Influence of mental health and alcohol or other drug use risk on adolescent reported care received in primary care settings

Rates of alcohol and other drug use (AOD) continue to be high [1] and adolescent AOD use is associated with significant health and social consequences [2‐8]. AOD use also increases risk of having an AOD disorder as an adult [9], and is associated with high economic and societal costs [10, 11]. Because most adolescents seek care in a primary care (PC) setting at least once a year [12‐14], early identification or treatment by PC clinic staff is a promising way to prevent or ameliorate AOD among adolescents [15], and multiple guidelines recommend such screening [16‐18]. However, rates of screening and intervention for AOD in PC are low for adolescents [19‐22]. Some of the reasons for low AOD screening rates are that providers are unsure of the importance of prevention and approval of alcohol screening [23], limited organizational support, lack of training, discomfort [24], and limited opportunity [25]. Other obstacles include lower provider perceived alcohol-management skills, and lower provider self-efficacy [23, 25].

National surveys on adolescent AOD use and mental health problems consistently find overlap between these disorders [26‐28]. Adolescent reports of AOD use and mental health symptoms also co-occur [29]. To our knowledge, the potential additive or interactive effect of having poor mental health and risky AOD use on PC screening/intervention has not been examined. We address this gap in the literature, by examining the association between AOD use and adolescent-reported screening/intervention by medical providers in PC settings. Our research questions were: 1) Are adolescents with greater risk for AOD more likely to report being screened by a medical provider in PC for AOD use and followed up with intervention compared to adolescents with less risk for AOD use? 2) Does having poorer mental health in addition to higher AOD risk increase the odds that adolescents will report receiving an intervention in a PC setting to address AOD risk?

Adolescent AOD risk is a continuing concern. The PC setting provides an optimal opportunity for querying adolescents about risk behavior, including AOD use. This study contributes new information to the literature on adolescent AOD screening by examining both AOD use and mental health status together. Another contribution of this study is its examination of a large and diverse sample of underserved adolescents to understand the extent to which AOD risk and mental health influence the care that adolescents receive. Fully 85% of the sample is from diverse racial and ethnic backgrounds and unlike earlier studies includes adolescents from the full age range (12–18 year olds) incorporating those under age 16.

We found that consistent with previous research [19, 21, 22], overall rates of screening and intervention for adolescent AOD use were low. Specifically, less than two thirds reported being screened for use, and only a third of those at risk for AOD use (yellow or red flag on the PESQ) who were screened for AOD use reported receiving some type of intervention.

We also observed significant associations between demographic characteristics and reported care. Older adolescents were more likely to report being screened, but less likely to report being counseled which could be explained by the higher rates of use among older adolescents. Adolescents from racial/ethnic minority groups were less likely to report being screened. This suggests potential disparities in care across race/ethnicity.

This study has several strengths. It is the first to examine the likelihood of adolescents’ receipt of care from a medical provider for AOD risk for varying levels of risk with a large and diverse population, as well as examining the additive effect of having poor mental health on reported care. Nevertheless, findings must be interpreted with a few caveats. The outcome measures of AOD screening and intervention are based on adolescent self-reports, which could be biased [36]. Further, we relied on a one year retrospective reporting period, which, given its length, could limit accuracy. For example, cognitive factors such as poor recall or comprehension [37] could compromise accuracy of responses and situational factors including social desirability [38], and perceived lack of confidentiality could also lead to underreporting of risky behavior. However, we designed clinic recruitment procedures for maximum confidentiality by securing private space to conduct assessments for study eligibility. Further, surveys were web-based self-reports that could be completed in private areas. We also included a fictitious drug in the survey and very few respondents reported taking it (only 10 of 1573 adolescents), which suggests that reporting was not necessarily biased [39] and estimates of AOD use in our sample match national survey norms [40]. Finally, this U.S. based study may not generalize to other areas in the U.S. or to other countries with different healthcare systems.

We also cannot determine whether the large number of adolescents who did not report receiving any form of intervention was due to a positive screening but no care or because youth were screened and deemed not to be at risk. Despite this uncertainty, we know that adolescents in the red flag group, who were current AOD users, reported not being screened for use e.g., less than 100% of those in need were screened. This suggests that PC is missing opportunities to identify adolescents at risk and intervene with them early in their lifespan to prevent future consequences of prolonged AOD use. Finally, because of the way in which the screening and intervention question was worded, we cannot separate out counseling for AOD use from counseling for mental health problems. Future research is needed to disentangle counseling for AOD use and from mental health counseling.

With continuing high prevalence of AOD use among adolescents, strategies for facilitating the opportunity to intervene and educate adolescents in primary care about AOD use may be warranted. These strategies should address some of the barriers to screening and intervention by providing organizational support and training [24] so that PC can more easily integrate screening into the adolescent’s appointment and ultimately prevent or delay AOD use into adulthood when it is less risky. Such efforts, however, should acknowledge that there is inconclusive evidence for screening’s effectiveness in reducing substance use among adolescents [41], and also recognize that PC providers may screen; however, competing time demands [42, 43] and/or limited training [23] may prevent them from being able to deliver effective interventions.

Although less accurate than validated interviewer-administered diagnostic instruments, single item screening questions (SISQs) are a promising approach to screening for risky health behaviors in PC settings because they are both practical and feasible [44‐46]. SISQs are sufficiently brief for incorporation into busy practice settings, are less likely to be biased by social desirability, and also may facilitate conversations in a less stigmatized manner [47, 48]. Recently, a study validated the use of a self-administered SISQ for AOD use on a tablet for adult primary care patients [49]. Tablet administration decreases provider burden and may lessen stigma for patients compared with responding to provider questions directly. Such an approach could be broadly incorporated into primary care practice and may be adaptable for use with adolescents. Moreover, such a screening approach could decrease discomfort associated with discussing a sensitive topic and would also be time efficient.

However, screening alone is not enough. It must be paired with approaches for delivering brief interventions in the primary care setting. Consistent with Sterling et al. (2012) [24] implementing clinical practices and policies to address the barriers to intervention are needed. These include restructuring practice to allow for extra time needed for encounters with at-risk adolescents, such as flexible scheduling, reimbursement for longer visits with at-risk patients, or advance visit self-screening. Other facilitators to screening and intervention may include additional training for medical providers to increase comfort with addressing AOD use (e.g., de-stigmatize) [50, 51], as well as addressing concerns regarding patient confidentiality and adverse consequences of documenting AOD use in the medical record. Intervening in as little as 15 min can lead to positive behavior change [52]. Additionally, future research should examine the relative effectiveness of the screening, brief intervention, and referral to treatment model [53, 54] for risky AOD use to facilitate provider competency for delivering such care for adolescents in PC settings. Finally, given the high rates of comorbidity between AOD use and mental health issues, strategies are needed to facilitate medical providers’ understanding of the importance of potential identifying the need for counseling of both AOD and mental health care for at risk youth.

Risky AOD use by adolescents remains a concern, particularly among adolescents with poor mental health functioning. Although there are barriers to screening [23‐26], many providers are aware of the important role of screening for both of these problems so that adolescents may be referred to needed services. While screening rates were low in this large and diverse sample of adolescents, those at highest risk were significantly more likely to be screened and receive intervention. Findings highlight the continued need to decrease barriers in PC settings for screening and intervention with adolescents at risk for AOD use. Older adolescents were more likely to be screened but not to receive intervention, and were actually less likely to receive counseling. Adolescents from minority groups were significantly less likely to be screened than white adolescents but race/ethnicity was not associated with receipt of any type of intervention.

These findings underscore the importance of identifying practical, effective, and cost-effective strategies for addressing AOD risk among adolescents in PC settings. Further, to ensure that adolescents who screen positive for AOD use receive some sort of intervention and further assessment of mental health status, practice-based strategies that support the extra time needed for at-risk youth through flexible scheduling and reimbursement for expanded encounter durations are needed. Finally, strategies for facilitating PC provider competency including training about how to screen in a sensitive manner that feels comfortable and addresses issues of stigma, perceived confidentiality, and potential adverse consequences of patient disclosure are needed.