An estimated 11% of adolescents have an episode of depression by age 18 (Merikangas et al. 2010) and depressed youth are at greater risk of suicidality (Hawton, Saunders & O’Connor 2012), physical health problems including obesity (Goodman & Whitaker 2002), and high-risk behaviors (Armstrong & Costello 2002). However, only 60% of depressed adolescents receive treatment (Costello et al. 2014).

Although the US Preventative Services Task Force now recommends depression screening for adolescents in primary care, it’s not clear that screening for depression alone will change outcomes. Given that psychiatrists treat only 10% of individuals with a mental disorder, efforts are underway to extend the reach of psychiatrists by moving from traditional practice models to collaborative models of care (Unutzer & Lieberman 2013).

Collaborative care models for treatment of depression in adults consistently show improved outcomes and enhanced receipt of evidence-based care (Archer et al. 2012). The objective of this study was to determine whether collaborative care improves outcomes compared with usual care for the treatment of depression in adolescents.

Methods

This NIMH-funded study was conducted in the US across nine primary care clinics in the Group Health system in Washington State. There were 101 adolescent participants aged 13-17 who screened positive for depression, defined as:

• Patient Health Questionnaire 9-item (PHQ-9) ≥ 10 on two occasions and a Child Depression Rating Scale-Revised (CDRS-R) score ≥ 42, or
• Met criteria for depression on the Kiddie-Structured Interview for Affective Disorders and Schizophrenia

Exclusions for participation included bipolar disorder, substance or alcohol misuse, developmental delay, current psychiatric care, and suicidal plan or recent attempt.

Participants were followed for 12 months after being randomised to:

• Usual care (control), or
• The Reaching Out to Adolescents in Distress (ROAD) collaborative care intervention; an adaptation of the IMPACT Team Care model (“IMPACT: Evidence-based depression care,” 2014)

The intervention group had a depression care manager (DCM), supervised by a psychiatrist and primary care physician (PCP), who coordinated care, provided education, delivered brief CBT, and supported antidepressant treatment for participants. The intervention group could select treatment with antidepressants, brief CBT, or both. The usual care participants and their PCPs were notified of the depression diagnosis, and encouraged to seek mental health treatment, which was readily available in the Group Health system.

The primary outcome measure was:

• Change in depressive symptoms from baseline to 12 months using a modified version of the Child Depressive Rating Scale Revised (CDRS-R)

Secondary outcomes included the following measurements at 12 months:

• Change in functional status (Columbia Impairment Scale (CIS), where >15 indicates impairment)
• Treatment response (≥50% reduction on the CDRS-R from baseline)
• Treatment remission (PHQ-9 score <5)

Results

Statistical analyses were completed using intent-to-treat principles. The population demographics included 72% female and 31% non-White.

With regard to the primary outcome:

• At 12 months the CDRS-R scores for the intervention group decreased by a mean of 9.4 points more than the usual care group, which was statistically significant (P=0.001)
  • The intervention group CDRS-R scores decreased from 48.3 to 27.5
  • Versus 46 to 34.6 for the control group

For secondary outcomes:

• At 12 months the intervention group had statistically significant increases in the number of responders (67.6% intervention vs. 38.6% control, P=0.009) and remitters (50.4% intervention vs. 20.7% control, P=0.007) compared to usual care
• The intervention group was four times more likely to have a full response
• While there was a decrease in functional impairment, there was no statistically significant difference between the two groups on the CIS (P=0.04)

Overall, 86% of the intervention group compared with 27% of the control group received psychotherapy or medications that met study quality standards, defined as ≥4 sessions of brief CBT or ≥90 days of antidepressant treatment.

The estimated cost of the intervention was $1,403 per patient.

Conclusions

The ROAD collaborative care intervention for adolescent depression in a primary care setting resulted in greater adherence to evidence-based treatments for depression and greater improvement in depressive symptoms compared with usual care. The authors suggest that:

Collaborative care interventions for youth with depression are both feasible and effective in improving outcomes.

Despite identification of depression in the control group, only 27% of control participants received evidence-based care despite having access to mental health resources. Therefore, screening for depression alone is unlikely to result in increased receipt of mental health care; resources and the infrastructure of a collaborative care model is required to engage youth in treatment.

Limitations

• The study size was decreased from target of n=160, to n=101 due to reductions in grant funding, which therefore decreased the power of the study
• Only ~40% of those eligible for the study were actually screened due to parental refusal or inability to contact the adolescent, calling into question the feasibility of telephone interviews as a screening method
• The sample was relatively homogeneous (72% female 31% non-White) and excluded severe depression (suicidality, psychiatric care currently, recent hospitalization), which may limit the generalizability of the effectiveness of this intervention
• Improvement in depressive symptoms correlated with an improvement in functioning, but functioning was not significantly different between the two groups at 12 months. It’s possible that the lack of statistically significant difference in functioning may have occurred because the study was not sufficiently powered to detect this difference

Summary

This study provides evidence that the effectiveness of collaborative care for treating depression is not limited to adults, but is also applicable to adolescent depression.

Collaborative care presents an opportunity to deliver effective evidence-based care for adolescent depression, while minimizing the demand for formal psychiatric consultation, which can be a limited resource and more costly compared with other health care providers. Therefore, collaborative care models appear to be an opportunity to “do more with less”.

Future research

Further research is needed to help address the following questions:

• Are there long-term cost-savings for collaborative care interventions in the treatment of adolescent depression?
• How can the acceptability of depression screening be improved, especially among ethnic minorities and males?
• Does this model provide benefit for those with more severe or complex illness (e.g. comorbid substance use)?
• Are there predictors of response to collaborative care treatment models for adolescent depression?
• Does collaborative care treatment for adolescent depression improve overall functioning and outcomes associated with depression including obesity and substance use?

Links

Richardson, L., Ludman, E., McCauley, E., et al. (2014). Collaborative care for adolescents with depression in primary care: a randomized clinical trial. Journal of the American Medical Association, 312(8), 809-816. [PubMed abstract]

Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD006525. DOI: 10.1002/14651858.CD006525.pub2.

Armstrong, T.D., Costello, E. (2002). Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity (PDF). Journal of Consulting and Clinical Psychology, 70(6), 1224-1239.

Costello, E.J., He, J.P., Sampson, N.A., Kessler, R.C., Merikangas, K. (2014) Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatric Services, 65(3), 359-366. [PubMed abstract]

Goodman, E., Whitaker, R. (2002). A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics, 110(3), 497-504. [PubMed abstract]

Hawton, K., Saunders, K.E., O’Connor, R. (2012). Self-harm and suicide in adolescents. Lancet, 379(9834), 2373-2382. [PubMed abstract]

Merikangas, K.R., He, J.P., Burstein, M., et al. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980-989. [PubMed abstract]

Unützer, J., Lieberman, J. (2013, November 12). Collaborative Care: An integral part of psychiatry’s Psychiatric News. Retrived from http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1774036

US Preventive Services Task Force. (2009). Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation S Pediatrics, 23(6), 1611.

IMPACT: Evidence-based depression care. (2014). Retrieved October 21, 2014, from http://impact-uw.org/implementation/buildingteam.html