Mental health services can be integrated into adolescent primary care

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Collaborative depression care: practical and effective

Approximately 11% of adolescents experience depression by age 18 years, and about 40% of those go untreated, but the findings by Dr. Richardson and her associates highlight the substantial potential that pediatric primary care clinicians have to improve identification and treatment of adolescent depression, according to Dr. Gloria M. Reeves and Dr. Mark A. Riddle.

"The high prevalence of adolescent depression and significant association of depression with other health concerns support the need to integrate depression screening and treatment in pediatric primary care settings," they wrote in an editorial (JAMA 2014;312:797-8).

The sizable proportion of adolescents (61%) whose parents refused to provide consent for screening suggests an area for future research to explore barriers to screening, and the study "provides an excellent foundation for future research on pediatric primary care clinician treatment of adolescent depression," they said. Collaborative care can be structured to promote evidence-based, personalized, and effective care, they added.

Dr. Reeves is with the University of Maryland, Baltimore. She reported having no disclosures. Dr. Riddle is with Johns Hopkins University, Baltimore. He reported receiving salary support from the Center for Mental Health Services in Pediatric Primary Care.




A collaborative care intervention in a primary care setting was more effective than was usual care for the treatment of adolescents with depressive symptoms in the randomized, controlled Reaching Out to Adolescents in Distress study.

The findings support the integration of mental health services for adolescents into the primary care setting, noted Dr. Laura P. Richardson of the University of Washington, Seattle, and her colleagues. The report was published online Aug. 26 in JAMA.

The investigators recruited adolescents aged 13-17 from nine pediatric and family medicine clinics in Washington State. Seventy-two percent were female, and 31% were nonwhite.

After 12 months, 50 of the adolescents who screened positive for depression at baseline and who then received an initial in-person education and engagement session and regular follow-up by specially trained depression care managers had a significantly greater 9.4-point decrease in mean Child Depression Rating Scale–Revised scores than did 51 adolescents who received usual care (a decrease from 48.3 to 27.5 vs. from 46 to 34.6). Those in the intervention group also were more likely than were controls – who were screened for depression and encouraged to access depression care through their group health coverage – to achieve depression response (67.6% vs. 38.6%; odds ratio, 3.3) and remission (50.4% vs. 20.7%; OR, 3.9), the researchers noted (JAMA 2014 Aug. 26 [doi:10.1001/jama.2014.9259]).

Despite having good access to mental health services, few control group patients in this study received evidence-based psychotherapy or antidepressant medication, suggesting that screening alone is unlikely to result in increased mental health treatment even if benefits are available to cover the cost, the researchers wrote. "To increase receipt of evidence-based treatments, resources are needed to identify and engage youth," they added.

Dr. Richardson and her associates cited the relatively small sample size a study limitation. "In addition, the sample selection of English speakers who were mostly white and female from a single integrated care system in the Pacific Northwest may limit generalizability," they wrote.

The National Institute of Mental Health funded the study. Dr. Richardson disclosed ties with the Palo Alto Medical Foundation. Her coauthor, Elizabeth McCauley, Ph.D., reported ties with Do Education and the Washington State Psychological Association. Coauthor Dr. David Brent reported having received fees for continuing medical education events and royalties from Guilford Press, ERT, and UpToDate.

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