Team care for teen depression is found cost-effective

Dr. Ludman describes how collaborative care pays off for adolescents who have depression

by Evette J. Ludman, PhD, senior research associate at Group Health Research Institute, an affiliate investigator at the Fred Hutchinson Cancer Research Center, and an affiliate associate professor in psychiatry and behavioral sciences at the UW School of Medicine

Adolescent depression is a clinical problem that is as challenging as it is widespread. Up to one in five have major depression by age 18. Depressed youth are at greater risk of suicide, substance abuse, early pregnancy, dropping out of school, recurrent depression, and poor long-term health. Various treatments have been proven effective, including medications and psychotherapy, but most depressed teens don’t receive any of them.

It’s crucial to find a better way to approach and treat this problem. And my colleagues at Group Health, Seattle Children’s, the University of Washington (UW) and I are proud to have done just that, in a research project  that gave teens access to medications if they chose, or to convenient evidence-based psychotherapy right at their primary care doctors’ offices .

Two years ago, we showed that the Reaching Out to Adolescents in Distress (ROAD) collaborative care model (a.k.a. Reach Out 4 Teens) was effective in treating major depression in teens, significantly improving outcomes. We ran a randomized clinical trial at nine of Group Health’s primary care clinics and reported effectiveness results in JAMA.

But what about the cost?

Now we’ve analyzed this yearlong trial’s costs—and the cost of the participants’ use of health care—and found that this collaborative care is also cost-effective. We published “The Costs and Cost-Effectiveness of Collaborative Care for Adolescents with Depression in Primary Care Settings: A Randomized Clinical Trial” in JAMA Pediatrics.

Even by the most conservative benchmarks that health care economists use for willingness to pay, this collaborative-care model is a cost-effective approach for treating teen depression: We found that the intervention resulted in a net increase in quality-adjusted life-years (QALYs) at only slightly higher cost:

• Collaborative care resulted in an increase of 0.04 QALY over usual care, at a cost of $883 above usual care—only marginally more expensive.
• The mean adjusted incremental cost-effectiveness ratio was $18,239 per QALY. This is well within the realm of what is widely considered worthwhile to pay for.

During the year of the intervention, overall health plan costs were lower for the intervention ($5,161) group than with the usual care ($5,752) group, but this difference was not statistically significant. Delivering the intervention cost an additional $1,475 per person.

All about the trial

In the trial, 101 teens age 13–17 who were depressed on screening were randomly assigned to receive either collaborative care or the care that they would usually receive. With usual care, teens received their depression screening results and could get mental health services at Group Health.

With collaborative care, a care manager continually reached out to the adolescents in the intervention group—delivering and following up on treatment—medication or therapy—in a primary-care setting (the office of a pediatrician or family doctor, not a psychiatrist or psychologist).

The first author of this paper is Davene R. Wright, PhD, an investigator at Seattle Children’s Research Institute and an assistant professor of pediatrics at the UW School of Medicine. The principal investigator of the ROAD trial and the corresponding author of this paper is Laura P. Richardson, MD, MPH, an investigator at Seattle Children’s Research Institute, a professor of pediatrics at the UW School of Medicine, and an affiliate investigator at Group Health Research Institute (GHRI).

Our coauthors are Wren L. Haaland, MPH, a biostatistician at Seattle Children’s Research Institute; Elizabeth McCauley, PhD, a professor of psychiatry and behavioral sciences at the UW School of Medicine and Seattle Children’s; and Jeff Lindenbaum, MD, who was Group Health’s director of teen health services. National Institute of Mental Health grant R01 MH085645-01A1 funded this clinical trial NCT01140464.

May it spread

Collaborative care for depression in adults has repeatedly proven effective and cost-effective in randomized controlled trials—and it is being used in routine practice in many sites around the world.

A few other health care systems have approached our group for more information as they consider adopting Reach Out 4 Teens. But so far we know of no system that has implemented it as part of usual care for adolescents. Now, with our new findings on cost-effectiveness, we’re hoping that will change—and that more youth will get to enjoy the benefits of this kind of care.

For more information on the trial and contacting us, please see the Reach Out 4 Teens site: reachout4teens.org.