Collaborative care improves depression in teens

Seattle Children’s, Group Health, and University of Washington study in JAMA

Seattle, WA—How best to care for the many adolescents who have depression? In a collaborative care intervention, a care manager continually reached out to teens—delivering and following up on treatment in a primary-care setting (the office of a pediatrician or family doctor, not a psychiatrist or psychologist) at Group Health Cooperative. Depression outcomes after a year were significantly better with this approach than with usual care, according to a randomized controlled trial published in JAMA.

Depression is common in adolescents: 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.

“Proven treatments are available, including medications and psychotherapy,” said Laura P. Richardson, MD, MPH, an investigator at Seattle Children’s Research Institute Center for Child Health, Development, and Behavior, a professor of pediatrics at the University of Washington (UW) School of Medicine, and an affiliate investigator at Group Health Research Institute. “But most American teens with depression don’t get any treatment for it. We want to change that.”

Outreach is important

The joint Seattle Children’s–Group Health–UW study was called Reaching Out to Adolescents in Distress (ROAD). In the study, 101 teens age 13–17 who were depressed on screening at nine Group Health Medical Centers in Washington state 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.

In the collaborative care intervention, a depression care manager was based in the primary care doctor’s practice. The care manager educated and helped each teen and their parents make individual decisions about treatment. Then the care manager either provided brief cognitive behavioral therapy sessions or worked with the teen’s doctor to choose and initiate an antidepressant medication.

“For adolescents, as for adults, depression can make it difficult to seek help and follow through,” Dr. Richardson said. “That’s why it’s so important that the care manager reached out to the teens regularly to see whether they were improving—and met weekly with a mental health specialist supervisor to review how the patients were responding to care.” For youth whose depression didn’t respond to the initial treatment, the care manager stepped up the treatment, following a proven protocol.

The results

At one year, depressed teens who received collaborative care were more than three times more likely to receive evidence-based treatment, and they had more decreases in depressive symptoms using a commonly used measure of depression, with more than twice as much remission of depression, compared with those who received usual care. The intervention model cost $1,403 per participant.

“The body and mind are intimately connected,” Dr. Richardson added. “So it makes good sense to organize treatment for depression in this way, integrating care for mental and physical health within primary care.”

Collaborative care for depression has been proven in more than 70 randomized controlled trials in adults, including TEAMcare, involving some of the same researchers. But only two studies had previously tested collaborative care for depression in teens, with mixed results.

Next, the research team will work to develop strategies to support clinics that are interested in implementing this model in practice.

National Institute of Mental Health grant R01 MH085645-01A1 funded this study.

Dr. Richardson’s co-authors were Evette Ludman, PhD, a 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; Jeff Lindenbaum, MD, Group Health’s director of teen health services; Cindy Larison, MA, a biostatistician at Seattle Children’s Research Institute; Chuan Zhou, PhD, research associate professor of pediatrics at the UW School of Medicine and Seattle Children’s; Greg Clarke, PhD, a senior investigator at Kaiser Permanente Center for Health Research, in Portland, OR; David Brent, MD, a professor of psychiatry, pediatrics, and epidemiology at the University of Pittsburgh and Western Psychiatric Institute and Clinic, in Pittsburgh, PA; Elizabeth McCauley, PhD, a professor of psychiatry and behavioral sciences at the UW School of Medicine and Seattle Children’s; and Wayne Katon, MD, professor and vice chair of the UW School of Medicine’s department of psychiatry and behavioral sciences. Dr. Katon is also an affiliate investigator at Group Health Research Institute. Drs. Richardson, Zhou, and Katon are also affiliated with the UW School of Public Health.

ROAD

More information about the joint Seattle Children’s–Group Health–UW Reaching Out to Adolescents in Distress (ROAD) study is at http://www.reachout4teens.org.

Seattle Children’s Research Institute

Located in downtown Seattle’s biotech corridor, Seattle Children’s Research Institute is pushing the boundaries of medical research to find cures for pediatric diseases and improve outcomes for children all over the world. Internationally recognized investigators and staff at the research institute are advancing new discoveries in cancer, genetics, immunology, pathology, infectious disease, injury prevention and bioethics, among others. As part of Seattle Children’s Hospital, the research institute brings together leading minds in pediatric research to provide patients with the best care possible. Seattle Children’s serves as the primary teaching, clinical and research site for the Department of Pediatrics at the University of Washington School of Medicine, which consistently ranks as one of the best pediatric departments in the country.

UW Medicine

UW Medicine is part of the University of Washington. Its mission is to improve the health of the public by advancing medical knowledge, providing patient care, and training the next generation of physicians and other health professionals. Its system includes Harborview Medical Center, Northwest Hospital & Medical Center, Valley Medical Center, UW Medical Center, UW Neighborhood Clinics, UW Physicians, UW School of Medicine and Airlift Northwest. UW Medicine is affiliated with Seattle Children’s, Fred Hutchinson Cancer Research Center, the Veteran’s Affairs Healthcare System in Seattle, and the Boise VA Medical Center. It shares in the ownership and governance of the Seattle Cancer Care Alliance and Children’s University Medical Group.

About Kaiser Permanente

Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 12.4 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal Permanente Medical Group physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: kp.org/share.