Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial.
BACKGROUND
Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings.


OBJECTIVE
To evaluate the effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices.


METHODS
Randomized controlled trial conducted between 1999 and 2003 enrolling 418 primary care patients with current depressive symptoms, aged 13 through 21 years, from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States.


METHODS
Usual care (n = 207) or 6-month quality improvement intervention (n = 211) including expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients' depression, training for care managers in manualized cognitive-behavior therapy for depression, and patient and clinician choice regarding treatment modality. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment.


METHODS
Depressive symptoms assessed by Center for Epidemiological Studies-Depression Scale (CES-D) score. 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.


RESULTS
Six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (mean [SD] CES-D scores, 19.0 [11.9] vs 21.4 [13.1]; P = .02), higher mental health-related quality of life (mean [SD] MCS-12 scores, 44.6 [11.3] vs 42.8 [12.9]; P = .03), and greater satisfaction with mental health care (mean [SD] scores, 3.8 [0.9] vs 3.5 [1.0]; P = .004). Intervention patients also reported significantly higher rates of mental health care (32.1% vs 17.2%, P<.001) and psychotherapy or counseling (32.0% vs 21.2%, P = .007).


CONCLUSIONS
A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.
Asarnow
Joan Rosenbaum
JR
UCLA Neuropsychiatric Institute, David Geffen School of Medicine at UCLA, Los Angeles, Calif 90024-1759, USA. jasarnow@mednet.ucla.edu
Jaycox
Lisa H
LH
Duan
Naihua
N
LaBorde
Anne P
AP
Rea
Margaret M
MM
Murray
Pamela
P
Anderson
Martin
M
Landon
Christopher
C
Tang
Lingqi
L
Wells
Kenneth B
KB
D000293:Adolescent; D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003863:Depression / Q000628:therapy*; D003866:Depressive Disorder / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000592:standards*; D011613:Psychotherapy / Q000592:standards; D011785:Quality Assurance, Health Care
D000928:Antidepressive Agents