Collaborative care improves depression in teens

Dr Richardson

Teens who received the collaborative care intervention in primary care had significantly greater improvements in depressive symptoms than teens who were receiving treatment as usual, according to a study published in JAMA.  

In a joint Seattle Children’s–Group Health–University of Washington study, called Reaching Out to Adolescents in Distress (ROAD), 101 teens aged 13 to 17 years who were depressed on screening at 9 Group Health Medical Centers in Washington state were randomly assigned to receive either collaborative care or the care that they would usually receive. With usual care, teens received their depression screening results and could get mental health services at Group Health. 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). Teens in the intervention group were also more likely to report higher satisfaction with the treatment they received.

Treatment as usual teens underwent screening followed by a diagnostic baseline interview. They were given the results of their baseline interview and encouraged to seek treatment. Their parents and primary care doctors were also given these results and encouraged to help the teen start treatment. Despite these efforts to reduce barriers, only 27% of usual care teens received a course of treatment that met minimal quality standards (at least 4 sessions of psychotherapy or 90 days of antidepressants) compared to 86% of intervention teens.

“These findings emphasize that screening alone is unlikely to improve outcomes,” said Laura Richardson, MD, MPH, an adolescent medicine specialist at Seattle Children’s Hospital and principal investigator in the Center for Child Health, Behavior and Development at Seattle Research Institute. “Improving depression outcomes will require strategies that engage teens in treatment in the primary care settings where depression is identified.”

Collaborative care Intervention teens were invited to schedule a 1-hour education and engagement session with a depression care manager. At the end of this session, the teens (with the input of their parents) were encouraged to choose the treatment they would like to start with – psychotherapy, antidepressant medications, or both. The depression care manager helped them to start this treatment. Brief cognitive behavioral therapy was provided by the depression care manager in the clinic. Medications were prescribed by the primary care provider with input from the psychiatric supervisory team (delivered via the care manager). The care manager monitored adherence to treatment, side effects and depressive symptoms (using the PHQ-9) for all teens regardless of type of treatment selected.

“Depression is one of the most common chronic health conditions among adolescents,” said Dr Richardson. “It is associated with significant morbidity and risk of mortality from suicide. It is also associated with higher rates of healthcare utilization and costs among teens, both due to mental health expenditures and higher rates of medical service use.”

Depression screening among adolescents is now recommended by the US Preventive Services Task Force but systems are still working out strategies to implement this screening in a manner that improves outcomes and doesn’t overwhelm available mental health resources, according to Dr Richardson.

The collaborative care model tested in this study was effective in improving treatment engagement in the primary care setting with relatively little increased cost, $1,403 per patient in the study, according to the researchers.

“Levels of mental health specialty care were no different between the 2 groups but outcomes were significantly better for the intervention teens,” Dr Richardson said.

Most of the intervention youth selected psychotherapy, as a result there were only modest increases in antidepressant use among intervention teens relative to control teens, according to Dr Richardson.

“Over the second 6 months of the study, differences in antidepressant use narrowed between the 2 groups, largely because of greater increases in the use of antidepressants among control teens who continued to be symptomatic,” she said.

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“By reorganizing care designing a system that actively engages teens in depression treatment, collaborative care significantly improves outcomes for adolescent depression,” Dr Richardson said.