Lifetime prevalence for major depression in adolescence is estimated at 15 percent to 20 percent, current prevalence is estimated as high as 6 percent, and 28.3 percent of adolescents report periods during the past year of depressive symptoms leading to impairment, according to background information in the article. Untreated depression is associated with suicide, a leading cause of death for youth aged 15 to 24 years, and with other negative outcomes including school dropout, pregnancy, substance abuse, and adult depression. Few depressed adolescents receive effective treatment for depression in primary care settings.
Joan Rosenbaum Asarnow, Ph.D., of the David Geffen School of Medicine at UCLA, Los Angeles, and colleagues conducted a study (Youth Partners-in-Care [YPIC]) to determine if a quality improvement intervention for adolescents would improve use of evidence-based treatments, depression outcomes, mental health–related quality of life, and satisfaction with mental health care after a 6-month intervention period. The randomized controlled trial was conducted between 1999 and 2003 and included 418 primary care patients, aged 13 through 21 years, with current depressive symptoms. The participants were from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States, and were assigned at random to receive either usual care at their primary care clinic or a quality improvement intervention.
The quality improvement intervention included expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients' depression, training for care managers in cognitive-behavior therapy for depression, with patient and clinician choice regarding treatment. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment.
Depressive symptoms were measured using the Center for Epidemiological Studies-Depression Scale (CES-D). Secondary outcomes were mental health–related quality of life assessed by Mental Health Summary Score (MCS-12) and satisfaction with mental health care assessed using a 5-point scale.
The researchers found that six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (average CES-D scores, 19.0 vs. 21.4), higher mental health–related quality of life (average MCS-12 scores, 44.6 vs. 42.8), and greater satisfaction with mental health care (average scores, 3.8 vs. 3.5). Intervention patients also reported significantly higher rates of receiving mental health care (32.1 percent vs. 17.2 percent) and psychotherapy or counseling (32.0 percent vs. 21.2 percent).
"This is the first demonstration that depression and quality-of-life outcomes can be improved through a quality improvement intervention for depressed adolescents in primary care settings. Building on prior demonstrations of improved outcomes from quality improvement interventions for adult and late-life depression, our results indicate that this approach can be adapted successfully for younger populations with similar outcomes. Both the YPIC study and [another study involving adults] achieved a roughly 10 percentage-point difference in the percentage of patients falling in the clinically significant range on the CES-D as well as achieving clinically meaningful improvements in mental health-related quality of life. Because evidence supporting depression treatments is less established for adolescents than for adults, it is noteworthy that similarly designed quality improvement interventions are effective in youth, adults, and elderly persons," the authors write.
"Despite increases in youth antidepressant use and primary care clinician prescriptions for antidepressant medications in the past decade, our results indicate that when both psychotherapy and medication were available options within primary care, psychotherapy (the more difficult option) was generally preferred," they add.
"In conclusion, the present results demonstrate that quality improvement interventions for adolescent depression are feasible in primary care settings and associated with benefits on measures of depression, quality of life, and satisfaction with mental health treatment. Our quality improvement model and results are consistent with the recommendation of the U.S. Preventive Services Task Force that depression screening in primary care is effective when combined with access to treatments such as those provided in the YPIC trial," the researchers write.
(JAMA. 2005;293:311-319. Available post-embargo at JAMA.com)
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