2012. Vol.3, No.10, 870-877
Published Online October 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.310131
Copyright © 2012 SciRes.
Depression Screenings during Routine Visits in a
Reproductive Healthcare Setting: Identifying
Depressive Symptoms in African
American Adolescent Males
Kenia Johnson1*, Karia Kelch-Oliver2, Chaundrissa Oyeshiku Smith3,
Sophia Edukere Green3, Triphinia M. Wallace4, Melissa Kottke3, Marietta H. Collins3
1Department of Social Scien c es, Chattahoochee Technical College, Marietta, GA, USA
2Morehouse School of Medicine, Atlanta, GA , U SA
3Emory University Scho ol o f Medicine, Atlanta, GA, USA
4Community Counseling Solu tions , East Point, GA, USA
Received July 11th, 2012; revised August 13th, 2012; a ccepted September 15th, 2012
Depression is a disorder which affects many youth, and only one third of adolescents receive mental
health treatment for their depression. Yet, approximately 90% of adolescents visit their primary care pro-
viders on average 2 - 3 times per year. This number suggests the important role that primary care settings
can play regarding the early diagnosis and treatment of depression during adolescence. This paper pre-
sents findings of clinically significant depressive symptoms in African American male adolescents re-
ceiving routine health care services within an adolescent reproductive health clinic. The adolescent re-
productive health clinic is housed within a large urban, university-affiliated teaching hospital. 49 African
American male adolescents (ages 13 to 19) completed the Center for Epidemiologic Studies Depression
Scale (CES-D) (Radloff, 1977), a brief depression screening questionnaire, as a part of their clinic visit.
Results revealed higher rates of depressive symptoms in this subsample of African American male ado-
lescents when compared to estimated prevalence rates of depression for adolescents as reported by
large-scale studies and meta-analysis data. This supports the notion that primary and reproductive health-
care settings are viable settings for the identification of depressive symptoms, particularly among
low-income, African American male adolescents. Risk factors, symptom presentation, and mental health
stigma associated with this population are discussed. Psychosocial interventions and recommendations for
the integration of primary healthcare and behavioral health consultation services are presented.
Keywords: Adolescents; Depressive Symptoms; African American Males; Reproductive Health Clinics;
Depression in children and adolescents was scarcely recog-
nized in the empirical literature until the 1970s (Angold,
Worthmon, & Costello, 2003), but has now become a major
public health concern (Cote et al., 2003) due in part to
large-scale studies reporting that up to 3% of children and 8%
of adolescents suffer from depression (US Department of
Health and Human Services, 2001). The prevalence rates of
depression are similar for males and females before puberty,
but after puberty depression rates increase, especially in fe-
males (Angold et al., 2003). Comparatively, female adolescents
have a 2 to 3 times higher prevalence rate of major depressive
episode (12% - 13%), whereas the prevalence rate of major
depressive episode for male adolescents is approximately 4% to
6% (Substance Abuse and Mental Health Services Administra-
tion Office of Applied Studies, 2008). Overall, based on meta-
analytic data, the prevalence of depression estimates for ado-
lescents ages 13 to 18 is approximately 5% to 15% (Costello,
Erkanli, & Angold, 2006). Adolescents who are depressed are
at least three times more likely than non-depressed adolescents
to remain depressed during young adulthood (Cardemil, Rei-
vich, & Seligman, 2002; Cote et al., 2003; Kessler et al., 2001).
Moreover, depressed teens are more likely to drop out of school,
engage in substance abuse, and become teen parents compared
to non-depressed teens (Horowitz & Garber, 2006; US Depart-
ment of Health and Human Services, 2008). Unfortunately,
only about one third of adolescents receive professional help
for their depression, despite such high prevalence rates of ado-
lescent depression (Kessler et al., 2001; Stein, Zitner, & Jensen,
2006; Wu et al., 2001). Therefore, early identification and
treatment of adolescent depression is crucial in order to prevent
more detrimental psychosocial outcomes later in life.
Racial/Ethnic and Socioeconomic Differences in
Generally, depressive symptoms in low-income, urban Afri-
can American adolescents are largely understudied (Shaffer,
Forehand, & Kotchick, 2002). Although research remains lim-
ited, it has been suggested that racial/ethnic minority adoles-
K. JOHNSON ET AL.
cents may be at an elevated risk for depression (Cardemil et al.,
2002; Rushton, Forcier, & Schectman, 2002; Shaffer et al.,
2002). Reviewing the adult literature, some research suggests
higher rates of depression in African Americans compared to
Caucasians (Wight, Aneshensel, Botticello, & Sepúlveda, 2005).
However, overall results appear inconsistent within the adult
literature, with other studies reporting lower (Angold et al.,
2002; Riolo, Nguyen, Greden, & King, 2005) or equivalent
rates of depression between African American and Caucasian
individuals (Kessler et al., 2003; Shaffer et al., 2002). In a study
among a sample of African American adolescent females,
Collins et al. (2010) found that clinically significant depressive
symptoms were endorsed at rates higher than the general popu-
lation. Research has also indicated that depressive symptom
presentation may manifest differently across racial and ethnic
groups (Cardemil et al., 2002; Shaffer et al., 2002). African
American adolescents have reported more symptoms of dimin-
ished pleasure, increased anger, aggression, and irritability than
Caucasian, Hispanic, and Asian American adolescents (Choi &
Gi Park, 2006). Varied depressive symptom presentation in
African American youth may mask the symptoms, making it
less recognizable to health care professionals, further compli-
cating accurate assessment and diagnosis.
Additional studies of adolescent depression which include
racial and ethnic minorities indicate that poverty, low socio-
economic status, and lack of academic and educational attain-
ment are significant risk factors for depression (Anderson &
Mayes, 2010; Cardemil et al., 2002; Riolo et al., 2005). A sub-
stantially higher proportion of racial and ethnic minority youth
are among the economically disadvantaged, which creates more
stressful environmental risk factors (Anderson & Mayes, 2010).
Thus, urban, low-income African American adolescents living
in high-risk environments (i.e., characterized by crime and
violence, poverty, substance abuse) may experience depression
at higher levels than adolescents from other racial/ethnic groups
in the US (Cardemil et al., 2002; Lindsey, Joe, & Nebbitt, 2010;
US Department of Health and Human Services, 2001). African
American adolescents, especially males, may be more suscepti-
ble due to low social support networks, greater exposure to
delinquent peers and violence, the perception of fewer future
opportunities, and other risks associated with living in high-risk
environments (Hammack, Richards, Luo, Edlynn, & Roy, 2004;
Lindsey et al., 2010; Nebbitt & Lombe, 2008). Therefore, iden-
tification of mechanisms to improve early detection of depres-
sive symptoms among African American male adolescents
warrants further attention.
Perceived Stigma and Outcomes of Untreated
Differences by race/ethnicity in help-seeking, accessing
mental health and using psychotropic medications may also
account for differences in prevalence rates among African
American adolescents, particularly African American adoles-
cent males (Riolo et al., 2005). African American adolescents
are reported to be less likely to seek and receive treatment for
depression compared to their Caucasian counterparts (Riolo et
al., 2005; US Department of Health and Human Services, 2001).
The SAMSHA report revealed that in 2008, 9.5% of African
American adolescents, as compared to 12.7% of Caucasian
adolescents, utilized outpatient mental health services (Sub-
stance Abuse and Mental Health Services Administration Of-
fice of Applied Studies, 2008). The underutilization of formal
mental health services among African American adolescents
with depression has spawned studies designed to examine fac-
tors that underlie symptom and help-seeking behaviors (Lindsey
et al., 2010). Explanations for the observed lower rates of men-
tal health use for this group of individuals include distrust of
mental health professionals because of historical abuses relating
back to slavery and a perceived lack of cultural sensitivity by
providers (Goldston et al., 2008). Additionally, institutional
barriers to mental health care, such as the absence of or inade-
quate health insurance and the prevalence of culturally inap-
propriate screening measures, diagnostic procedures, and treat-
ment modalities exist that diminish help-seeking and treat-
ment compliant behaviors (Atdjian & Vega, 2005; Copeland,
Prior studies have shown that African American adolescents,
especially African American adolescent males who experience
depression, may be particularly sensitive to stigma associated
with depression and mental health treatment (Lindsey et al.,
2010). In their examination of mental health stigma, social
support, and depressive symptoms in African American males,
Lindsey et al. (2010) showed an association between partici-
pants’ use of mental health professionals and feeling “shamed.”
Furthermore, Lindsey et al. (2010) suggested that the un-
der-utilization of mental health services by African American
males was related to feelings of being stigmatized by their peers.
African American male adolescents tend to view the acknowl-
edgement of depressive feelings as culturally incongruent (Mo-
lock et al., 2007; Moses, 2009), and thus will typically talk to
family and friends prior to and/or in lieu of seeking mental
health services (Lindsey et al., 2010).
Additionally, suicidal ideation and suicide, which could be
an outcome of untreated depression and depressive symptoms,
is the third leading cause of death among adolescents (Ander-
son, 2002; Franko et al., 2005; Mazzaferro et al., 2006; Ru-
dolph, 2008). Although women have been documented to make
more suicide attempts, American males of all ethnicities con-
tinue to be more effective at ending their lives (Centers for
Disease Control and Prevention National Center for Injury
Prevention and Control). According to the 2007 United States
Census Bureau, it is reported that American males of all ages
completed suicide at a rate of 18.4 out of every 100,000 while
their female counterparts completed suicide at a much lower
rate of 4.7 per 100,000. This trend was shown to be similar
among African Americans, with higher suicide rates for African
American males of all ages (8.8 per 100,000) compared to the
suicide rates for African American females of all ages (1.7 per
100,000) (Centers for Disease Control and Prevention National
Center for Injury Prevention and Control). Recent reports indi-
cate observing the highest suicide completion risk among 25 -
44 year old individuals (13.7 per 100,000) and among 15 - 24
year old African American males (10.3 per 100,000) (Centers
for Disease Control and Prevention National Center for Injury
Prevention and Control).
However, this trend may not provide an accurate representa-
tion of this phenomenon within the African American adoles-
cent culture. Goldston et al. (2008), reported that for some de-
pressed youth, stigma and the importance of not appearing vul-
nerable results in “precipitated” suicide, which refers to in-
stance in which individuals try to provoke others into killing
them, thereby the individual seems to be a victim of a homicide.
Cases of precipitated suicide are disproportionately present in
Copyright © 2012 SciRes. 871
K. JOHNSON ET AL.
African American males and may be viewed as more culturally
appropriate means to ending their lives (Gibbs, 1988). Clinical
factors such as depression, hopelessness, and poor problem-
solving skills have been identified as significant contributors to
suicide and suicidal behaviors (Boyd & Foley, 2009).
Integration of Mental Health and Primary Care in
Identifying Adolescent Depressive Symptoms
Primary care providers (PCPs) (i.e., providers in family
medicine, pediatrics, obstetrics/gynecology, or adolescent medi-
cine) are often the first (and sometimes only) point of contact
individuals have with the health care system (Nimalasuriya,
Compton, & Guillory, 2009). Racial/ethnic minority and low-
income adolescents have been shown to access primary care
clinics more often than mental health clinics (Stein et al., 2006).
Within research protocols, mental health problems have been
identified in 8% to 13% of adolescents attending routine physi-
cal examinations in pediatric practice (Husky, Miller, McGuire,
Flynn, & Olfson, 2011). African Americans, in particular, are
more likely to receive mental health care from a PCP than from
a mental health specialist (Gallo, Bogner, Morales, & Ford,
2005; Stockdale, Lagomasino, Siddique, McGuire, & Miranda,
2008). Approximately, 90% of adolescents visit their primary
care providers on average 2 to 3 times per year (Stein et al.,
2006). These statistics indicate that there is an opportunity for
primary care providers to provide universal screening of de-
pression, and in doing so, potentially prevent suicide among a
significant number of adolescents (Frankenfield et al., 2000;
Kramer, Beaudin, & Thrush, 2005); particularly in those groups
that are at-risk for depressive symptoms (e.g., low-income,
racial/ethnic minority adolescents).
Within primary care settings, pediatricians are often de facto
providers of mental health care to young people, with the
unique opportunity for the universal screening, identification,
and treatment of a significant percentage of adolescents at risk
for depression (Husky et al., 2011). The US Preventive Ser-
vices Task Force (USPSTF) recommends that all primary care
providers should have “systems in place, whether within the
primary care setting itself (i.e., on-site) or through collabora-
tions with mental health professionals, to ensure the accurate
diagnosis, effective treatment, and follow-up of depression”
(US Preventive Services Task Force, 2009). It is further rec-
ommended by the USPSTF that primary care providers screen
adolescents for depression annually from 12 through 18 years
of age during routine visits (Hamrin & Magorno, 2010). Sev-
eral obstacles appear to impinge on a PCP’s ability to screen for
mental health concerns. Prior studies of pediatric, adolescent
medicine, and family physicians have indicated reports that
time constraints related to medical productivity requirements,
limited/no reimbursement for mental health services, lack/
limitation of skills need to diagnosis and effectively treat men-
tal health needs, and limited/no treatment referrals all represent
challenges faced by PCPs in integrating mental health assess-
ment into their practice (Hacker et al., 2006; Zuckerbrot et al.,
Yet, there is evidence among studies conducted in the adult
depression literature which demonstrate the effectiveness of
collaborative care between mental health and primary care
(Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007). More-
over, an integrated model of collaborative care is considered to
be especially important for racial/ethnic minority and/or low-
income adolescents who may have limited access to healthcare
services. The use of standardized screening tools in pediatric
practice (e.g., Beck Depression Inventory-Primary Care Ver-
sion, Patient Health Questionnaire for Adolescents) have been
shown as an effective method to improve detection rates of
depression and other psychosocial issues during routine pri-
mary care visits (Johnson, Harris, Spitzer, & Williams, 2002;
Winter, Steer, Jones-Hicks, & Beck, 1999). For example, in a
sample of patients aged 4 years 11 months to 19 years of age,
Hacker et al. (2006) implemented the Pediatric Symptom
Checklist (35-item) to identify mental health problems during
an annual screening at an urban pediatric setting. Results re-
vealed that 6% of the patient population endorsed positive Pe-
diatric Symptom Checklist scores, which indicated that the
child had emotional or behavioral problems that warranted
clinical attention. The authors concluded that mental health
screenings can be effectively implemented within a pediatric
clinic setting. Similarly, Collins et al. (2010) incorporated a
brief depression screening tool, The Center for Epidemiologic
Studies Depression Scale (CES-D), as a part of the routine
clinical procedures within an urban reproductive health clinic.
The patient population included African American adolescent
females between ages 12 and 19 years. The CES-D was able to
identify approximately 19% of adolescent females presenting
with clinically significant levels of depressive symptoms.
Zuckerbrot, Maxon, Pagar et al., (2007) implemented the
administration a 22-item paper-and-pencil survey (i.e., Colum-
bia Depression Scale, CDS) to all eligible patients. The results
revealed that the average completion time of the paper-and-
pencil survey was 4.6 minutes, and appeared to be well per-
ceived, had minimal staff resistance, and was accepted among
parents, patients, and providers. Therefore, Zuckerbrot et al.
(2007) concluded that brief universal systematic depression
screenings can be successfully implemented within pediatric
clinics. Despite this finding, a limited number of PCPs have
utilized standardized assessment methods to screen for depres-
sive symptoms in their adolescent patient population (Zucker-
brot & Jensen, 2006) suggesting that cases of depression are
being missed, which could result in detrimental mental health
trajectories, particularly among low-income African American
male adolescents, given the purported vulnerability and limited
access of mental health clinics among this population.
Statement of the Problem
This paper implemented a standardized depression screening
tool and examined the detection rates of depressive symptoms
in primarily low-income, African American male adolescents
who receive routine reproductive health care services in an
adolescent reproductive health clinic located within an urban
hospital. It was expected that integrating a depression screening
tool during a routine physical examination would identify
clinically significant depressive symptoms within a population
that generally would not self-identify or receive mental health
treatment. As previously stated, the rate of depression for ado-
lescents in the general population is estimated to be between
5% and 15%. However, there are numerous environmental
experiences associated with this population of low-income,
African American male adolescents such as socioeconomic
stress, exposure to trauma, difference in symptom presentation,
and the stigma of mental health. Therefore, given these vari-
ables, it was hypothesized that the use of an instrument assess-
Copyright © 2012 SciRes.
K. JOHNSON ET AL.
ing depression within a primary care adolescent reproductive
health clinic would reveal endorsements of clinically significant
depressive symptoms among African American adolescent
males at this clinic. It was further expected that, within this
sample, depressive symptoms would be endorsed at an equal or
greater rate than that of the general adolescent population.
Note: This research was an outgrowth of another study which
identified clinically significant depressive symptoms in African
American females in an urban reproductive health clinic
(Collins et al., 2010). Therefore the methodological issues are
the same as the abovementioned study.
Participants included 49 African American adolescent males
between ages 13 and 19 years (M = 17.61, SD = 1.35) that at-
tended an appointment at a large, university-affiliated, public
hospital-based adolescent primary care reproductive health
clinic in the southeastern region of the United States. All ado-
lescent patients requesting services at the clinic completed a
depression screening questionnaire. The depression screening
questionnaire was included in the Adolescent Reproductive
Health Clinic’s routine clinic intake packet. Thus, the data were
collected as part of routine clinical procedures, as the intake
and all depression symptom questionnaires completed during
the clinic visit are included in the study results. Only completed
depression screening questionnaires were used in the final sam-
ple. Approval for the inclusion of the depression screening
questionnaire was obtained from the university-affiliated Insti-
tutional Review Board.
The hospital-based adolescent primary care reproductive
health clinic is housed within a large urban, university affiliated
teaching hospital and provides an array of services to primarily
African American, low income adolescent males and females.
The clinic typically accommodates nearly 2000 female and
male adolescent clinic visits annually, of which 20% are males.
The average age of patients served in the clinic is 17 years old
(range 11 - 20 years old), and 92% of patients describe them-
selves as African American. Services provided in the clinic
include: pregnancy tests and prevention, testing and treatment
for sexually transmitted infections (STIs), contraceptives, rou-
tine gynecological and postpartum examinations, sports physi-
cals, pregnancy prevention educational sessions for parents and
adolescents utilizing a postponing sexual involvement curricu-
lum, case management, and psychological counseling. STI
diagnosis and treatment and pregnancy tests are the most fre-
quently used services. Staff includes medical providers/clini-
cians (medical doctors, medical interns/residents, physician
assistants, nurses), health educators, and psychology trainees
(psychology interns and postdoctoral fellows). Psychology
trainees are available to provide mental health consultation to
adolescents referred by staff and receive consultation and
weekly supervision from a licensed clinical psychologist who is
on-call for any mental health emergency. Approximately 20%
of all adolescents served at the clinic are referred to psychology
trainees for mental health consultation. Although adolescent
reproductive health clinics exist nationally and worldwide, the
inclusion of mental health services, an individualized case
management approach using health educators, peer educators/
teen leaders, a computer center, and the clinic’s partnership
with the local school system make this clinic particularly uni-
Adolescents in the sample completed a brief depression
screening questionnaire (e.g., Center for Epidemiologic Studies
Depression Scale (CES-D), Radloff, 1977) as part of a routine
clinic visit. During check-in at the clinic, adolescents were
provided with a consent form explaining the purpose of the
study and requesting permission to obtain a copy of their re-
sponses on the questionnaire for research. Adolescents are con-
sidered “emancipated” for reproductive health care services
within the state where the study was conducted; therefore, pa-
rental consent was not required for clinic services. Parental
consent was not required for the depression screening measure
because it was considered to be a routine part of the ongoing
intake procedures within the clinic. Adolescents were provided
with the clinic’s routine intake packet. The CES-D form was
one of several forms in the intake packet that all adolescents
requesting services in the clinic completed prior to being seen
by the medical provider/clinician. Adolescents also responded
to an additional item that assessed for suicidal ideation (SI).
Adolescents who obtained a total score of 16 or above on the
depression screening tool and/or endorsed SI on the clinic form
were referred to a psychology trainee (psychology postdoctoral
fellow or intern) and provided with a brief psychosocial as-
sessment (i.e. mental health screening) by the psychology
trainee as part of their routine visit to the reproductive health
clinic. Adolescents who endorsed SI were assessed by the psy-
chology trainee for suicidal intent and plan, and if the adoles-
cent was determined to be suicidal, referral for psychiatric hos-
pitalization was made. As needed, adolescents were provided
with ongoing mental health services after parental consent was
obtained for psychological services.
The Center for Epidemiologic Studies Depression Scale
(CES-D) (Radloff, 1977) is a 20-item self-report depression
screening measure. Participants were asked to respond to the
items based on their feelings within the past week. Items are
rated on a four-point scale, with 0 = rarely or none of the time
(less than 1 day), 1 = some or a little of the time (1 - 2 days), 2
= occasionally or a moderate amount of time (3 - 4 days), and 4
= most or all of the time (5 - 7 days). The CES-D scores range
from 0 to 60, with higher scores indicating more severe depres-
sive symptoms. Consistent with previous studies, a total score
of 16 or greater is indicative of adolescents with clinically sig-
nificant depressive symptoms. Furthermore, Munoz (2005)
offered the following guide for interpreting CES-D scores,
which will be applied in the analysis of the current study: aver-
age range of depressed symptoms (scores less than 16), border-
line elevation of depressed symptoms (scores 16 to 24), and
significant elevation of depressed symptoms (scores 24 and
above). The CES-D has been used effectively with adolescents,
and reliability and validity have been tested and established in
African American populations (Radloff, 1991). The CES-D is
Copyright © 2012 SciRes. 873
K. JOHNSON ET AL.
Copyright © 2012 SciRes.
shown to be valid and to have good test-retest reliability (.77 - .92).
Within the current sample, internal consistency for the CES-D
was .85. One item was added to the CES-D in the current study
that was not included in the total CES-D score. Participants
were asked to respond to an item regarding their experience of
suicidal thoughts within the past week, “I felt that I would be
better off dead or had thoughts of hurting myself”.
The total number of depressive symptoms endorsed on the
CES-D ranged from 0 to 36 (M = 8.92, SD = 8.19). A Spear-
man’s rank correlation analysis revealed that there was not a
significant relationship between age and total number of de-
pressive symptoms endorsed on the CES-D. However, ap-
proximately 18% (n = 9) of the overall sample of n = 49 re-
ported significant levels of depressive symptoms on the CES-D
(score of 16 or higher) with a mean score of 23.67 (SD = 6.28).
Within the subsample of participants with CES-D scores higher
than 16, approximately 67% (n = 6) of the subsample endorsed
borderline elevation of depressive symptoms (CES-D score
between 16 and 24) with a mean score of 20.17 (SD = 2.64),
and approximately 33% (n = 3) of the subsample reported sig-
nificant depressive symptoms indicative of a clinical diagnosis
of depression (CES-D score above 24) with a mean score of
30.67 (SD = 5.51). The reported rates of depressive symptoms
within the overall sample and subsample of African American
male adolescents in the present study are higher than the esti-
mated prevalence rates of depression reported for adolescents
ages 13 - 18 (5% - 15%) (Costello et al., 2006). Within the
subsample of participants with CES-D scores higher than 16,
correlation analysis was performed to determine the relation-
ship between age and endorsement of significant levels of de-
pressive symptoms on the CES-D, and did not find any signifi-
cant associations. Additionally, approximately 6% (n = 3) of
the total sample endorsed the additional item indicating experi-
ence of suicidal thoughts within the past week. Table 1 dis-
plays descriptive information including means and standard
deviation, for the subsample of participants whose total CES-D
scores were higher than the published cutoff (CES-D scores
The purpose of this study was to demonstrate the clinical
utility of implementing a brief mental health screening measure
within a reproductive health care setting to support identifica-
tion of depressive symptoms among a low-income, African
American male adolescent population. In this study, we were
able to support our hypothesis with our major finding that the
inclusion of the CES-D resulted in approximately 18% of Afri-
can American male adolescents being successfully identified as
experiencing clinically significant depressive symptoms which
are higher than the estimated prevalence rates of depression
reported for adolescents ages 13 to 18 years old (5% - 15%).
Given the relatively small overall sample size (n = 49), this
finding is noteworthy as it also supports previous research re-
porting the identification of mental health problems in 8% to
13% of adolescents attending routine physical examinations
(Husky, Miller, McGuire, Flynn, & Olfson, 2011). Additionally,
the results of the current study are consistent with results from
the Collins et al. study (2010) in which approximately 19% of
African American females accessing primary care in a repro-
ductive health clinic were identified as experiencing significant
depressive symptoms using the CES-D. The results across this
study and the Collins et al. study (2010) may offer broader
implications for identifying and understanding depression
within the general population of African American youth. As
previously mentioned, research has indicated varied depression
symptom presentation across racial and ethnic groups (Carde-
mil et al., 2002; Shaffer et al., 2002). In particular, the literature
has noted increased reports of symptoms of diminished pleasure,
increased anger, aggression, and irritability among African
American adolescents than Caucasian, Hispanic, and Asian
American adolescents (Choi & Gi Park, 2006). The use of the
CES-D with African American adolescents may serve as a
first-stage screening device that allows for the identification of
depressive mood that can develop into a depressive episode or
another form of serious depression should it continue for long.
Furthermore, although it was not statistically significant, it is
important to note that three participants within this small sam-
ple indicated experiencing suicidal thoughts within the past
week. Thus, the addition of the item inquiring about suicidal
ideation to the CES-D in the current study seemed to give pro-
viders an assessment of multiple risk factors during a routine
visit. Moreover, the design of the study allowed for the imme-
diate referral, consultation, and follow-up by a mental health
trainee/professional when significant depressive symptoms or
suicidal ideation were endorsed. These findings support the
assertion that primary care and reproductive health settings,
particularly those that serve low-income and/or at-risk racial/
ethnic minority adolescents, can successfully and feasibly
screen patients for mental health issues as a part of routine
medical care. These results also indicate that screening for de-
pressive symptoms in African American adolescent males in
primary care and reproductive health clinics is effective in
identifying a population of youth that generally may not self-
identify themselves as being in need of mental health treatment.
Elevated depression scores repor t on the C ES-D among the subsample (n = 9).
Age in years Frequency (n = 9) Mean SD Range of C ES-D Scores
13 - - - -
14 - - - -
16 1 - - 21
17 2 30.00 8.49 24 - 36
18 4 21.25 6.55 17 - 31
19 2 23.50 2.12 22 - 25
K. JOHNSON ET AL.
Additionally, this study supports research that suggest that
screening for suicide risk factors is possible and more likely to
occur in conjunction with mental health screenings that are
perceived to cause little disruption to routine clinic procedures
(Frankenfield et a l., 2000).
It is important to consider the limitations of the findings of
this study. First, it is likely that the results were unable to detect
significant group differences between age and depressive sym-
ptoms given the small sample size, and still disproportionate
number of participants representing each group. Given the rela-
tive homogeneity of this sample with regard to race, gender,
and socioeconomic status, it is likely that generalizeability is
limited. Furthermore, the CES-D is a measure of global distress
related to depressive symptoms, which unfortunately did not
account for further investigation of subcategories of depression
such as somatic, neurovegetative, or mood/cognitive symptoms
which may have yielded different results. Finally, this study
relied solely on self-report of depressive symptoms, and the
results may be limited by the participants’ potential tendency to
present in a socially desirable manner, thus minimizing depres-
sive symptoms. Collaborative information (i.e., objective, te acher
and/or parental report) regarding the participants’ experience of
depression were not obtained or incorporated.
It is common for adolescent males present to clinics with
chief complaints unrelated to depression, such as sports-related
injuries or difficulties with a chronic condition such as asthma,
dermatological problems such as acne, or acute infections such
as strep throat (Westwood & Pinzon, 2008). As previously
mentioned, in the case of African American male adolescents, it
is possible that cultural stigma associated with depression as
well as gender socialization may lead to differences in depres-
sion symptom presentation which are more socially acceptable.
Survey reports reveal that roughly 20% or less of adolescents
seen in primary health clinics or pediatric emergency medicine
are actually screened for mental health issues (Husky et al.,
2011). Yet, by the time adolescents reach the age of 16-year-old,
it has been estimated that as many as approximately 37% of
adolescents will meet criteria for at least one mental disorder
(Husky et al., 2011). Thus, it is important for brief mental
health screenings to be integrated into primary care practices to
improve identification of mental health difficulties among ado-
lescents. Furthermore, universal screening of depressive symp-
toms that are sensitive to the differences within the African
American male adolescent population is especially essential.
Demonstrating the feasibility of screening for depressive
symptoms in adolescents is only a start to addressing this issue.
Consultation, referral, and treatment of these symptoms are an
important aspect of adolescent health and of this research. In
the case of adolescent depression, in which prevalence rates
increase with age, some adolescents may present to primary
care and reproductive health clinics with clinically significant
depression. However, others may present with less severe sub-
clinical forms of depression (i.e., depressive symptoms) that
may be more common in this population of African American
male adolescents, and also require clinical attention. Consistent
with the recommendation for systematic screening and the in-
tegration of biological and psychological treatments that in-
cludes diagnosis, psychotherapy, and follow up (US Preventive
Services Task Force, 2009), the clinic within the current study
provided multiple services entailing sports physicals, case
management, psychological consultation, and ongoing mental
health services as needed (with parental consent). A unique
feature to this study was the inclusion of mental health profes-
sionals within the primary clinic, which has been noted as an
effective strategy in encouraging appropriate psychosocial
treatment for adolescents experiencing mental health difficul-
ties (Bower, Garralda, Kramer, Harrington, & Sibbald, 2001;
Kelleher, Campo, & Gardner, 2006). However, within settings
in which staff may not include mental professionals, empirical
studies on the efficacy of primary care-initiated psychosocial
intervention for adolescents have shown promising results
(Asarnow et al., 2005; Johnson et al., 2002; Walker et al., 2002).
The types of psychosocial interventions offered by primary care
clinicians may include counseling (e.g., reflective listening,
problem solving, cognitive reframing, psychoeducation via
literature or information), prescribing psychotropic medication,
or a referral to specialty care mental health clinic (Williams,
Klinepeter, Palmes, Pulley, & Foy, 2004; Williams, O’Connor,
Eder, & Whitlock, 2009). Also, if on-site mental health consul-
tation is not feasible, primary care and reproductive health set-
tings should be encouraged to establish relationships with men-
tal health professionals in the community for consultation and
referral of adolescents with depressive symptoms. As research
continues in this area, it will be essential that it focuses not only
on identifying feasible screening mechanisms for identifying
depression in primary care settings, but also identifying practi-
cal applications of psychosocial interventions to treat those who
are identified with depressive symptoms within primary care
Results of the current study are in support of the integration
of routine, universal depression screening and subsequent re-
ferral to mental health professions within primary care and
reproductive health settings. It is hoped that the results of the
current study contribute to an increased awareness of the need
for early identification and treatment of underserved African
American adolescent males with depressive symptoms. Despite
the fact that depression during adolescence is a major public
health concern with potential long term consequences, it often
is unrecognized, under-diagnosed, and/or untreated. Given the
public health concern of adolescent depression, the stigma of
mental health in some communities, as well as the likelihood
that most depressed adolescents do not receive mental health
services, it is imperative that primary care and reproductive
health settings consider incorporating a brief depression screen-
ing measure in their routine practices. Additionally, consulta-
tion and referral for mental health treatment for adolescents
with depressive symptoms will facilitate the delivery of behav-
ioral health services and lead to meaningful improvements in
Anderson, E. R., & Mayes, L. C. (2010). Race/ethnicity and internaliz-
ing disorders in youth: A review. Clinical Psychology Review, 30,
Anderson, R. (2002). Deaths: Leading causes for 2000 (Vol. 50). Na-
tional Vital Statistics Reports. Hyattsville, MD: Centers for Disease
Control and Prevention, National Center for Health Statistics, Na-
Copyright © 2012 SciRes. 875
K. JOHNSON ET AL.
tional Vital Statistics System.
Angold, A., Erkanli, A., Farmer, E., Fairbank, J., Burns, B., Keeler, G.,
& Costello, E. (2002). Psychiatric disorder, impairment, and service
use in rural African American and white youth. Archives of General
Psychiatry, 59, 893- 901. doi:10.1001/archpsyc.59.10.893
Angold, A., Worthmon, C. M., & Costello, E. J. (2003). Gender differ-
ences at puberty. In C. Hayward (Ed.), Puberty and depression. New
York: Cambridge University Press.
Asarnow, J., Jaycox, L., Duan, N., LaBorde, A., Rea, M., Murray, P.,
Anderson, M., Landon, C., Tang, L., & Wells, K. (2005). Effective-
ness of a quality improvement intervention for adolescent depression
in primary care clinics a randomized controlled trial. Journal of the
American Medical Association, 293, 311-319.
Atdjian, S., & Vega, W. A. (2005). Disparities in mental health treat-
ment in US racial and ethnic minority groups: Implications for psy-
chiatrists. Psychiatric Services, 56, 1600-1602.
Bower, P., Garralda, E., Kramer, T., Harrington, R., & Sibbald, B.
(2001). The treatment of child and adolescent mental health prob-
lems in primary care: A systematic review. Family Practice, 18,
Boyd, M., & Foley, M. (2009). Psychiatric nursing: Contemporary
practice (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.
Cardemil, E. V., Reivich, K. J., & Seligman, M. E. P. (2002). The pre-
vention of depressive symptoms in low-income minority middle
school students. Prevention & Treatment, 5, 1-28.
Centers for Disease Control and Prevention National Center for Injury
Prevention and Control (2012). Web-based Injury Statistics Query
and Reporting System (WISQARS). www.cdc.gov/ncipc/wisqars
Choi, H., & Gi Park, C. (2006). Understanding adolescent depression in
ethnocultural context: Updated with empirical findings. Advances in
Nursing Science, 29, E1-E12.
Collins, M. H., Kelch-Oliver, K., Welkom, J. S., Johnson, K., Kottke,
M., & Smith, C. O. (2010). Clinically significant depressive symp-
toms in African American adolescetn females in an urban reproduc-
tive health clinic. Journal of Clinical Psychology in Me di c al S et t i ng s ,
17, 175-182. doi:10.1007/s10880-010-9200-9
Copeland, V. C. (2006). Disparities in mental health service utilization
among low-income African American adolescents: Closing the gap
by enhancing practitioner’s competence. Child and Adolescent Social
Work Journal, 23, 407-431. doi:10.1007/s10560-006-0061-x
Costello, J., Erkanli, A., & Angold, A. (2006). Is there an epidemic of
child or adolescent depression? Journal of Child Psychology & Psy-
chiatry, 47, 1263-1271.
Cote, M., Mullins, L., Hartman, V., Ho ff, A., Balderson, B., Chaney, J.,
& Domek, D. (2003). Psychosocial correlates of health care utiliza-
tion for children and adolescents with type 1 diabetes mellitus. Chil-
dren s Health Care, 32, 1-16. doi:10.1207/S15326888CHC3201_1
Frankenfield, D. L., Keyl, P. M., Gielen, A., Wissow, L. S., Werthamer,
L., & Baker, S. P. (2000). Adolescent patients—Healthy or hurting?
Missed opportunities to screen for suicide risk in the primary care
setting. Archives of Pediatrics and Adolescent Medicine, 154, 162-
Franko, D., Striegel-Moore, R., Bean, J., Tamer, R., Kraemer, H.,
Dohm, F., Crawford, P., Schreiber, G., & Daniels, S. (2005). Psy-
chosocial and health consequences of adolescent depression in black
and white young adult women. Health Psychology, 24, 586- 593.
Gallo, J. J., Bogner, H. R., Morales, K. H., & Ford, D. E. (2005). Pa-
tient ethnicity and the identification and active management of de-
pression in late life. Archives of Internal Medicine, 16 5 , 1962-1968.
Gibbs, J. T. (1988). Conceptual, methodological, and sociocultural
issues in Black youth suicide: Implications for assessment and early
intervention. Suicide & Life-Threatening Behavior, 18, 73-89.
Goldston, D. B., Molock, S. D., Whitbeck, L. B., Murakami, J. L., Zay as ,
L. H., & Hall, G. C. N. (2008). Cultural considerations in adolescent
suicide prevention and psychosocial treatment. American Psycholo-
gist, 63, 14. doi:10.1037/0003-066X.63.1.14
Hacker, K. A., Myagmarjav, E., Harris, V., Suglia, S. F., Weidner, D.,
& Link, D. (2006). Mental health screening in pediatric practice:
Factors related to positive screens and the contribution of paren-
tal/personal concern. Pediatrics, 118, 1896-1906.
Hammack, P. L., Richards, M. H., Luo, Z., Edlynn, E. S., & Roy, K.
(2004). Social support factors as moderators of community violence
exposure among inner-city African American young adolescents.
Journal of Clinical Child and Adolescent Psychology, 33, 450-462.
Hamrin, V., & Magorno, M. (2010). Assessment of adolescents for
depression in the pediatric primary care setting. Pediatric nursing, 36,
Horowitz, J. L., & Garber, J. (2006). The prevention of depressive
symptoms in children and adolescents: A meta-analytic review.
Journal of Consulting and Cl in i c al Psychology, 74, 401-415.
Husky, M. M., Miller, K., McGuire, L., Flynn, L., & Olfson, M. (2011).
Mental health screening of adolescents in pediatric practice. The
Journal of Behavioral Health S er v ic es an d Research, 38, 159- 169.
Johnson, J. G., Harris, E., Spitzer, R. L., & Williams, J. B. W. (2002).
The patient health questionaire for adolescents: Validation of an in-
strument for the assessment of mental disorders among adolescent
primary care patients. Jour n a l o f Adolescent Health, 30, 196-204.
Kelleher, K. J., Campo, J. V., & Gardner, W. P. (2006). Management of
pediatric mental disorders in primary care: Where are we now and
where are we going? Current O pi nion in Pediatrics, 18, 649-653.
Kessler, R. C., Avenevoli, S., & Ries Merikangas, K. (2001). Mood
disorders in children and adolescents: An epidemiologic perspective.
Biological Psychiatry, 49, 1002-1014.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikan-
gas, K. R., Rush, A. J., Walters, E. E., & Wang, P. S. (2003). The
epidemiology of major depressive disorder. JAMA: The Journal of
the American Medical Association, 289, 3095-3105.
Kramer, T., Beaudin, C., & Thrush, C. (2005). Evaluation and treat-
ment of depression (Part I): Benefits for patients, providers, and pay-
ors. Disease Management a n d H e a lt h O u t c o m es , 13, 295-306.
Lindsey, M. A., Joe, S., & Nebbitt, V. (2010). Family matters: The role
of mental health stigma and social support on depressive symptoms
and subsequent help seeking among African American boys. Journal
of Black Psychology, 36, 458- 482. doi:10.1177/0095798409355796
Mazzaferro, K., Murray, P., Ness, R., Bass, D., Tyus, N., & Cook, R.
(2006). Depression, stress, and social support as predictors of high-
risk sexual behaviors and STIs in young women. Journal of Adoles-
cent Health, 39, 601- 603. doi:10.1016/j.jadohealth.2006.02.004
Molock, S. D., Barksdale, C., Matlin, S., Puri, R., Cammack, N., &
Spann, M. (2007). Qualitative study of suicidality and help-seeking
behaviors in African American adolescents. American Journal of
Community Psychology, 40, 52-63. doi:10.1007/s10464-007-9122-3
Moses, T. (2009). Self-labeling and its effects among adolescents di-
agnosed with mental disorders. Social Science & Medicine, 68,
Nebbitt, V. E., & Lombe, M. (2008). Assessing the moderating effects
of depressive symptoms on antisocial behavior among urban youth in
public housing. Child and Adolescent Social Work Journal, 25, 409-
Nimalasuriya, K., Compton, M. T., & Guillory, V. J. (2009). Screening
adults for depression in primary care: A position statement of the
American College of Preventive Medicine. Journal of Family Prac-
tice, 58, 535-538.
Radloff, L. (1977). The CES-D scale: A self-report depression scale for
research in the general population. Applied Psychological Measure-
Copyright © 2012 SciRes.
K. JOHNSON ET AL.
Copyright © 2012 SciRes. 877
ment, 1, 385-401. doi:10.1177/014662167700100306
Radloff, L. (1991). The use of the Center for Epidemiologic Studies
Depression Scale in adolescents and young adults. Journal of Youth
and Adolescence, 20, 149-166. doi:10.1007/BF01537606
Riolo, S., Nguyen, T., Greden, J., & King, C. (2005). Prevalence of
depression by race/ethnicity: Findings from the National Health and
Nutrition Examination Survey III. American Journal of Public
Health, 95, 998-1000. doi:10.2105/AJPH.2004.047225
Rudolph, K. D. (2008). Adolescent depression. In I. H. Gotlib, & C. L.
Hammen (Eds.), Handbook of depression (2nd ed., pp. 444-446).
New York, NY: The Guilford Press.
Rushton, J., Forcier, M., & Schectman, R. (2002). Epidemiology of
depressive symptoms in the National Longitudinal Study of Adoles-
cent Health. Journal of the American Academy of Child & Adoles-
cent Psychiatry, 41, 199-205.
Shaffer, A., Forehand, R., & Kotchick, B. (2002). A longitudinal ex-
amination of correlates of depressive symptoms among inner-city
African-American children and adolescents. Journal of Child and
Family Studies, 11, 151-164. doi:10.1023/A:1015121424404
Stein, R. E. K., Zitner, L. E., & Jensen, P. S. (2006). Interventions for
adolescent depression in primary care. Pediatrics, 118, 669-682.
Stockdale, S. E., Lagomasino, I. T., Siddique, J., McGuire, T., &
Miranda, J. (2008). Racial and ethnic disparities in detection and
treatment of depression and anxiety among psychiatric and primary
health care visits, 1995-2005. M e d ic a l C a re , 46, 668-677.
Substance Abuse and Mental Health Services Administration Office of
Applied Studies (2008). The NSDUH Report—Major depressive
episodes among youths aged 12 to 17 in the United States: 2004 to
2006. Rockville, MD.
US Department of Health and Human Services (2001). Mental health:
Culture, race, and ethnicity—A supplement to mental heatlh: A re-
port of the Surgeon General. Rockville, MD: US Department of
Health and Human Services, Substance Abuse and Mental Health
Services Administration, Center for Mental Health Services
US Department of Health and Human Services (2008). Results from the
2007 National Survey on Drug Use and Health: National findings.
(DHHS Publication No. SMA 08-4343, NSDUH Series H-34).
Rockville, MD: Substance Abuse and Mental Health Services Ad-
US Preventive Services Task Force (2009). Screening and treatment for
major depressive disorder in children and adolescents: Clinical
Walker, Z., Townsend, J., Oakley, L., Donovan, C., Smith, H., Hurst,
Z., Bell, J., & Marshall, S. (2002). Health promotion for adolescents
in primary care: Randomised controlled trial. British Medical Jour-
nal, 325, 524-530. doi:10.1136/bmj.325.7363.524
Westwood, M., & Pinzon, J. (2008). Adolescent male health. Paediat-
rics & Child Health, 13, 31-36.
Wight, R. G., Aneshensel, C. S., Botticello, A. L., & Sepúlveda, J. E.
(2005). A multilevel analysis of ethnic variation in depressive symp-
toms among adolescents in the United States. Social Science &
Medicine, 60, 2073-2084. doi:10.1016/j.socscimed.2004.08.065
Williams, J., Klinepeter, K., Palmes, G., Pulley, A., & Foy, J. M.
(2004). Diagnosis and treatment of behavioral health disorders in pe-
diatric practice. Pediatrics, 114, 601- 606.
Williams, S. B., O’Connor, E. A., Eder, M., & Whitlock, E. P. (2009).
Screening for child and adolescent depression in primary care set-
tings: a systematic evidence review for the US Preventive Services
Task Force. Pedia trics , 123, e716-e736. doi:10.1542/peds.2008-2415
Winter, L. B., Steer, R. A., Jones-Hicks, L., & Beck, A. T. (1999).
Screening for major depression disorders in adolescent medical out-
patients with the Beck Depression Inventory for Primary Care.
Journal of Adolescent Health, 24, 389-394.
Wu, P., Hoven, C. W., Cohen, P., Liu, X., Moore, R. E., Tiet, Q.,
Okezie, N., Wicks, J., & Bird, H. R. (2001). Factors associated with
use of mental health services for depression by children and adoles-
cents. Psychiatric Services, 52, 189-195.
Zuckerbrot, R. A., Cheung, A. H., Jensen, P. S., Stein, R. E. K., &
Laraque, D. (2007). Guidelines for Adolescent Depression in Pri-
mary Care (GLAD-PC): I. Identification, assessment, and initial
management. Pediatrics, 120, e1299-e1312.
Zuckerbrot, R. A., & Jensen, P. S. (2006). Improving recognition of
adolescent depression in primary care. Archives of Pediatrics and
Adolescent Medicine, 160, 694-704. doi:10.1001/archpedi.160.7.694
Zuckerbrot, R. A., Maxon, L., Pagar, D., Davies, M., Fisher, P. W., &
Shaffer, D. (2007). Adolescent depression screening in primary care:
Feasibility and acceptability. Pediatrics, 119 , 101-108.