Collaborative care for adolescents with depression in primary care: a randomized clinical trial

Abstract

Importance: Up to 20% of adolescents experience an episode of major depression by age 18 years yet few receive evidence-based treatments for their depression.

Objective: To determine whether a collaborative care intervention for adolescents with depression improves depressive outcomes compared with usual care.

Design: Randomized trial with blinded outcome assessment conducted between April 2010 and April 2013.

Setting: Nine primary care clinics in the Group Health system in Washington State.

Participants: Adolescents (aged 13-17 years) who screened positive for depression (Patient Health Questionnaire 9-item [PHQ-9] score ≥10) on 2 occasions or who screened positive and met criteria for major depression, spoke English, and had telephone access were recruited. Exclusions included alcohol/drug misuse, suicidal plan or recent attempt, bipolar disorder, developmental delay, and seeing a psychiatrist.

Interventions: Twelve-month collaborative care intervention including an initial in-person engagement session and regular follow-up by master's-level clinicians. Usual care control youth received depression screening results and could access mental health services through Group Health.

Main outcomes and measures: The primary outcome was change in depressive symptoms on a modified version of the Child Depression Rating Scale-Revised (CDRS-R; score range, 14-94) from baseline to 12 months. Secondary outcomes included change in Columbia Impairment Scale score (CIS), depression response (≥50% decrease on the CDRS-R), and remission (PHQ-9 score <5).

Results: Intervention youth (n = 50), compared with those randomized to receive usual care (n = 51), had greater decreases in CDRS-R scores such that by 12 months intervention youth had a mean score of 27.5 (95% CI, 23.8-31.1) compared with 34.6 (95% CI, 30.6-38.6) in control youth (overall intervention effect: F2,747.3 = 7.24, P < .001). Both intervention and control youth experienced improvement on the CIS with no significant differences between groups. At 12 months, intervention youth were more likely than control youth to achieve depression response (67.6% vs 38.6%, OR = 3.3, 95% CI, 1.4-8.2; P = .009) and remission (50.4% vs 20.7%, OR = 3.9, 95% CI, 1.5-10.6; P = .007).

Conclusions and relevance: Among adolescents with depression seen in primary care, a collaborative care intervention resulted in greater improvement in depressive symptoms at 12 months than usual care. These findings suggest that mental health services for adolescents with depression can be integrated into primary care.

Trial registration: clinicaltrials.gov Identifier: NCT01140464.

Figure 1

Reaching Out to Adolescents in Distress (ROAD) Study Enrollment Flowchart

Figure 2

Mean CDRS-R and CIS Scores Over Time in Intervention vs Control Youth