculum, and 82% (n ¼ 42) completed the survey. Of the five residents not included in these analyses, four residents missed two sessions, and one resident missed all four sessions because of competing clinical assignments. Residents’ characteristics Most participating residents were categorical pediatrics, postgraduate year 2, female, and had no prior exposure to Child and Adolescent Psychiatry residency elective (Table 1). Forty-five percent of residents (n ¼ 19) had never initiated an SSRI medication in their pediatric continuity clinic. Of those residents who had started medication (n ¼ 23), 74% (n ¼ 17) had initiated an SSRI medication in two or fewer patients. Sixty percent of residents (n ¼ 25) identified themselves as not being the managing physicians of their adolescent patients’ depression medications. Change in residents’ knowledge and confidence Residents’ self-assessed knowledge associated with each of the seven domains of adolescent depression management increased (p < .001, for each domain) following participation in the curriculum (Table 2). The greatest difference in median scores occurred in the domains of medication initiation (pre 2.0 to post 4.0), nonpharmacologic intervention (pre 2.5 to post 4.0), and medication management (pre 2.0 to post 3.5). Residents’ self-assessed confidence in their ability to provide care associated with each of the seven domains of adolescent depression management also increased (p < .001, for each domain) following participation in the curriculum (Table 2). The greatest difference in median scores occurred in the domains of medication initiation (pre 2.0 to post 4.0), mental health service collaboration (pre 2.0 to post 4.0), and medication management (pre 2.0 to post 3.5).

M.D. Colburn et al. / Journal of Adolescent Health xxx (2019) 1e7 Table 1 Demographics of resident participants (N ¼ 42) n (%) Residency track Categorical pediatrics Child neurology Triple board (pediatrics, general psychiatry, and child and adolescent psychiatry) Internal medicine and pediatrics Pediatric genetics Physical medicine and rehabilitation Year of training PGY 1 PGY 2 PGY 3 PGY 4 Gender Female Male Other Child and adolescent psychiatry exposure Prior residency exposure No prior resident exposure

30 (72) 4 (10) 3 (7) 3 (7) 1 (2) 1 (2) 2 25 14 1

(5) (60) (33) (2)

27 (64) 15 (36) 0 (0) 6 (14) 36 (86)

PGY ¼ postgraduate year.

Both residents with and without experience initiating and managing SSRI medications in their pediatric continuity clinics demonstrated perceived increased knowledge and confidence within each of the seven domains (p  .001, for each domain) following participation in the curriculum (Table 2). Discussion This study demonstrated that residents’ self-assessed knowledge and confidence to diagnose and manage adolescent depression from identification through treatment and recovery increased following a case-based, adolescent depression curriculum simulating patient-provider continuity. Our findings also support that within the continuity clinics, many residents have never initiated medications for an adolescent with depression, and the majority are not the physician responsible for managing adolescent patients’ depression. Furthermore, regardless of the residents’ prior experience prescribing SSRI medications, selfassessed knowledge and confidence managing adolescent depression increased after the curriculum. Early identification and treatment of adolescent depression are critical to improve outcomes [7]. Because of the limited number of child and adolescent psychiatrists and the access of pediatricians to adolescents, diagnosis and management of depression are becoming an expectation for pediatricians [12]. Residency training impacts physician practice for decades [38] and gaps remain in current training. Curriculum that increases residents’ knowledge and confidence to diagnose and treat adolescent depression, as demonstrated in this study, may lead to increased capacity to manage adolescent depression in primary care. This training may be important regardless of prior SSRI prescribing experience, as all residents, at least in this study, demonstrated increased knowledge and confidence in diagnosing and managing adolescent depression after the curriculum. Given the many topics pediatric residents must master [16,25], creative learning strategies need continued exploration. Case-based curriculum provided residents the ability to follow a 1-year patient’s course during their 1-month AM rotation. This simulated patient-provider continuity allowed residents to

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explore dosing and titration of SSRI medications, monitor for and address medication side effects, determine medication success and failure, and assess duration of treatment and indications for cessation of pharmacotherapy. Training pediatric residents regarding medication management of adolescent depression is a necessary step toward improving the care of these youths within the primary care setting [32]. Given the barriers to patientprovider continuity for adolescent depression care residents may experience [13,14,21], it is important to implement curricula that address the full scope of adolescent depression management but can be delivered during the limited time of one rotation. The AM rotation may serve as an appropriate rotation to incorporate a curriculum to train pediatric residents on the diagnosis and management of adolescent depression. It is an ACGME required core rotation [25], with previously demonstrated success in teaching adolescent health topics [34]. In addition, the increased exposure to adolescent patients, given their higher rates of depression, may make the content more readily applicable to patients seen during clinical encounters. Frequent, just-in-time training on screening tools, medication initiation, and management could provide a framework for learning and application. AM physicians also have increased expertise in adolescent depression management, obtained through fellowship training, equipping them with the knowledge and skills to teach the content and model application at the bedside. Because of the national shortage of child and adolescent psychiatrists [12] and lack of training among many general pediatricians [14], an AM-based curriculum may be able to fill this training gap. There were several limitations to our study. First, the study was conducted in a single academic center. However, residents from both categorical and combined pediatric training programs with continuity clinic at multiple sites were included. Second, the lack of a control group prevents direct comparison of the curriculum to changes that would occur solely from completion of the AM rotation. However, despite routine bedside training in the AM rotation, postgraduate surveys have consistently identified mental health as an area for improved training. A recent study [34] using a control group was unable to demonstrate differences after didactic education, but only assessed screening, diagnosis, and initial treatment of both anxiety and depression in addition to eight other AM skill domains that were not mental health associated. However, our curriculum focused on adolescent depression with the inclusion of patient-provider continuity and medication management through recovery providing broader content that would be difficult to experience during a 4-week rotation. Third, while controlling for response shift bias [33,34] by employing retrospective pre-post survey design, additional bias (recall bias, social desirability, acquiescence, and cognitive dissonance [34,39]) may still have a played a role. We did use strategies to minimize such biases including minimal interval for participant recall (i.e., 1 month or less) and deidentified survey tools to promote honest assessment without fear of retaliation (i.e., session facilitators refrained from contributing to residents’ evaluations during the time of the study). Fourth, provider practice changes (i.e., depression diagnoses and SSRI prescription patterns) and patient outcomes (i.e., depression symptom trends and rates of recovery), important, higher level outcome metrics [40], were not assessed. Our study did not measure objective knowledge change, but instead the change in residents’ perception of their knowledge. Our findings support the need for future studies to assess applied knowledge, evidenced by provider practice change and its impact on patient outcomes.

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Table 2 Difference in resident self-assessed knowledge and confidence at each domain of depression management Variables

n

Domains

Knowledge Median

b

Identification and risk assessment Diagnostic criteria for depression Safety assessment Nonpharmacologic interventions Medication initiation Medication management Mental Health Service Collaboration Subset analysis by SSRI exposure in pediatric continuity clinic c No SSRI exposure in pediatric continuity clinic 17 1. Identification and risk assessment 2. Diagnostic criteria for depression 3. Safety assessment 4. Nonpharmacologic interventions 5. Medication initiation 6. Medication management 7. Mental health service collaboration d SSRI exposure in pediatric continuity clinic 25 1. Identification and risk assessment 2. Diagnostic criteria for depression 3. Safety assessment 4. Nonpharmacologic interventions 5. Medication initiation 6. Medication management 7. Mental health service collaboration

All residents

42

1. 2. 3. 4. 5. 6. 7.

Confidence Z

Pre

Post

3.0 3.0 3.0 2.5 2.0 2.0 2.0

4.0 4.0 4.0 4.0 4.0 3.5 3.0

5.448 5.514 4.855 5.341 5.596 5.732 5.160

3.0 3.0 3.0 2.0 2.0 2.0 2.0

4.0 4.0 4.0 4.0 4.0 3.0 3.0

3.0 3.0 3.0 3.0 3.0 2.0 2.0

4.0 4.0 4.0 4.0 4.0 4.0 3.0

p valuea

Median

Z

p valuea

Pre

Post

<.001 <.001 <.001 <.001 <.001 <.001 <.001

3.0 3.0 3.0 3.0 2.0 2.0 2.0

4.0 4.0 4.0 4.0 4.0 3.5 4.0

5.303 5.276 5.113 4.920 5.701 5.767 5.365

<.001 <.001 <.001 <.001 <.001 <.001 <.001

3.755 3.626 3.176 3.535 3.601 3.727 3.448

<.001 <.001 .001 <.001 <.001 <.001 .001

3.0 3.0 3.0 3.0 2.0 2.0 2.0

4.0 4.0 4.0 4.0 4.0 3.0 4.0

3.508 3.448 3.176 3.272 3.685 3.729 3.626

<.001 .001 .001 .001 <.001 <.001 <.001

4.028 4.179 3.716 4.042 4.350 4.434 3.874

<.001 <.001 <.001 <.001 <.001 <.001 <.001

3.0 3.0 3.0 3.0 2.0 2.0 2.0

4.0 4.0 4.0 4.0 4.0 4.0 4.0

4.035 4.035 4.042 3.727 4.388 4.481 4.028

<.001 <.001 <.001 <.001 <.001 <.001 <.001

SSRI ¼ selective serotonin reuptake inhibitor. a Bold values represent significant differences as tested by the Wilcoxon signed-rank test. b Analysis includes all participants' data. c Analysis excludes residents who have initiated and/or managed one or more patient's SSRI. d Analysis excludes residents who have not initiated or managed one or more patient's SSRI.

Despite the study limitations, there are several potential next steps in adolescent depression training including multisite implementation with outcomes including pre and post objective knowledge test coupled with impact on physician practice (i.e., screening tools used, prescriptions given, and mental health referrals), patient outcomes (i.e., emergency department utilization), and long-term follow-up to assess for sustained behaviors. Although our curriculum was created for residents, there is potential to create modified versions for nurse practitioner and physician assistant trainees pursuing primary care careers. Practicing pediatricians may also benefit from training based on data that reflects that many lack mental health training, resulting in knowledge and skill deficits [14]. Conclusion A case-based adolescent depression curriculum simulating patient-provider continuity implemented during an AM rotation improved pediatric residents’ self-assessed knowledge and confidence to diagnose and manage adolescent depression. Utilization of ACGME-required rotations may be a feasible option to expand mental health training. Although the scope of this project was adolescent depression, the concept could be expanded to additional mental health diagnoses. Acknowledgments The authors would like to thank Courtney Covert for her assistance with database development and management.

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