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A model screening program for youth

Columbia University's TeenScreen program brings kids' mental health issues to light
BY SARAH SILBERT HINAWI, E D M surrounded what methods are most successful at preventing and abating these problems. Popular approaches include educational programs, hot lines, and most recently, screening. President Bush's New Freedom Commission on Mental Health recommended that early mentai health screening, assessment, and treatment be common practices. In fact, this report identified TeenScreen as a model program for early intervention,* Studies conducted on the TeenScreen Program have provided the following support:
Screening finds high-school students who are suffering silently from life-threatening mental health conditions. In a study of almost 2,000 high-school students who participated in a TeenScreen assessment, 74% of students who were contemplating suicide and 50% of students who had made a prior suicide attempt were not previously known to be having problems by school personnel. In addition, 69% of students found to be suffering from depression were also unknown.'

"/ think that the survey that I just took wasveryhelpfuL.anditgavemeachance to let someone know how I feel." "IthinkaboutHulestiifflikethatiustabout everyday, hut I have no one to tell." "This interview made me feel that someone cared about myfeelings, that someone might have felt the same way I did." "It helped me relieve some problems inside that I haven't told [anyone] else." "I think that everyone should take the TeenScreen.. .if they need to get sometliing off their chest and feel good...."

hese are some respotises from participants in the Columbia University TeenScreen Program, a vokincary mental health and suicide-risk screening program beingconductedat more than 450 site5 around the nation. Specifically, these students took the DISC Predictive Scales (DPS), a self-administered, computerized interview that screens for eight DSM-IV disorders and suicidality. The DPS is one of several screening instruments currentlyoffered hy TeenScreen, a program that provides screening instruments and a structured clinical and case management protocol to help identify youth who are struggling, notify thei r parents, and support families in connecting to local mental health services for further evaluation.

Screening is an accurate predictor of mental health problems that may develop into more serious conditions. In one sttJdy, screening identified 64% of those who went on to experience recurrent depression or become suicidal in young adulthood.^

The TeenScreen Program's basic structure includes five elements:

Parental consent. Parental consent is required for every screening program. Participant assent. Youth are presented with their confidentiality rights and are given the chance to sign on or opt out of the screening process. Continued on page 43 'To read what the President's New Freedom Commission on Mental Health said about [he TeenScreen Program in itsfinal report, visit www. mentaUjealthcommission. govlreportslFinalReportlFullReport-05.htm.

Although no debate occurs about the significance of youth suicide and mental illness as problems in todays society, dehate has
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with Furosemide in Elderly Patients wlHi Dementia-Related Psychosis in placebocontioiled trials m elflerty paiienis wiiti dementia-related psycriosis, a higher incidence ol moiaiity was oCsen/ed in patients ireated with (urosemide pins oral risperidone (/.a^: mean age 89 years, range 75-97} when compared lo patients treated wrttiorairisperidore alone (3 T i ; mean age 84 years, range 70-96) of turosemide alone (4.r=: mean age 80 years, range 67-90}, The irtcraase in mortaiity in paeenis treated ujith fiKosemide pius orai nsperidone was observed in two ol the tour citntcai trials. No paldopfiysiotogicai meclianism has teen idenliiied to expiain Ihis linding. and no consistent paltem br cause of death obsen/ed. Nevertheless, caution shojkJ te exercised and Ihe risks and benelits o( ihis combination should be ccnsidersd pnor lo the decision lo use There was nc increased incidence a! mcrtalny among patients laking other diuretics as conccmiiant medication with rispendone. Irrespective of treatment, dehydration was an overaii nsi< factor fcr mortality and should theretore be caretully avoided in elderly patients wrth dementia-related psychosis RISPERDAL*' CONSTA' is not approved lor the treatment of patients with dementia-related psychosis. iSee also Boxed WARNmC WARNINGS: Increased Mortality in Elderly Patients with Dementia-Helated Psychosis) ADVERSE REACTIONS Associated with Disconlinualion of Treatment in the t2-week, placebo-controlled trial, the incidence ol schizophrenic patients who discontinued treatment due to an adverse event was lower with RiSPERDAL' CONSTA'(t 1%; 221202 patients} than miih placebo (13i: 13/98 patients). Incidence in Controlled Trials Commonly Otiserved Adverse Events in Conlrolled Cllnicat Trials In the 12 week placebo-controUsd tnaL spontaneously reported, trealment-emergeni adverse evenls with an incidence ol 5% or greater in ai least ooe cf ifie RlSPERDAL' CONSTA" groups (25 mg or 50 mg| and at least twice that of p l a c ^ were: somnolence, akalhisia, partunsonism. dyspepsia, constipation, dry mouth, laligue, weight increase. Adverse Events Occurring at an Incidence ol 2% or More in Patients Trealed with niSPERDAL* CONSTA"" were at least as Irequent among patients treated wtlh 25 mg or 50 mg RiSPERDAL" CONSTA" as patients trealed wiUi piaceOo in the 12-week, piacebo-conlrolied trial Dose Dependency of Adverse Events Eilcapyamida; Symptoms The overall incidence of EPS-related adverse events (akathisia. dystonia, parkinsonism, and iremor} in patienis trealed with 25 mg filSPERDAL- CONSTA" was comparable to that of patients ireated wilh placetm: the incidence cf EPS-reiated adverse evenfs was higher in pafients treated with 50 mgRISPERDAL'CONSTA*^. Vital Sign Changes: RISPERDAL* is associafed with orthostatic hypotension and taotiycardia (see PRECAUTIONS}. In the placet)o-controlled trial, orthostatic hypotension was observed m 2% ol patients treated with 25 mg or 50 mg RISPERDAL- CONSTA^ (see PRECAUTIONS). WeigM Changes: In the 12-week, piacebc-conlrclled tnal, 9'o of patients Ireated wilh FUSPERDAL" CONSTA*, compared witri 5% of palienis Ireated with placebo, experienced a weighi gain ol i7% of body weight at endpoint Laboratory Changes: The percentage ot patients treated with RISPERDAL" CONSTA* who expenenced potentially mportanl changes in routine serum chemistry, hematology, or urinalysis parameters was similar to or less than that ol placebo patients Additionally, no patients discontinued treatment due to dianges in serum chemislry. hematotogy, or unnaiysis pafarreters, ECG Chanpes.-The electrocardiograms ol 202 schizophrenic palients treated with 25 mg or 50 mg RISPERDAL* COMSTA' and 98 stfiizophrenic patients treated with placebo in a 12-week, double-blind, placebo-cootrolled trial were evalualed. Compared with placebo, there were no statistically signrticani differences in OTc intervals (using Fridericia's and linear correction lactors} during trealment wiBi niSPERDAL" CONSTA". Pain assessment and local miection sile reactions: The mean intensity of iniection pain reported by palients jsing a visual analog scale decreased in all treatment groups Irom the first to the lasl inieclion Alter the sisth infection (Week 10}. invesligalor ratings indicaled Ihal 1% of patients treated wrlh 25 mg or 50 mg RISPERDAL* CONSTA" experienced redness, swelling, or indjralion at Ihe injection site Other Events Observed During the Premarkeling Evaluation of RISPERDAL* CONSTA* Djring its premartteling assessment. RISPERDAL' CONSTA'' was administered to 1499 patients in mulliple-dose sludies The conditions and duration of exposure lo RISPERDAL'"' CONSTA' vaned greatly, and included (in overlapping calegones) cpen-label and double-blind sludies, uncontrolled and controlled studies, inpatient and outpatient studies, lied-dose and ntration siudres. and short-term and long-ierm exposure studies. The lollowing reactions were reported: (Note frequent adverse events are ihose occurring in at leasl 1/100 patients Inlrequent adverse events are Ihose occumng in 1/100 to 1/1000 patients, rare evenls are those occurring in fewer Ihan 1/1000 patients. II is important to emphasize Ihal, although the events reported occurred during treatment with RISPERDAL' CONSTA', they were not necessarily caused by it.} Psychiatnc Disorders Frequent aniiety, psychosis, depression, agitation, naivouaiess, paranoid reaction, delusion. apalfiy. Inlrequent: anorexia, impaired conceniration, impolenre, eniotuxial lability, manic readion, decreased libido. increased appetite, amnesia, confusion, euphona, depersonalizalk)n, paronina, delinum, psyOiotic depression. Central and Periphery Nervous System Disorders Frequent- tiypertonia, dystonia. Infrequent- dyskinesia. vertigo, ieg cramps, lardive dyskinesia', involuntary muscle contractions, paraesthesia, abnormal gait, bradykinesia. convulsions, hypokinesia. alaxia, fecal incontinence, ocuk)gync cnsis, letany, apraxia. dementia, migraine. Ram. neuroleptic malignant syndrome. Body as a V^ole/General Disordws Frequent: back pain, chest pain, asthenia. Inlrequent. malaise, choking. Gasttoinlestinal Disorders Frequent: nausea, vomiting, abdominal pain Inlieqtient: gastntis, gastroesophageal reflux, flatulence, hemontioids, melena. dysphagia, recial hemcrtiage, stomatitis, colitis, gastnc ulcer, gingivitis, irritable bowel syndrome, ulcerative stomatilis mspiratory System Disorders FmQueni: dyspnea Inlrequent pneumonia, stridor, hemcjptysis Hare: pulmonary edema. Skin and /^ipendage Disorders Frequent rasti. Inlrequent eczema, pruritus, erythematous rash, denraiilis, alopecia, seborrbea, pholosensitivity reaction, increased sweating. Metabolic and Nutritional Disorders Intiequent- hyperuricemia. hyperglycemia, hyperlipemia, hypokalemia, glycosuria, hypercholesterolemia, obesity, dehydration, diabetes mellilus, hyponatremia. Museulo-Skeletal System Disorders Frequent arthralgia. skeletal pain inlrequeni- torticollis, arttirosis, muscle weakness, tendinitis, arthritis, arthropathy. Heart Rate and Rhythm Disorders Frequent: tachycardia Inlrequent: bradycardia, AV block, palpitation, bundle t)ranch block, flare. T-wave inversion Cardiovascular Disorders Frequent- hypotension Inlrequent: poslural hypolension. Urinary System Disorders Frequent unnary inconlinence tnlrequent hematuria. mictunticn frequency, renal pain, unnary retention Vision Disorders infrequent: coniunctivitis. eye pain, abnonnal accommodalion Reproductive Disorders, Female FKQuenl. amenorrtiea. Intrequent: nonpuerperal lactation, vaginilis, dysmenorrhea. breast pain, leukorrhea Resistance mechanism Disorders Infrequent: abscess. Liver and Biliary System Disorders Frequeni increased hepatic enzymes Intiequeni. hepatomegaly, increased SGPT. flare: bilirubinemia, increased GGT, fiepalitis, hepatocellular damage, laundice, fatty liver, increased SGOT. Reproductive Disorders, Male Infrequent ejaculation failure Application Site Disorders Frequent- infection sile pain. Inlrequent. miection site reaction Hesring and Vesfibo/arOisorderslnfrequenl: earache, dealness.heanng decreased Red Blood Cell Disorders Frequent, anemia White Celt and Resistance Disorders Inlrequent: lymphadencpalhy, leucopenia, cervical lymphadenopalhy Hare granulocytcpema, leukocytosis, lymphcpema. Endocrine Disorders Inlrequent: hyperprolactmemia, gynecomastia, hypothyroidism. Platelet, Bleeding and Clotting Disorders Inlrequent purpura. epistaxis. Rare, pulmonary embolism, hematoma thrombocylopenia. Myo-. Er\do-, and Pericsrdial and Velve Disorders Infrequent: myocardial ischemia, angina pectoris, myocardial inlarction Vascular iExtracardiac) Disorders Inltequent- phletiilis Rare: intermitleni claudicalion. flushing, thrombophlebitis, Postintroduction Reports Adverse events reported since market introductbn which were temporally (bul not necessarily causally) relaled to oral RISPERDAL' therapy include the following: anaphylaclic reaction, angioedema, apnea, airial fibnllation, cerebrovascular disorder, including cerebrovascular accident, hyperglycemia, diahetes melMus aggravated, including diabetic ketoacidosis, intestinal obstnjction, laundice, mania, pancreatitis, Parkinson's disease aggravated, pulmonary embolism. There have been rare reports of sudden dealh a/id/or cardiopulmonary arrest in patients receiving oral RISPERDAL" A causal relationship with oral RISPERDAL* has not been eslablished. It is importani to note lhat sudden and unexpected death may occur in psychotic patients vilieffier they remain untreated or wtielher they are trealed with oUier anbpsychotic dnjgs. DRUG ABUSE AND DEPENDENCE

ADOLESCENTS

Continued from page 38

Instrument administration. Once assent has been obtained, the participant completes a screening instrument. These instruments are not diagnostic but do identity which youths are at risk and need more screening. Clinical interview. Ttie ciinicai interview is an essential part ot the screening process. During this interview, a mentai health protessional assesses the screening instrument's results and based on this assessment, determines the need for further evaluation. Approximately one-third ot those who take the screening instrument go on for a clinical interview, Case management/parental notification. To make the link to further mental health services for identified teens (usually 17% of the original population screened will need this kind of referral), some case management is necessary. This inciudes contacting parents, providing information and resources, and helping families that accept the referral through at least the first appointment.

The ieenScreen Program's strength is in several keyand uniqueattributes: Screening instrument breadth and effectiveness. All ot the screening instruments used by tbeTeenScreeii Program have been developed and researched by the Division of Child and Adolescent Psychiatry at Columbia University. Most'leenSereen sites use one of two main screening instruments, the Columbia Health Screen (CHS) and the DPS. Both instruments are the subject of research published in tbe journal ofthe American Academy of Child and Adolescent Psychiatry^ which has shown them to be effective and valid screening tools.'"' The CHS is a paper-and-peneil screen looking for the risk factors for suicide, and it includes questions about depression, suicidal ideation and attempts, anxiety, alcohol and drug use, and general health problems. It usually takes about ten minutes to complete, and it can be used for youth ages 11 to 18. The CHS is available in English and Spanish. The DPS ts a computerized mental health screen that includes questions about depression, suicidal ideation and attempts, anxiety, alcohol and drug use, and general health problems. It is designed for youth ages 9 to 18, and it also takes about ten minutes to complete. Participants take tbe screen on a computer and hear the questions read aloud through headphones. The DPS is available in English and Spanish. Program flexibility and accommodation. No two TeenScreen sites run the same way. Because of screening programs' diverse
BEHAVIORAL HEALTH MANAGEMENT 4 3

Controlled Substance Class RISPERDAL' CONSTA* (nsperidone} is not a controlled substance. For more information on symptoms and trealment of overdosage, see full prescribing information, 7519504 - US Patent 4,804,663 Revised April 2005 Janssen 2003 0t-CS-352BS

JANSSEN
iluSviile.NJ 03560

PHARMACEUTICA PROOUCTS, L.P

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DOES MORE THAN ONE DIAGNOSIS MEAN MORE THAN ONE TREATMENT PROVIDER?
At Rogers Memorial Hospital, we specialize in dual and multiple diagnoses. Our continuum of residential mental health care is managed by full-time, on-staff medical experts. Eating Disordets Center Obsessive Compulsive Disorder Center Herrington Recovery Center Child & Adolescent Center JCAHO accredited Free phone assessments

naturescreenings have been conducted everywhere from foster care to clinics, to the most common setting, schoolsprotocols are developed to accommodate each screening environment. TeenScreen staff and materials provide guidance for developing sites on how screening might work in their community or organization, and they help design a screening strategy specific to their needs and goals. A selection of instruments is available (computerized or paper-and-pencil). Staff selection can vary significantly, according to individual stafFqualifications and availability, and screening can be conducted using a variety of methods and environments. Affordability. TeenScreen provides its servicesconsulting, training, aiid programmatic materialsand screening instruments yrfc of charge to qualifying communities (this qualification is based on commitment to screening, as well as screening plan and potential). This means that the program's only costs are running it on the site level, which includes staffing, administrative costs such as filing and mailing supplies, and other optional costs such as computers. Clinical and case management guidelines. The goal of screening young people for mental health disorders and suicidality is to ensure that identified youth get a complete mental health evaluation and any other help they need. TeenScreen is the only screening program for youth that offers a structure for clinical foUow-up and case management. These protocols were developed by clinical faculty in Columbias Division of Child and Adolescent Psychiatry, and they offer clinicians and case tnanagers tools and guidelines to conduct their work. These materials both facilitate and safeguard the clinical interview and case management process, making an accurate and effective referral more likely. TeenScreen has gone from its inception as a research project in the early 1990s to a national public-health initiative today. With statewide screening initiatives underway in Florida, Iowa, Nevada, New Mexico, and Ohio; new federal legislation supporting screening as a method of suicide prevention and providing funding for local screening efforts; and an ever-expanding number of sites throughout the country, the program has never been clo.ser to achieving its goal of offering a voluntary mental health screening to all American youth, BHM

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congratulates

Pikes Peak lVlental Health Center

Colorado Springs, Colorado Winner of the 2005 Ernest Amory Codman Award
The Codman Award recognizes excellence in the use of performance measures to achieve health care quality improvement.

Sarah Silbert Hinawi, EdM, was formerly the Special Projects Coordinator for the Columbia University TeenScreen Program. For mote information, please visit www.teenscreen.otg. To send comments to the atithot and editors, please e-mail teenscreen1105@ behaviotal.net. To otdet reprints in quantities of 100 or mote, call (866) 3776454.

www.jcaho.org/codman.htm

References
1. Shaffer D, Craft L. Methods ot adolescent suicide prevention. J Clin Psychiatry l999;60(suppl 2):70-4. 2. McCuireL, Flynn L. The Columbia TeenScreen Program: Providing mental health check-ups to youth. Emotional and Behavioral Disorders in Youth 2003;2:83-6. ^. Shaffer D, Scott M, Wilcox H. et al. The Columbia Suicide Screen: Validity and reliability ofa screen for youth suicide and depression. J Am Acad Child Adolcsc Psychiatry 2004;43:71-9. 4. Lucas CP, Zhang H, Fisher I'W, et al. The DISC Predictive Scales (DPS): Efficiently screenmg for diagnoses. | Am Acad Child Adolesc Psychiatry 2001; 40:443-9.

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