Collaborative care in primary care works for depressed teens: study

By Megan Brooks

NEW YORK (Reuters Health) - Depressed adolescents can benefit from collaborative care delivered in primary care, new research shows.

The collaborative care intervention, which provided education and evidenced-based treatment and encouraged parent participation, resulted in greater improvement in depressive symptoms at 12 months than usual care, researchers report in JAMA August 27.

"The cost of delivering the intervention was approximately $1400 per patient served, which is lower than many other medical interventions that we commonly perform, such as MRI studies," first author Dr. Laura P. Richardson of Seattle Children's Research Institute and University of Washington School of Medicine, Seattle, told Reuters Health by email.

"Studies have shown that depression is associated with worse health outcomes," she added. "As our country moves towards improving quality of care and patient-centered outcomes under new initiatives such as the Accountable Care Organizations and the Patient-centered Medical Home, there may be additional incentives for offering this type of treatment not just to improve depression outcomes but also to improve health for adolescents as a whole."

The study included 101 adolescents 13 to 17 years old with depression from nine primary care clinics in the Group Health Cooperative in Washington State. Fifty were randomly allocated to collaborative care and 51 to usual care for 12 months.

Collaborative care involved developmentally sensitive materials and structured involvement of both the adolescent and parent in an initial education and engagement session, choice of treatment (antidepressant medication, cognitive behavioral therapy (CBT) or both) and follow-up sessions delivered by master's-level depression care managers. In the usual care group, youth received depression-screening results and could access mental health services through Group Health.

By 12 months, adolescents receiving collaborative care had a greater decline in depressive symptoms than their peers in usual care; 68% of collaborative care adolescents had at least a 50% decline in depressive symptoms compared to 39% of usual care adolescents.

The overall rate of depression remission at 12 months was 50.4% with collaborative care vs. 20.7% with usual care (p=0.007).

"These findings suggest that mental health services for adolescents with depression can be effectively integrated into primary care," the authors conclude in their article.

"Implementing this type of intervention in a primary care practice would not be difficult. Many clinics are already implementing this model with their adult patients. The main challenge would be identifying someone who can serve in the depression care manager role and allocating enough time for that staff member to actively reach out to patients and track their progress," Dr. Richardson said.

"The care manager could be someone who is already employed by the clinic, such as a nurse or a social worker, or a new employee specific to that role," she added. "The care managers in our study covered 4 to 5 clinics each, so it would also be possible for clinics to share or work together to provide this service. Additionally, practices would need a child mental health expert who could help to supervise and support the care manager. Given the short time commitment of this role (1-2 hours per week), this would be most effectively done by developing a partnership with a mental health provider in the community or region."

What would be the incentive for primary care clinics to adopt this approach? "At this time, the main incentive is to improve outcomes for depressed patients," Dr. Richardson said.

"As a pediatrician, I see these patients as being some of the most challenging patients we treat. It is difficult to watch our patients struggle and to wish that we could do more. The collaborative care model helps to address some of the barriers we face in treating depression such as limited time and difficulty engaging our patients in treatment and significantly improves outcomes," Dr. Richardson added.

In a linked editorial, Dr. Gloria M. Reeves, of the University of Maryland School of Medicine, and Dr. Mark A. Riddle, of the Johns Hopkins University School of Medicine, both in Baltimore, praise the researchers for providing a "practical and effective strategy for screening, evaluating and treating adolescent depression in primary care."

They think it's noteworthy that in the intervention group, 54% of families opted for combined medication and psychotherapy treatment, 38% chose psychotherapy only, and 4% chose medication only (4% dropped out prior to treatment selection).

"These data suggest that most families prefer adolescent depression treatment that has a psychotherapy component, a treatment modality that is less commonly available in primary care practices compared with medication treatment," Drs. Reeves and Riddle say.

They conclude, "Pediatric primary care clinicians have substantial potential to improve identification and treatment of adolescent depression. This study suggests that collaborative care treatment of adolescent depression can be structured to promote care that is evidence-based, personalized, and effective. Further research on this type of model has tremendous potential to benefit both families and clinicians."

The project was funded by the National Institute of Mental Health.

SOURCE: http://bit.ly/YVT2Qj and http://bit.ly/1pa7zmo

JAMA 2014;312:797-798,809-816.

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