As many as one in five U.S. teenagers experience an episode of major depression by the time they turn 18. Sadly, depression among teens often goes unrecognized, increasing the risk of suicide, substance abuse, and many other problems. Even among those who are diagnosed, few receive proper treatment. But now there’s a ray of hope from a new NIH-funded study that’s found success using a team approach that pairs depressed teens and their parents with a counselor .
Faced with a shortage of psychiatrists who specialize in child mental health, a multidisciplinary team from the Seattle Children’s Research Institute, University of Washington School of Medicine, and Group Health in Seattle decided to use a strategy called “collaborative care” to treat depressed teenagers. There are more than 70 clinical trials showing that team-based care approaches work well for adults with depression, but there were only two such previous studies in teens—and results were mixed.
To carry out their study, pediatrician Laura Richardson and her colleagues identified 101 teens who screened positive for major depression at nine primary care clinics in the Group Health system in Washington state. (Depressed teens who also had substance abuse problems or who had attempted or planned suicide were not included in this study group). The teens were then randomly assigned to either usual care or collaborative care.
In the usual approach, Group Health sent a letter to the depressed teen and his or her parents that described the teen’s condition and encouraged the teen to use the Group Health system to get help in the form of psychotherapy or anti-depressant medication. The letter listed phone numbers that could be used to schedule either a psychotherapy session with a child mental health specialist or a visit to a doctor who could prescribe antidepressants.
In the collaborative approach, contact was initiated by depression care managers with master’s degrees in social work, psychology, or family therapy, plus experience in working with teens. A depression care manager set up a face-to-face meeting with each teen and his or her parents to discuss the teen’s symptoms, the impact on the family, and possible treatments. At their initial meeting, this “team” jointly weighed the pros and cons of psychotherapy versus anti-depressants and together decided what treatment or combination of treatments to try. The depression care manager then facilitated the choice by scheduling psychotherapy sessions with the teen and/or by coordinating with a physician to write a prescription for anti-depressant medication. The care manager also followed up, by phone or in person, with the teenager every week or two to monitor the impact of the intervention.
As part of the collaborative care strategy, depression care managers tracked the teens’ symptoms using a short, standardized screening questionnaire. The results of the questionnaire were analyzed and discussed in weekly meetings between the care manager and a supervisory team that consisted of a psychiatrist, psychologist, and a pediatrician. If a teen’s depressive symptoms weren’t improving or were growing worse after four to six weeks, the care manager would reach out to the teen, figure out why, and, in consultation with the supervisory team, recommend a change in treatment. At the end of the 12-month study, the care manager, teen, and parents met again to devise a relapse prevention plan and to discuss steps to take if the depression recurred.
Researchers found that this team-based approach to treating depression among adolescents appears to pay off. Far more teens responded to collaborative care (67%) than usual care (39%), with half of the collaborative care group experiencing complete remission of their depressive symptoms compared to just one-fifth of the usual care group.
The key to collaborative care’s impressive success seems to lie in its initial face-to-face meeting, and continued visits and calls. If faced with side effects from medications or difficulties in scheduling therapy, many depressed teens are likely to stop treatment rather than call a medical professional for help. However, through a proactive, team-based approach, depression care managers were able to establish rapport with the teens and their parents, helping them to troubleshoot, address, and sometimes even avoid issues with medications or psychotherapy.
The interpersonal connections forged among the team members at the first meeting and strengthened by regular follow-up really seem to have made the difference. The next challenge is to implement this team-based strategy more broadly, perhaps incorporating the role of a depression care manager into more health care settings across the nation with the aim of improving outcomes for depressed teens and their families.
 Collaborative care for adolescents with depression in primary care: a randomized clinical trial. Richardson LP, Ludman E, McCauley E, Lindenbaum J, Larison C, Zhou C, Clarke G, Brent D, Katon W. JAMA. 2014 Aug 27;312(8):809-16.
Laura P. Richardson, Center for Child Health, Behavior and Development, Seattle Children’s Research Institute
Depression in Children and Adolescents (National Institute of Mental Health/NIH)
Recognizing teen depression (National Library of Medicine/NIH)
NIH support: National Institute of Mental Health