Establishing Mental Wellness Screening As Standard of Care in Pediatric Sickle Cell Patients

Sickle cell disease (SCD) is an inherited hemoglobinopathy characterized with multi-organ involvement and frequent pain crises. Somatic complaints can give rise to neuropsychiatric disorders, among which anxiety and depression are the most common. Although mental health plays an important role in health outcomes, there is not a standardized approach to screen sickle cell patients for depression at most sickle cell centers across the country and at Texas Children's Hospital (TCH). The long-term goal of this project is to screen sickle cell patients over the age of 12 for depression across TCH hospitals: TCH-West Campus (TCH-WC), TCH-Woodlands (TCH-WL) and TCH-Medical Center (TCH-MC). Over the past two years, we successfully implemented depression screening at TCH-WC as standard of care through a series of PDSA cycles. The focus of this quality improvement project is to implement depression screening at TCH-WL.

At TCH-WC, all sickle cell patients aged 12 years of greater are screened for depression using the Patient Health Questionnaire-9 modified for Adolescents (PHQ-A) . From October 2022 to July 2023, 71% of the patients that qualified for screening identified low risk, 16% identified mild risk and 12% identified moderate to severe risk of depression. Eleven percent endorsed suicidality. Psychology/Social Work (SW) saw 77.4% of patients with moderate to severe depression and 100% who screened positive for suicidality on the same day as screening.

Now that our depression screening protocol is standard of care at TCH-WC, we extended this screening to TCH-WL in February 2023. Our goal is to increase the annual depression screening rate from 0 to 50% in English/Spanish speaking patients aged 12 years and older with sickle cell disease who present for follow-up care to the TCH-WL. During our first PDSA cycle at TCH-WL, one hematologist administered the PHQ-A to sickle cell patients > 12 years. No intervention was needed if patient scored 0-6 on the PHQ-A. Psychological resources were provided via handout if patient scored 7-9. SW referral was placed and patient was preferably seen same day if patient scored > 10 on the PHQ-A. If unable to be seen same day, SW followed-up via phone call. If patient screened positive for suicidality, an urgent SW referral was made and patient was seen in clinic the same day. Three sickle cell patients >12 years presented for follow up with the assigned provider. Two-thirds (67%) of patients were given the PHQ-A; half (50%) screened positive.

During the second PDSA cycle at TCH-WL, all patients with SCD over the age of 12 who presented to TCH-WL Hematology Clinic were screened. The patients were given the PHQ-A by the Medical Assistant/nurse prior to the start of the appointment and then they followed the outlined and detailed algorithm listed above based on score.Forty-five patients were eligible for screening. Forty-two percent (19/45) were given the PHQ-A; 73% endorsed mild risk of depression; 26% endorsed moderate to severe risk; 22% endorsed suicidal ideation. 80% of patients with moderate to severe risk received same day SW assessment; 100% of patients with suicidal ideation received same day SW assessment.

Over the course of our project, we have been able to maintain our goals at TCH-WC and came close to achieving our goal of screening 50% of eligible patients for depression at TCH-WL. We are working with staff and providers at TCH-WL to determine barriers and optimize clinic flow in order to achieve >50% screening. In the future, we plan to expand our project to our largest sickle cell clinic, TCH-Medical Center, and for depression screening to become standard of care for all sickle cell patients at Texas Children's Hospital.