Implementing Routine Mental Health Screening and Structured Follow-up for Youth With Juvenile Idiopathic Arthritis: A Single-center Quality Improvement Project
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Published on: January 20, 2019
Emily Xiao1, Karen Beattie2, Tania Cellucci2,3
1From the Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
Introduction:
Youth with juvenile idiopathic arthritis (JIA) have higher rates of anxiety and depression, yet pediatric rheumatology clinics rarely embed systematic mental health care into routine care. Unrecognized symptoms can impair physical functioning and disease management. The objectives of this quality improvement initiative were to increase (1) anxiety/depression screening from 0% to ≥75% and (2) algorithm-concordant follow-up for youth screening positive from 0% to ≥75%.
Methods:
Our team implemented iterative plan-do-study-act cycles in a pediatric rheumatology clinic at McMaster Children's Hospital. A key driver diagram and fishbone analysis informed interventions, including workflow redesign, staff training, electronic medical record supports, and a standardized follow-up algorithm. We screened youth with JIA 12-18 years of age using the Patient Health Questionnaire-4 (PHQ-4), an ultra-brief self-report tool used to detect anxiety and depression. Process measures included the percentage of eligible visits with PHQ-4 screening completed and the percentage of screened visits with documented algorithm-concordant follow-up. Outcome measures captured screening results while balancing measures assessed patient and healthcare provider acceptability.
Results:
PHQ-4 screening increased from 0% to sustained percentages of ≥75% across 266 audited visits (May 2024-August 2025). Overall, 17% of youth screened positive (PHQ-4 ≥ 3). After implementing the follow-up algorithm, ≥75% of screened visits documented education, referral, and/or safety planning. Screening was acceptable to patients and health care providers, with no reported workflow disruption.
Conclusions:
Embedding PHQ-4 screening with a structured follow-up pathway is feasible and sustainable in a pediatric rheumatology clinic, supporting timely and equitable identification of mental health needs and advancing integrated biopsychosocial care for youth with JIA.
