COPE for Depressed and Anxious Teens: A Brief Cognitive‐Behavioral Skills Building Intervention to Increase Access to Timely, Evidence‐Based Treatment

Adolescents are not receiving the evidence-based mental health services they need (National Research Council {NRC} & Institute of Medicine {IOM}, 2009). A 2010 nationally representative sample of US adolescents (National Co-morbidity Survey, Adolescent Supplement (NCS-A) found that approximately one in every four to five youth meets criteria for a mental disorder that will impair their functioning across their lifetime (Merikangas et al., 2010). In adolescents ages 13 to 18 years, the prevalence of mental disorders with distress and/or severe impairment is 22% (11% with mood disorders, 8.3% with anxiety disorders, and 9.6% behavior disorders) (Merikangas et al., 2010). Forty percent of teens who meet criteria for one disorder have co-morbidity which meets criteria for another class of lifetime disorder (Merikangas et al., 2010). Unfortunately, these young people are suffering, but fewer than 25% are getting the treatment they need (Foy, 2010). Because many common mental disorders first emerge in childhood/adolescence and are now being considered neurodevelopmental disorders, prevention, early intervention and timely evidence-based treatment are critical (Merikangas et al., 2010; March, 2009). Advanced Practice Psychiatric Nurses (APPN), along with their family NP and pediatric NP colleagues, strive to provide excellent evidence-based treatment for the many depressed and anxious teens they see in their practice settings. It is a challenge to find developmentally appropriate, evidence-based interventions that are portable and easily used by clinicians who have the time constraints, productivity requirements, and full schedules characteristic of practice settings today (Foy, 2010). Interventions that incorporate the principles of sound, empirically tested psychotherapy, such as cognitive behavioral therapy (CBT), into manuals or formats that are well accepted by the teens and their parents are needed. There are time-tested manualized CBT based programs available for anxious and depressed teens: Lewinsohn & Clarke (Adolescent Coping with Depression Course CWD – A (Lewinsohn, Clarke, Hops, and Andrews, 1990); Coping with Stress Course, CWS (Clarke et al., 1995); Steady Project (Clarke, Debar, Ludman, Asarnow, and Jaycox, 2002), but these are primarily structured for the 50 minute individual therapy hour characteristic of the traditional psychotherapy model (Whisman, 2008; Rhode, Feeny, & Robins, 2005). In busy clinics today, it is the 20–30 minute medication management visit that frames our practice and challenges us to find new models of effective, evidence based treatment. The high prevalence of depression and anxiety in young people, in combination with current estimates that the national economic burden of mental disorders on the well being of American youth and their families approaches a quarter of a trillion dollars, underscores the importance of actively addressing emerging mental health needs of American youth (Merikangas et al., 2010). The United States Preventive Services Task Force (USPSTF) has recommended that all young people ages 12 – 18 years old be routinely screened for major depressive disorder in primary care (USPSTF, 2009). The USPSTF recommendation adds the caveat, “when systems are in place to ensure: accurate diagnosis, cognitive-behavioral or interpersonal psychotherapy and follow up” (USPSTF, 2009 p. 1223). Screening for elevated levels of depression and anxiety can be routinely conducted in clinical settings, with such instruments such as the Patient Health Questionnaire-9 (PHQ-9) for depression and Generalized Anxiety Disorder-7 (GAD-7) for anxiety, which are both in the public domain and can be used without a fee. Anxiety is often co- morbid with depression. Advanced practice psychiatric nurses have the knowledge and skills to screen, diagnose, perform psychotherapy, and provide follow-up care for adolescents and are in ideal positions to evaluate and provide treatment for teens needing mental health care (Wheeler, 2008). Further, primary care advanced practice nurses also can be instrumental in screening, identifying and providing evidence-based care for adolescents with mild to moderate depressive and anxiety symptoms. There is strong evidence to support Cognitive Behavior Therapy (CBT) as an effective first line treatment for depressed and anxious teens (March, 2009; Williams, O’Connor, Eder, and Whitlock, 2009; Watanabe, Hunot, Omori, Churchill, & Farukawa, 2007). There is a need for evidence-based CBT interventions that are portable, have demonstrated ease of use, and can be used in a variety of settings where adolescents are routinely seen. Teens are often placed on long waiting lists for specialty psychiatric care, when they need access to timely, active, evidence-based treatment (Jaycox et al., 2006; Weersing & Weisz, 2002). One cognitive behavioral skills building program for teens that can be presented in the 20 – 30 minute visits characteristic for current advanced practice was developed by Melnyk (2003) and is named COPE, an acronym for “Creating Opportunities for Personal Empowerment.” COPE is a manualized – 7 session, brief, time limited cognitive behavioral skills building therapy (CBSBT) that has been delivered in a variety of settings, including outpatient mental health centers, primary care clinics and schools. The developmentally based intervention is clearly written with teen appropriate illustrations, and has been well accepted by adolescents from 12 years to 18 years of age and their parents (Lusk & Melnyk 2011a). Measured outcomes pre- and post-COPE indicate this CBT based intervention decreases anxiety and depression in teens, and improves self concept (Lusk & Melnyk, 2011a). Because the COPE sessions can be delivered within 20 – 30 minute visits, including the usual medication management visits, the advanced practice NP can practice within the full scope of the advanced role and provide therapy (Wheeler, 2008) as well as medication management and follow up. Evidence-based psychotherapy can be part of standard care for teens seen in practices where COPE is offered. In many clinical settings, insurance and Medicaid reimburse the APPN for the COPE sessions (CPT Code 90805) as individual psychotherapy & evaluation and management which is often reimbursed at a slightly higher rate than (CPT 90862) medication monitoring. The COPE sessions clearly meet the CPT code 90805 criteria of face to face therapy for more than 50% of the visit (Schmidt, Yowell, & Jaffe, 2004), with time spent assessing the teen for need for medication, response to treatment (medication if applicable), vital signs (pulse, blood pressure) or other evaluation of health status and ongoing management of health concerns.