A Practical and Effective Primary Care Intervention for Treating Adolescent Depression

Abstract

Adolescent depression is a major 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 10-to 19-year-old youth worldwide, above common physical health problems like anemia and asthma. 2 The effects of depression on overall health are widespread and pervasive because of 3 principal concerns: depression is associated with serious mental health problems (eg, suicidality), 3 physical health problems (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 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. A 2009 American Academy of Pediatrics policy statement emphasized that pediatric primary care clinician (pediatric PCC) mental health competencies should "go beyond managing ADHD [attentiondeficit/hyperactivity disorder]" to address other conditions including adolescent depression. 7 Pediatric PCCs have evidencebased options for treating depression. There are currently 2 medications approved by the US Food and Drug Administration for adolescent depression (fluoxetine, escitalopram) as well as 2 types of evidence-based psychotherapy interventions: cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). 8 In this issue of JAMA, Richardson et al 9 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 care model intervention vs usual care. The collaborative care model included an engagement and psychoeducation component, and parents and adolescents 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 CBT model and psychopharmacology treatment was provided using a protocol to support adequate dosing with evidence-based medication. The primary outcome was a blinded rating of change in depression severity score from baseline to 12 months, 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 hea...

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