Collaborative Care for Adolescents With Depression in Primary Care

Abstract

IMPORTANCE Up to 20%of adolescents experience an episode of major depression by age 18 years yet few receive evidence-based treatments for their depression. OBJECTIVE To determine whether a collaborative care intervention for adolescents with depression improves depressive outcomes compared with usual care. DESIGN Randomized trial with blinded outcome assessment conducted between April 2010 and April 2013. SETTING Nine primary care clinics in the Group Health system in Washington State. PARTICIPANTS Adolescents (aged 13–17 years) who screened positive for depression (Patient Health Questionnaire 9-item [PHQ-9] score ≥10) on 2 occasions or who screened positive and met criteria for major depression, spoke English, and had telephone access were recruited. Exclusions included alcohol/drug misuse, suicidal plan or recent attempt, bipolar disorder, developmental delay, and seeing a psychiatrist. INTERVENTIONS Twelve-month collaborative care intervention including an initial in-person engagement session and regular follow-up by master’s-level clinicians. Usual care control youth received depression screening results and could access mental health services through Group Health. MAIN OUTCOMES AND MEASURES The primary outcome was change in depressive symptoms on a modified version of the Child Depression Rating Scale–Revised (CDRS-R; score range, 14–94) from baseline to 12 months. Secondary outcomes included change in Columbia Impairment Scale score (CIS), depression response (≥50% decrease on the CDRS-R), and remission (PHQ-9 score <5). RESULTS Intervention youth (n = 50), compared with those randomized to receive usual care (n = 51), had greater decreases in CDRS-R scores such that by 12 months intervention youth had a mean score of 27.5 (95%CI, 23.8–31.1) compared with 34.6 (95%CI, 30.6–38.6) in control youth (overall intervention effect: F2,747.3 = 7.24, P < .001). Both intervention and control youth experienced improvement on the CIS with no significant differences between groups. At 12 months, intervention youth were more likely than control youth to achieve depression response (67.6%vs 38.6%, OR = 3.3, 95%CI, 1.4–8.2; P = .009) and remission (50.4%vs 20.7%, OR = 3.9, 95%CI, 1.5–10.6; P = .007). CONCLUSIONS AND RELEVANCE Among adolescents with depression seen in primary care, a collaborative care intervention resulted in greater improvement in depressive symptoms at 12 months than usual care. These findings suggest that mental health services for adolescents with depression can be integrated into primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01140464.

Screening for Depression in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

“…17 More patients in the control group experienced an emergency department visit with a primary psychiatric diagnosis than in the intervention group (10% vs 2%). However, this study was not powered to detect differences.…”

“…17 The intervention was based on the Improving MoodPromoting Access to Collaborative Treatment model and was adapted for adolescents. Patients randomly assigned to the collaborative care group had an initial in-person session that included their parents, choice of treatment type(s), and regular follow-up with depression care managers (28% received psychotherapy alone, 4% received pharmacotherapy alone, and 54% received both).…”

Suicide and Suicide Attempts in Adolescents

“…Collaborative care is encouraged, because it has been shown to result in greater reduction of depressive symptoms in a primary care setting. 61 Recommendations should include that all firearms are removed from the home, because adolescents may still find access to locked guns stored in their home, and that medications, both prescription and over-the-counter, are locked up. Vigorous treatment of the underlying psychiatric disorder is important in decreasing short-term and long-term risk of suicide.…”

Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial

“…3,11,12 Consistent with youth and parent pre ferences for nonpharmacologic treatments such as psychotherapy, [13][14][15] we examined whether a viable alternative could be effectively delivered in primary care: brief cognitive behavioral therapy (CBT). Although primary care CBT has been tested with depressed adolescents in several previous trials, 13,16,17 none specifically examined the effects of CBT in patients unreceptive to pharmacotherapy.…”