Depression among youth in primary care: Models for delivering mental health services

This article emphasizes the promise of efforts to improve care for depression within the primary care setting. These efforts, however face a number of potential obstacles. We have reviewed the literature on the detection and treatment of depression among youth in primary care settings and argue that primary care offers underutilized potential for reaching out to youth and improving access to high-quality care for depression. Much work remains to be done before this potential can be realized. The recommendations below highlight crucial directions for future research and clinical efforts: 1. Traditional primary care practices offer an opportunity to identify and reach youth who need care for depression. To reach youth who do not present in typical primary care settings, outreach is needed to emergency services, urgent care, and obstetric-gynecologic settings. The increased emphasis on developing school-based and school-linked health centers may also prove helpful for increasing the number of youth who are seen in primary care because there centers bring the services to a setting that is easily accessible to most youth. 2. Strategies for improving detection of depression in primary care settings must be developed and tested. Given the constraints of primary care visits, these strategies must be relatively brief and not require extensive primary care provider time. Use of nonphysicians such as practice assistants, nursing staff or associated mental health workers will be needed to support physician efforts. Furthermore, although brief self-report instruments may be useful in identifying a broad group of youth who may benefit from care, available instruments are likely to lead to over-identification and will require additional screening and triage of youth to appropriate services. Some identified youth may be require or want care; others may require further evaluation; others can be treated through primary care resources; and others will have complex conditions that require specialty consultation or referral. 3. Low rates of detection and evidence-based treatment for depression in primary care settings underscore the urgent need to understanding the barriers to care within primary care settings and to develop interventions that reduce potential barriers and improve access to high-quality care. 4. Detection efforts within primary care settings are likely to yield a somewhat different population than the population of youth identified in specialty mental health clinics or schools. Notable, physical health problems are likely to be more common in primary care populations. The limited extent data also suggest that, as in most non-primary care samples of depressed youth, youth with depression seen in primary care settings are likely to present with a number of comorbid mental health conditions. Thus, there is a need to test extent treatments within primary care settings, and adaptation may be required to meet the needs of youth seen through primary care. 5. Motivation for treatment is likely to be lower for youth identified through primary care than for those seen in specialty care, particularly when youth have not identified themselves as requiring treatment. Strategies need to be developed and tested to enhance motivation and to target treatment efforts at those youth who are most likely to benefit from services. 6. The confidential nature of the patient-provider relationship, particularly in primary care settings where youth have sought care for sensitive issues (e.g., pregnancy, birth control), underscores the need to develop effective strategies for working with families and mobilizing parents to support treatment and recovery. In primary care settings, parents may be less likely to be aware of youth problems, and youth may be reluctant to disclose difficulties to their parent. 7. Research is needed to identify service-delivery strategies tht are practical in real-world settings and are associated with improved quality of care and outcomes in children and adolescents treated for depression in primary care settings. 8. Collaborative models of service delivery seem to be promising. These models build on the strengths of primary care settings and relationships and suport primary care providers with resources that enables them to expand with diagnostic and treatment targets to include depression and other mental health problems. The recent and ongoing studies reviewed in this articles provide some examples of these models. Future research is needed to clarify the effectiveness, costs,and benefits of this approach.