A Practical and Effective Primary Care Intervention for Treating Adolescent Depression

Adolescent depression is amajor pediatric public health concern. Approximately 11% of US adolescents experience an episode of depression by age 18 years.1 The World Health Organization ranks unipolar depression as the leading cause of “illness and disability” for 10to 19-year-old youthworldwide,abovecommonphysicalhealthproblems like anemiaandasthma.2Theeffectsofdepressiononoverallhealth are widespread and pervasive because of 3 principal concerns:depression isassociatedwithseriousmentalhealthproblems (eg, suicidality),3 physical healthproblems (eg, obesity),4 and adolescent high-risk behaviors (eg, substance use).5 Yet best available data indicate that approximately 40% of adolescent depression goes untreated.6 Thehighprevalenceof adolescent depression and significant associationofdepressionwithotherhealth concerns support the need to integrate depression screening and treatment in pediatric primary care settings. A 2009 American Academy of Pediatrics policy statement emphasized that pediatric primary care clinician (pediatric PCC) mental health competencies should “gobeyondmanagingADHD[attentiondeficit/hyperactivitydisorder]” toaddressother conditions includingadolescentdepression.7PediatricPCCshaveevidencebased options for treating depression. There are currently 2 medications approved by the US Food and Drug Administrationforadolescentdepression(fluoxetine,escitalopram)aswell as 2 types of evidence-based psychotherapy interventions: cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT).8 In this issue of JAMA, Richardson et al9 provide a practical and effective strategy for screening, evaluating, and treating adolescent depression in primary care. The authors completed depression screening among youth aged 13 to 17 years from a large pediatric primary care network. A sample of 101 adolescents with depression were randomized to a 12-month pediatric collaborative caremodel intervention vs usual care. Thecollaborativecaremodel includedanengagementandpsychoeducation component, andparents andadolescents could select psychotherapy, medication, or combined treatment. Master’s-level clinicians served as depression care managers to implement treatment and monitor adherence and response. Psychotherapy was provided using a CBTmodel and psychopharmacology treatment was provided using a protocol to support adequate dosingwith evidence-basedmedication. The primary outcome was a blinded rating of change in depression severity score frombaseline to 12months, and the secondary outcomes included treatment response, remission, and functional impairment. Adolescents who received the collaborative care intervention had significantly greater improvement of depression symptoms compared with the usual care group. By 12 months, approximately 67% of adolescents achieved response and 50% remission in the intervention group compared with only 38% response and 20% remission in the usual care group, even though all youth had access to mental health services. The data further indicate that adolescents referred for usual care often received suboptimal treatment. Only 27% of youth in the usual care group compared with 86% of the intervention group met the threshold for quality-of-treatment standards. Of note, in the intervention group, 54% of families opted for combinedmedication and psychotherapy treatment, 38% chosepsychotherapyonly, and4%chosemedicationonly (4% droppedout prior to treatment selection). These data suggest thatmost familiesprefer adolescentdepression treatment that has a psychotherapy component, a treatmentmodality that is less commonly available in primary care practices compared with medication treatment. The authors also estimated that the collaborative care treatment cost was $1403 per patient. This cost included supervision expenses as well as costs for aspects of the intervention outside of office visits (eg, outreach).Thus, thecollaborativecare interventionwasevidencebased, effective, and relatively inexpensive. Some limitations of the depression screening process in this novel collaborative care study raise considerations for future research and clinical care. First, a sizable proportion of eligible adolescents (61%) did not complete the depression screening. In approximately half of these cases, the parent actively refused to have their child screened by refusing to provide consent. Depression is a health condition that is often associated with significant stigma. Parents may have concerns about their child being “labeled” with a mental health disorder and may be reluctant to discuss emotional concerns by telephone. Universal psychoeducation to promote awareness about adolescent depression and reduce stigma may be helpful prior to screening so parents are not caught off guard regarding why their child is being screened and so acceptance rates of screening are improved. Some parents also may have concerns about confidentiality and may be uncomfortable discussing mental health issues, so it may be helpful to offer the option of initial screening by telephone or in person, instead of only inviting those who screen positive by telephone for a face-to-face evaluation. Related article page 809 Opinion