Teens With Depression Benefit From Collaborative Care Model

A collaborative care intervention for adolescents with depression who are being treated in primary care resulted in greater improvement in depressive symptoms at 12 months than that seen in a comparable group of adolescents treated in a usual-care model.

The findings, reported in the August 27 JAMA Psychiatry, suggest that mental health services for adolescents with depression can be integrated into primary care. The study is one of the first to look at collaborative care for adolescents and, along with an AJP in Advance study looking at collaborative care for disadvantaged OB-GYN patients with depression (see article above), helps expand the potential for collaborative care beyond the insured adult populations in which it has been largely studied.

From April 2010 to April 2013, 101 adolescents aged 13 to 17 seen at nine primary care clinics in the Group Health Cooperative system in Washington state were randomized to a collaborative care model for depression care or to usual care. All subjects screened positive for depression on the nine-item Patient Health Questionnaire (PHQ-9) on two separate occasions or screened positive on one occasion and met criteria for major depression. Exclusion criteria included alcohol/drug misuse, having recently planned or attempted suicide, bipolar disorder diagnosis, developmental delay, and currently being in treatment with a psychiatrist.

Study co-author Wayne Katon, M.D., director of the Division of Health Services and Psychiatric Epidemiology at the University of Washington, told Psychiatric News that participants in the treatment arm received the Reaching Out to Adolescents in Distress (ROAD) model, a collaborative care intervention based on the IMPACT Team Care model (Psychiatric News, November 2, 2012) and adapted for adolescents.

The lead author of the study was Laura Richardson, M.D., of the Department of Pediatrics at the University of Washington.

Adaptations for the study included developmentally sensitive materials and structured involvement of both the adolescent and parent in the initial education and engagement session, the choice of treatment, and follow-up contacts.

Intervention components were delivered by depression care managers, who were master’s level clinicians employed by the study. The education and engagement session included eliciting the youth’s perspectives on their symptoms, providing depression education, and encouraging active treatment participation of the adolescents and their parents. During the session, the care manager helped the teen and the parent decide to pursue treatment with antidepressant medication, brief cognitive-behavioral therapy (CBT), or both.

Adolescents randomized to receive usual care and their parents received a letter summarizing their PHQ-9 results and encouraging follow-up to initiate depression care. Their primary care clinicians received letters summarizing the results and recommending treatment.

Katon, Richardson, and colleagues found that adolescents receiving the collaborative care intervention had significantly greater improvement in depression than those randomized to usual care; they also had significantly more mental health visits and were significantly more likely to adhere to the antidepressant treatment regimen.

When patients were asked to report their satisfaction with the treatment, those in the intervention group were significantly more likely to say they were “moderately to very satisfied” with care at six months.

Overall, 86 percent of patients in the intervention group received either psychotherapy or medications that met study quality standards, compared with 27 percent of the control group. Youth in the intervention group were significantly more likely than control youth to receive four or more psychotherapy sessions in the first six months of the study.

In an interview with Psychiatric News, Katon said the study is one of very few to look at collaborative care for adolescents with depression. “Of the 80 some trials at NIMH [National Institute of Mental Health] on collaborative care, only one or two have looked at teenagers,” he said. “In this study it was shown to work very well with teenagers, who experienced improved quality of care, received more counseling visits, and demonstrated a very robust finding showing improvement in depression symptoms.” ■