Integrating Routine Mental Health Screening and Follow-Up in Pediatric Rheumatology Clinic: A Quality Improvement Initiative

Objectives Youth with Juvenile Idiopathic Arthritis (JIA) experience higher rates of anxiety and depression compared to the general population, which can worsen physical symptoms and reduce treatment adherence. [1] Despite this, there is a lack of primary prevention in pediatric subspecialty clinics, leaving many youth undiagnosed and untreated. This quality improvement initiative sought to increase (i) mental health screening rates from 0% to at least 75% and (ii) structured follow-up of screenings from 0% to at least 75%.

Methods This 2-phase initiative was conducted at McMaster Children’s Hospital Rheumatology clinic, serving >800 youth with JIA annually. Eligible patients were 12-18 years old attending in-person clinics. We employed driver diagrams, fishbone analysis, and workflow mapping to identify barriers and refine processes. In Phase 1, clinicians administered the Patient Health Questionnaire (PHQ-4) verbally upon arrival, and documented results in the electronic health record (EHR) using standardized templates.[2] During Phase 2, a structured algorithm, co-created by a multidisciplinary team, was implemented to ensure follow-up was tailored to the patient’s score, with options including education and resource provision, referral to allied health professionals, connection to community support, or urgent safety assessment. Follow-up action was recorded in the EHR. Process, outcome, and balancing measures were tracked.

Results Between May 2024 and February 2025, screening rates increased from 0% to >75% and were sustained (Figure 1). Phase 2, implemented May to August 2025, saw >75% of positive screens have documented follow-up actions in the EHR, consistent with the care algorithm. Of 266 patients screened, 221 (83%) scored in the normal range (0-2), 33 (12%) mild (3-5), 7 (3%) moderate (6-8), and 5 (2%) severe (9-12) on the PHQ-4. Balancing measures indicated that screening was acceptable to both patients and clinicians, as assessed through in-house questionnaires. Across both phases, key enablers included iterative education and reminders to sustain engagement, workflow modifications to address time constraints, and integration of EHR tools and feedback charts to support adherence and provider buy-in. Weekly performance feedback, statistical process control charts, and targeted staff training further facilitated implementation and sustainment.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1.

Control chart of proportion of eligible patients screened using PHQ-4

Conclusion This QI initiative demonstrates that integrating routine PHQ-4 screening into pediatric rheumatology care is both feasible and sustainable, improving identification of at-risk youth and standardizing follow-up. Lessons learned provide a scalable model for other pediatric subspecialty clinics.

References [1.] Fair DC. Open Access Rheumatol 2019;11:237-52. [2.] Kroenke K. Psychosomatics 2009;50:613-21.