Adolescent Depression In Primary Care Research Articles

Supporting Quality Integrated Care for Adolescent Depression in Primary Care: A Learning System Approach.

Quality integrated care, which involves primary care and mental health clinicians working together, can help identify and treat adolescent depression early. We explored systemic barriers to quality integrated care at the provincial level in Ontario, Canada using a learning system approach. Two Ontario Health Teams (OHTs), regional networks designed to support integrated care, completed the Practice Integration Profile (PIP) and participated in focus groups. The OHTs had a median PIP score of 69 out of 100. Among the PIP domains, the lowest median score was case identification (50), and the highest one was workspace (100). The focus groups generated 180 statements mapped to the PIP domains. Workflow had the highest number of coded statements (59, 32.8%). While the primary care practices included mental health clinicians on-site, the findings highlighted systemic barriers with adhering to the integrated care pathway for adolescent depression. These include limited access to mental health expertise for assessment and diagnosis, long wait times for treatment, and shortages of clinicians trained in evidence-based behavioral therapies. These challenges contributed to the reliance on antidepressants as the first line of treatment due to their accessibility rather than evidence-based guidelines. Primary care practices, within regional networks such as OHTs, can form learning systems to continuously identify the strategies needed to support quality integrated care for adolescent depression based on real-world data.

Improving Adolescent Depression in Primary Care: A Quality Improvement Initiative

The coronavirus disease 2019 pandemic has exacerbated and increased the prevalence of depression in adolescents. There is significant evidence supporting best practices for treating adolescent depression; yet, many adolescents remain unidentified or untreated by their primary care provider. For this quality improvement initiative, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) were implemented in a primary care setting. After GLAD-PC implementation, 90% of participants identified as having depression received an intervention compared with 60% of patients in the baseline group. The results showed that implementing GLAD-PC led to a significant increase in the treatment of adolescent depression in primary care.

Detecting and Managing Adolescent Depression in Primary Care: A Pilot Randomized Controlled Trial

We conducted a pilot randomized controlled trial of 100 youth to receive “Enhanced Screening as Usual” which was a basic report listing mental health symptom scores (n=23) or Screening Wizard 2.0, a web-based enhanced screener for adolescents and parents producing an extensive report for providers (n=77). All participants completed self-report assessments and electronic health-record review. Patients receiving Screening Wizard 2.0 were more likely to receive a referral for outpatient psychotherapy (25.7% vs. 18.2%) compared to Enhanced Screening as Usual, odds ratio = 1.56. Satisfaction with Screening Wizard 2.0 was high, with mean scores of 6.5 on a 1-7 scale.

Achieving Quality Integrated Care for Adolescent Depression: A Scoping Review

While primary care is often the first point of contact for adolescents with depression, more than half of depressed adolescents are either untreated or undertreated. A scoping review had been completed to summarize approaches for achieving quality integrated care in primary care focused on adolescent depression. The scoping review followed the methodological framework for scoping studies from Arksey and O'Malley. Articles were grouped into themes and mapped to 6 quality domains for integrated care from the practice integration profile survey and 3 levels of stakeholders based on WHO's definition for health systems (patient/family, primary care team, and national/sub-national health system). A total of 868 records were screened resulting in 22 articles at the patient/family-level (5/22), the primary care team-level (18/22), and the national/sub-national health system-level (16/22). The results highlighted multilevel approaches to support the delivery of quality integrated care for adolescent depression in primary care: (1) population-focused using patient registries, routine screening based on standardized algorithms, and patient-centered strategies, (2) team-driven where primary care clinicians collaborate with mental health clinicians as part of a primary care team, (3) evidence-based delivery of mental health services across the integrated care pathway from screening to follow-up visits, and (4) measurement-guided by leveraging the electronic health record infrastructure to learn from patient outcomes. More research is needed on how to provide quality integrated care for adolescent depression, specifically on patient engagement and retention, grounded in the frontline experiences of patients, families, and clinicians and supported by national and/or sub-national guidelines. A learning system could help integrate mental health services in primary care in a way that is consistent across the national and/or sub-national health system.

The Use of Electronic Health Record Tools to Improve Evidence-Based Treatment of Adolescent Depression in Primary Care.

The aim of the current study was to evaluate primary care pediatrician (PCP) adoption of an electronic health record (EHR) documentation tool and their delivery of a behavioral activation (BA) intervention within their routine practice with adolescents who screened positive for depression. We used the RE-AIM framework to describe PCP adoption and implementation of EHR documentation tools and brief evidence-based protocols. Utilization was assessed using a customized toolbar (ie, actions toolbar) via retrospective chart review. A pre-post design was used to measure changes in PCP-reported knowledge, comfort, and feasibility managing depression before and after they were trained. A mixed-effects logistic regression model was used to analyze associations of resource utilization with depression severity. PCPs used the actions toolbar to document responses to elevated Patient Health Questionnaire (PHQ-9) scores for 29.80% of encounters. The PCPs utilized the BA protocol for 10.5% of encounters with elevated PHQ-9 scores. Higher depression severity categories were associated with significantly higher odds of utilization relative to mild severity. The training was rated highly acceptable and PCPs reported significant post-training increases in comfort and feasibility. This is the first study of its kind to implement and evaluate PCP utilization of an EHR documentation tool aimed to improve delivery of an evidence-based intervention for adolescent depression. Teaching PCPs to implement brief interventions has potential to increase access to evidence-based care; however, large-scale practice change requires an effective implementation strategy that does not increase provider burden and is fully integrated into physician documentation and workflow.

JPP Student Journal Club Commentary: Addressing Adolescent Depression in Primary Care.

JPP Student Journal Club Commentary: Addressing Adolescent Depression in Primary Care.

Addressing Adolescent Depression in Primary Care: Building Capacity Through Psychologist and Pediatrician Partnership.

Early identification and treatment of depression during adolescence can contribute to healthier outcomes across the lifespan, yet adolescent depression has been underidentified and undertreated. The American Academy of Pediatrics' (AAP) Guidelines for Adolescent Depression in Primary Care (GLAD-PC) were created to enhance the identification and treatment of adolescent depression. Integrated psychologists in a pediatric primary care setting partnered with providers and clinic staff to implement an adolescent depression screening initiative and transform primary care practice around identification and management. From January 2017 through August 2018, 2107 adolescents between the ages of 11 and 18 were screened using the PHQ-9A. Eleven percent (n = 226) of adolescents had an elevated screen with a score of ≥ 10 and 7% (n = 151) screened positive for suicidal ideation. Identification of depressive symptoms led to increased integrated behavioral health services delivered by psychologists, psychiatrists, and psychology trainees. Psychologists integrated in primary care can support primary care practices to develop service delivery systems aligned with AAP's GLAD-PC and address the diverse implementation barriers associated with incorporating clinical practice guidelines in real-world settings. Universal screening for adolescent depression and response protocols were successfully implemented in a pediatric primary care clinic under the leadership of psychologists and pediatrician partners.

42.3 PARTNERING WITH PEDIATRICIANS: IMPACT OF EXPERIENTIAL TRAINING WITH STANDARDIZED PATIENTS ON SCREENING AND DIAGNOSIS OF ADOLESCENT DEPRESSION IN PRIMARY CARE

Although primary care providers (PCPs) could achieve early identification of adolescent depression, they report inadequate training in depression care. This session describes a model for experiential depression training using standardized patients and demonstrates the long-term impact of this PCP training on the screening and diagnosis of adolescent depression in primary care.

Impact of Experiential Training With Standardized Patients on Screening and Diagnosis of Adolescent Depression in Primary Care

PurposePrimary care providers (PCPs) report inadequate training in depression care. The objective of this study was to examine the long-term impact of PCP training with standardized patients on screening and diagnosis of adolescent depression in primary care. MethodsA retrospective review of electronic medical and billing records for adolescent (aged 12–18 years) well-visits assessed the frequency of screening and new diagnoses of depression. Twenty-five PCPs participated in training. The study included all adolescent well-visits in the 12 months before and after PCP training. Adolescents with a previous diagnosis of depression were excluded from the sample. Univariate and multivariable analyses were used to assess associations with screening. Odds ratios were used to describe the magnitude of associations. ResultsThe analysis included 7,108 well-visits for adolescents (mean age 14.5 years, standard deviation 1.7 years; gender: 52% male; race: 65% white, 13% black, 22% other races; ethnicity: 25% Hispanic; insurance: 67% commercial). Depression screening rate increased significantly after training from 51% to 80% of adolescents seen at well-visits (adjusted odds ratio 40.8, 95% confidence interval 32.6–51.0, p < .0001). Although the likelihood of being screened for depression increased post-training, there was variation based on patient's insurance. A significantly greater percentage of adolescents were newly diagnosed with depression after training (2.22% vs. .89%, p < .0001). ConclusionsPCPs who participated in experiential training using standardized patients were more likely to screen for and diagnose adolescent depression in the 12 months after training. Future studies are needed to examine the effects of PCP training on patient outcomes.

Improving Adolescent Depression Screening in Pediatric Primary Care

ObjectiveDepression among adolescents is a leading public health problem. Although screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care. MethodsSeventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over 7 months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices. ResultsAs practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over 7 months. Adolescents at participating practices had 3.5 times greater odds (95% confidence interval [CI], 1.14–10.98, P = .03) of being screened for depression and 37.5 times greater odds (95% CI, 7.67–183.48, P < .0005) of being screened with a validated tool than adolescents at control practices, accounting for patient characteristics. ConclusionsThere were significant within practice increases in adolescent depression screening after a QI learning collaborative, as well as in comparison with control practices 1 year later.

Effect of Internet-Based Cognitive Behavioral Humanistic and Interpersonal Training vs Internet-Based General Health Education on Adolescent Depression in Primary Care

Although 13-20% of American adolescents experience a depressive episode annually, no scalable primary care model for adolescent depression prevention is currently available. To study whether CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training) reduces the hazard for depression in at-risk adolescents identified in primary care, as compared to a general health education attention control (HE). The Promoting AdolescenT Health (PATH) study compares CATCH-IT and HE in a phase 3 single-blind multicenter randomized attention control trial. Participants were enrolled from 2012 to 2016 and assessed at 2, 6, 12, 18, and 24 months post-randomization. Primary care. Eligible adolescents were 13-18 years with subsyndromal depression and/or history of depression and no current depression diagnosis or treatment. Of 2,250 adolescents screened for eligibility, 446 participants completed the baseline interview and 369 were randomized into CATCH-IT (n=193) and HE (n=176). CATCH-IT is a 20-module (15 adolescent modules, 5 parent modules) online psychoeducation course that includes a parent program, supported by three motivational interviews. Time-to-event for depressive episode; depressive symptoms at 6 months. Mean age was 15.4 years, and 68% were female; 28% had both a past episode and subsyndromal depression; 12% had a past episode only, 59% had subsyndromal depression only, and 1% had borderline subsyndromal depression. The outcome of time-to-event favored CATCH-IT but was not significant with intention-to-treat analyses (N=369; unadjusted HR=0.59; 95% CI 0.27, 1.29; p=0.18; adjusted HR=0.53; 95% CI 0.23, 1.23, p=0.14). Adolescents with higher baseline CES-D10 scores showed a significantly stronger effect of CATCH-IT on time-to-event relative to those with lower baseline scores (p=0.04). For example, for a CES-D10 score of 15 (significant sub-syndromal depression), HR=0.20 (95% CI 0.05, 0.77), compared to CES-D10 of 5 (no sub-syndromal depression), HR=1.44 (95% CI, 0.41, 5.03). In both CATCH-IT and HE groups, depression symptoms declined and functional scores increased. CATCH-IT may be better than HE for preventing depressive episodes for at-risk adolescents with sub-syndromal depression. CATCH-IT may be a scalable approach to prevent depressive episodes in adolescents in primary care.

6.6 Impact of Provider Training on Screening and Detection of Adolescent Depression in Primary Care

Adolescent depression remains underrecognized and undertreated partly because of inadequate primary care provider (PCP) training in depression care. Training for PCPs using standardized patients (SP) has shown promise to facilitate screening and detection of adolescent depression in cross-sectional studies, but the longitudinal impact remains unknown. The objective of this study was to examine the long-term impact of PCP training on screening and detection of adolescent depression in primary care.

4.6 Efficacy of Presenting the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) to Improve Pediatric Trainees’ Knowledge and Comfort Regarding Screening and Managing Adolescents With Depression

In an effort to bridge the management gap between child/adolescent psychiatrists and pediatricians for adolescent depression, the goal of this study was to assess whether a lecture-style presentation of the 2018 revised Guidelines for Adolescent Depression in Primary Care (GLAD-PC) could improve the awareness and comfort of the screening and initial management of adolescent depression in future pediatricians.

Implementación de un programa de identificación terapéutica de depresión en adolescentes en el área sanitaria de Santiago de Compostela

Objetivo: Implementar y evaluar un programa de identificación terapéutica de depresión en adolescentes desarrollado en el Reino Unido (TIDY), entre adolescentes de 13-16 años que acuden a centros de Atención Primaria (AP) del área de Santiago de Compostela. Material y métodos: Se reclutaron profesionales de AP (PAP) que voluntariamente quisieron participar en el estudio, cuasi-experimental, de diseño antes-después. Se compararon estadísticamente los cambios en sus conocimientos y actitudes hacia la depresión adolescente y las tasas de cribado e identificación de la misma en los 80 días laborables antes y después de un periodo de formación. Se estudiaron también detalles específicos de la consulta de AP. Resultados: A pesar de la baja tasa de participación (23,19%), se observó una mejoría en los conocimientos y actitudes hacia la depresión adolescente, siendo sólo significativa en una de las características que se incluye en el diagnóstico de depresión (p&lt;0,05). Después de la formación se pasó de no hacer cribado a aplicarlo sistemáticamente. Las tasas de identificación bajaron del 3,39% al 0,86%. Dicha identificación se asoció con estar en seguimiento por depresión en la Unidad de Salud Mental Infanto-Juvenil (p=,01), tener antecedentes de problemas de salud mental (p=0,03), y tener un estado de salud subjetivo regular o malo (p=0,04). Conclusiones: El programa TIDY es un enfoque factible para mejorar la identificación de depresión adolescente en AP. Se requiere una evaluación adicional en un ensayo aleatorizado para evaluar la precisión del profesional, el impacto clínico y el coste-beneficio.

New Primary Care Guidelines Recommend Routine Screening for Depression in Adolescents

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessNew Primary Care Guidelines Recommend Routine Screening for Depression in AdolescentsRebecca GreenbergRebecca GreenbergSearch for more papers by this authorPublished Online:17 Apr 2018https://doi.org/10.1176/appi.pn.2018.4a8AbstractNew guidelines aim to improve access to care for adolescents with depression through screening and treatment in pediatric and other primary care settings.The American Academy of Pediatrics (AAP) in February published updated clinical practice guidelines to help pediatricians and other primary care providers identify and treat adolescents with depression. A notable change to the original guidelines, which were published in 2007, is the recommendation that clinicians universally screen children aged 12 and over for depression using a formal self-report screening tool during routine primary care visits. iStock/FatCamera“Research shows that only 50 percent of adolescents with depression are diagnosed before reaching adulthood,” wrote Rachel Zuckerbrot, M.D., lead author of the guidelines, and colleagues. Zuckerbrot is an associate professor of clinical psychiatry at Columbia University Medical Center and the site director of the Child and Adolescent Psychiatry for Primary Care (CAP PC) Program at Columbia University/New York State Psychiatric Institute.“In primary care (PC), as many as 2 in 3 youth with depression are not identified by their PC clinicians and fail to receive any kind of care. Even when diagnosed by PC providers, only half of these patients are treated appropriately,” the authors wrote. The updated guidelines, which are divided into two parts, were developed by a North American steering committee of researchers and clinical experts, with input from patients and their families. Part I of the guidelines focuses on how primary care providers can prepare their practice settings to identify and assist youth with depression. This section includes recommendations on how to screen adolescents for depression in accordance with DSM-5 criteria, educate patients and their families about depression and treatment options, establish relevant referral and collaborations with mental health resources in the community, and implement safety plans for adolescents who may be at risk for self-harm or suicide. Part II of the guidelines describes how primary care providers can best treat patients with depression and manage their care. Some of the topics covered in this section include when to begin treatment of depression, when to consult with mental health specialists, and how to work with mental health providers to support patient care. “There is a growing recognition that complex chronic conditions, such as depression, are most successfully managed with proactive, multidisciplinary, patient teams,” the authors of the guidelines wrote.“The earlier we identify teenagers who show signs of depression, the better the outcome,” Zuckerbrot stated in an AAP press release. ■“Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management” can be accessed here. “Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Manage-ment” is available here. ISSUES NewArchived

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management

To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting. By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience. These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized. The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management.

To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings. By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience. Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan. This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Prevention of Adolescent Depression in Primary Care

Depression affects millions of adolescents in the United States each year. This population may benefit from targeted preventive interventions. We sought to understand the internal factors that affect the ability of healthcare organizations to implement an intervention that involves mental health screening and depression prevention treatment of at-risk adolescents in primary care settings. From November 2011 to July 2016 we conducted a study of the implementation of a multisite (N=30) phase 3 randomized clinical trial of an Internet-based depression prevention intervention program (CATCH-IT). We describe the prevalence of internal barriers on the screening and enrollment process by reporting REACH (the proportion of target audience exposed to the intervention). A total of 369 adolescents were randomized into the intervention or control program. Mean REACH values for the study clinics were 0.216 for screening and 0.181 for enrollment to CATCH-IT. Mean REACH enrollment lost due to internal barriers was 0.233. This translated to 4,691 adolescents lost at screening and 2,443 adolescents lost at enrollment due to internal barriers. We propose a model of the implementation process that emphasizes the importance of positive relational work that assists in overcoming internal barriers to REACH. We also provide implications for policy and practice.

Why Adolescent Depression Is a Global Health Priority and What We Should Do About It

Why Adolescent Depression Is a Global Health Priority and What We Should Do About It

Retraction: Improving Treatment of Adolescent Depression in Primary Care

The following article from the Journal of Child and Adolescent Psychiatric Nursing, “Improving Treatment of Adolescent Depression in Primary Care,” by Scott Weber, et al, published online 7 December 2010, in Wiley Online Library (http://www.onlinelibrary.wiley.com), has been retracted by agreement between the journal Editor‐in‐Chief, Elizabeth Poster, and Wiley Periodicals, Inc. The retraction has been agreed due to significant overlap with previously published material.