Recruitment period: 1999-2002. Follow-up period: 2000-2003.
*Includes those that were completed outside of the 10-month window.
†Never refused directly, but never completed the interview.
‡Youth could not be reached either due to problems with locator
information (moved, disconnected telephones), or they never responded to telephone
messages or letters.
Based on patient response to selected treatment, patients may continue
with the original treatment (eg, medication, psychotherapy, none), switch
treatments, add additional treatments, or be referred for specialty consultation
or care. After randomization, when the quality improvement intervention began,
primary care clinicians were informed that the quality improvement patient
was in the study. CBT indicates cognitive-behavior therapy.
Asarnow JR, Jaycox LH, Duan N, LaBorde AP, Rea MM, Murray P, Anderson M, Landon C, Tang L, Wells KB. Effectiveness of a Quality Improvement Intervention for Adolescent Depression in Primary Care ClinicsA Randomized Controlled Trial. JAMA. 2005;293(3):311-319. doi:10.1001/jama.293.3.311
Author Affiliations: UCLA Neuropsychiatric
Institute (Drs Asarnow, Duan, Tang, and Wells) and Mattell Children’s
Hospital (Dr Anderson), David Geffen School of Medicine at UCLA, Los Angeles,
Calif; RAND Health Program, Santa Monica, Calif (Drs Jaycox and Wells); UCLA
School of Public Health, Department of Biostatistics (Dr Duan); Kaiser Permanente
Los Angeles Medical Center (Dr LaBorde); University of California, Davis,
School of Medicine (Dr Rea); Children’s Hospital Pittsburgh, University
of Pittsburgh, Pittsburgh, Pa (Dr Murray); Venice Family Clinic, Venice, Calif
(Dr Anderson); and Ventura County Medical Center, Landon Pediatrics, Ventura,
Calif (Dr Landon).
Context 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.
Design, Setting, and Participants 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
Intervention 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.
Main Outcome Measures 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.
Lifetime prevalence for major depression in adolescence is estimated
at 15% to 20%,1 current prevalence is estimated
as high as 6%,2 and 28.3% of adolescents report
periods during the past year of depressive symptoms leading to impairment.3 Untreated depression is associated with suicide, a
leading cause of death for youth aged 15 to 24 years,4,5 and
with other negative outcomes including school dropout, pregnancy, substance
abuse, and adult depression.2,5- 9
The treatment literature supports efficacy for cognitive-behavior therapy
(CBT),10- 14 interpersonal
psychotherapy,14- 16 and
some selective serotonin reuptake inhibitors,17- 21 with
recent data indicating an advantage of combined CBT and medication for the
treatment of adolescent major depression.21 Practice
parameters have been developed and algorithms tested to guide pharmacotherapy.22- 24 However, due to uncertainty
regarding the safety and efficacy of selective serotonin reuptake inhibitors
in youth,25,26 the US Food and
Drug Administration recently conducted hearings regarding treatment of adolescent
depression and directed a black box warning in the labeling for certain antidepressants
to encourage close observation for worsening depression, suicidality, or both.27
These advances have had limited impact on community care, with current
data indicating high unmet need28- 30 and
poorer quality and outcomes for community treatment compared with efficacy
studies.31,32 We address these
gaps by evaluating a quality improvement intervention aimed at improving access
to evidence-based treatments for depression (particularly CBT and antidepressant
medication) in primary care settings. We chose primary care settings for this
study because they are major points of health service contact33 and
provide valuable opportunities for effective care for depression but are characterized
by low detection and treatment rates for depression among youth.28 We
focus on youth with depressive disorders and youth with subsyndromal depressive
symptoms. The latter group was included because youth with subsyndromal depression
show impairments comparable to those seen in depressive disorders and have
increased risk of depressive disorder onset, and because cognitive-behavioral
interventions have been shown to be effective in preventing depressive disorder
We hypothesized that the intervention would improve use of evidence-based
treatments, depression outcomes, mental health–related quality of life,
and satisfaction with mental health care after the 6-month intervention period.
The quality improvement intervention was compared with usual care.
The Youth Partners-in-Care (YPIC) study is a multisite randomized effectiveness
trial comparing the quality improvement intervention with usual care. The
study protocol was approved by the institutional review boards from all participating
organizations. All participants and parents or legal guardians for youth younger
than 18 years provided written informed consent or assent, as appropriate.
Six study sites were selected that represented 5 health care organizations,
purposively selected to include public sector (2 sites), managed care (2 sites
from 1 organization), and academic health programs (2 sites). Participants
were recruited through screening consecutive patients. Screening procedures
and results are described in detail elsewhere.36 Following
common adolescent medicine practices,37 we
defined adolescence broadly. Inclusion criteria for screening were age 13
through 21 years and presenting at clinic for primary care visit. Exclusion
criteria included having previously completed screening, not English-speaking,
clinician not in the study, and sibling already in the study. Across sites,
4750 youth were eligible for screening during the recruitment period (Figure 1).
Patients completed brief self-administered screening questionnaires
in the clinics. Enrollment eligibility was based on youth meeting either of
2 criteria: (1) endorsed “stem items” for major depression or
dysthymia from the 12-month Composite International Diagnostic Interview (CIDI-12
[Core Version 2.1])38 modified slightly to
conform to diagnostic criteria for adolescents,39 1
week or more of past-month depressive symptoms, and a total Center for Epidemiological
Studies-Depression Scale (CES-D)40 score of
16 or greater (range of possible scores, 0-60); or (2) a CES-D score of 24
or greater. The screening questionnaire did not ask about suicidality.
Of 4750 youth eligible for screening, 4149 (87%) began screening, and
4002 (84%) completed screening. Roughly a quarter (1034/4002 [26%]) met enrollment
eligibility criteria. Among those, 418 (40%) enrolled in the study, completed
the baseline assessment, and were randomized. Among remaining eligible youth,
259 could not be contacted, 123 actively refused the study, and 234 passively
refused by not providing consent (166) or baseline assessments (68).
After completing the baseline assessments, participants were randomly
assigned to receive the quality improvement intervention or the usual care
condition using a computerized random number generator. To improve balance
across conditions in terms of clinician mix and patient sequence, we stratified
participants by site and clinician and blocked participants recruited from
the same clinician in pairs according to the time of their enrollment (98%
[409/418] of patients had primary care clinicians [n = 52] with
patients in both conditions). Screening/enrollment staff were masked to randomization
status and sequence and were different from assessment staff. There was also
a time delay between screening and randomization (median, 21 days). These
design features prevented protocol subversion due to selection bias in enrollment
that might occur with blocked randomization41 ;
we also applied the Berger-Exner test42 to
confirm this expectation.
Among the 418 youth enrolled, 344 (82%) completed the 6-month follow-up
assessment. Follow-up rates did not differ significantly across conditions
(81% in quality improvement vs 84% in usual care; P = .36).
The usual care condition was enhanced by providing primary care clinicians
with training and educational materials (manuals, pocket cards) on depression
evaluation and treatment.43 Patients receiving
usual care had access to usual treatment at the site but not to the specific
mental health providers trained in the CBT and care management services used
in the study. Throughout all phases of the study (including screening), all
patients were reminded that the clinics/clinicians were participating in this
project because they were interested in how the youths were feeling and that
it was important for them to talk to their physicians or nurses about any
difficulties, including problems with stress or depression. Serious concerns
were communicated to clinicians, and procedures were established to address
emergency situations and facilitate care for patients seeking care or information.
The quality improvement intervention included (1) expert leader teams
at each site that adapted and implemented the intervention; (2) care managers
who supported primary care clinicians with patient evaluation, education,
medication and psychosocial treatment, and linkage with specialty mental health
services; (3) training of care managers in manualized CBT for depression;
and (4) patient and clinician choice of treatment modalities (CBT, medication,
combined CBT and medication, care manager follow-up, or referral). The study
informed primary care clinicians regarding patient participation only in the
quality improvement condition.
Care managers were psychotherapists with master’s or PhD degrees
in a mental health field or nursing. The study provided a 1-day training workshop
on the study CBT and the study evaluation and treatment model, detailed manuals,
and regular consultation to support fidelity to the treatment model and provide
case-specific training in CBT and patient outreach/engagement strategies.
Quality improvement patients and their parents (when appropriate) were
offered a free clinic visit with the care manager (Figure 2). This visit emphasized evaluation of patient and family
needs, education regarding treatment options, and clarification of preferences
for different treatment options. A treatment plan was developed, finalized
with the primary care clinician, and modified as needed (eg, if a patient
started on CBT showed only a partial response, the care manager encouraged
another primary care clinician visit to consider medication). Care managers
followed up with patients during the 6-month intervention period, coordinated
care with the primary care clinician, assisted the clinician in patient management,
delivered the CBT, and incorporated CBT components into briefer follow-up
contacts. The study CBT was based on the Adolescent Coping
With Depression Course,44 developed
for individual or group sessions and adapted to enhance feasibility within
primary care practice settings. This manualized CBT45 included
a session introducing the treatment model, three 4-session modules emphasizing
different CBT components (activities/social skills, cognition, and communication/problem-solving),
and a final session emphasizing relapse prevention and follow-up care. Sessions
were designed to be 50-minute weekly sessions. The Texas Medication Algorithms
for Major Depressive Disorder23 guided medication
treatment and emphasized selective serotonin reuptake inhibitors as the first-stage
medication choice. Additional description of the intervention is provided
Youth baseline and 6-month follow-up assessments were conducted by interviewers
from the Battelle Survey Research Institute who were masked to intervention
assignment and used computer-assisted telephone interviews. Interviewers continued
attempts to contact participants until an active refusal was obtained or it
became clear that the participant could not be contacted. Interviewers were
trained and supervised by senior staff with official CIDI and Diagnostic Interview
Schedule training and more than 10 years of experience in conducting CIDIs
and the Diagnostic Interview Schedule. Interview quality was rated on 10%
of interviews for accuracy in presenting questions, probing, and coding; ratings
indicated good quality (3-point scale, 1 = highest rating; mean,
1.02 [SD, 0.06]). Emergency procedures were developed with each site, and
clinicians were available to address any emergencies or issues of serious
concern (eg, report of current suicidality, danger to self or others). Assessments
concluded with a reminder to patients that their physicians or nurses wanted
them to call if they had any problems or difficulties, and contact or referral
information was provided as needed.
Youth baseline and follow-up interviews assessed mental health–related
quality of life using the Mental Health Summary Score (MCS-12) (range of possible
scores, 0-100),48,49 overall mental
health using the Mental Health Inventory 5 (MHI-5) (range of possible scores,
5-30),50 service use during the previous 6
months using the Service Assessment for Children and Adolescents51 adapted
to incorporate items assessing mental health treatment by primary care clinicians,52 and satisfaction with mental health care using a
5-point scale ranging from very dissatisfied (1) to very satisfied (5).53 CIDI diagnoses of major depression and dysthymia
were evaluated at baseline and follow-up. To capture a broad range of youth
depression, depressive disorder was diagnosed regardless of history of manic
symptoms. The CES-D was administered at follow-up. Sociodemographic characteristics
were assessed at baseline. Ethnicity and race were self-classified to clarify
minority representation in the sample.
The primary outcome variable was CES-D total score. To clarify clinical
significance, we also examined the proportion of youth scoring in the severe
range (CES-D score ≥24). Secondary outcomes were MCS-12 scores and satisfaction
with mental health care. Process-of-care measures included rates of mental
health care, psychotherapy/counseling, and medication for mental health problems.
Because the CIDI-12 asked about the interval between baseline and 6-month
assessments, changes in depression diagnosis were not predicted.
We examined the demographic and baseline clinical characteristics of
the enrolled sample, and compared the quality improvement and usual care groups
to assess the balance across experimental groups at baseline using t tests for numerical variables and χ2 tests for categorical
variables (Table 1). We also conducted
the Berger-Exner test42 for selection bias
not captured by observed baseline characteristics.
To evaluate the effectiveness of the intervention, we conducted intent-to-treat
analyses with the intent-to-treat population for follow-up outcome measures.
Patients were analyzed according to the experimental group they were assigned
to, irrespective of whether they received treatment or used study resources
such as care management. We fitted analysis of covariance models for continuous
outcomes, and logistic regression models for dichotomous outcomes, with intervention
status as the main independent variable and the baseline measure for the same
outcome as the covariate. However, for follow-up CES-D score, we used baseline
MHI-5 score as the covariate, because CES-D score was not measured at baseline.
(CES-D and MHI-5 scores were highly correlated at follow-up [r = 0.78, P<.001]; therefore,
baseline MHI-5 score was used here as the proxy measure for baseline CES-D
score.) Intervention status and baseline measure were both specified as fixed
effects. To show effect sizes, we present unadjusted means and proportions
by intervention groups, as well as adjusted differences or odds ratios (ORs)
that are adjusted for the baseline measure. We also conducted sensitivity
analyses for intervention effects using a design-based nonparametric method,
the permutation test, to ascertain whether our findings are sensitive to model
We used nonresponse weighting57,58 to
address missing data for the 18% of patients who did not complete 6-month
follow-up assessments. The objective of nonresponse weighting is to extrapolate
from the observed 6-month sample to the original intent-to-treat sample. Nonresponse
weights were constructed by fitting logistic regression models to predict
follow-up status from baseline clinical and sociodemographic characteristics.
Separate models were fitted for each intervention group. The reciprocal of
the predicted follow-up probability is used as the nonresponse weight for
each participant. Intent-to-treat analyses for intervention effects, weighted
by nonresponse weights, were conducted using survey commands in STATA version
8.59 Weighted and unweighted analyses yielded
very similar results. We report only results from weighted analyses.
We used 2-sided P values of less than.05 as
the criterion for statistically significant differences. We used multivariate
analysis of variance to combine the results across primary outcome variables
to ascertain the potential for spurious significance due to multiple comparisons.
The enrolled sample was clinically and sociodemographically diverse
(Table 1). Most patients were female
(78%), ethnic minorities (87%), spoke a language other than English at home
(64%), and had at least 1 working parent (89%). The sample included those
with depressive disorders (43%, primarily major depression [42%]) and those
with subsyndromal depression (57%). Among youth with major depression, 60%
had CIDI-defined moderate to severe illness, 29% had recurrent illness, 3%
had comorbid dysthymia, and 15% had a history of manic episodes. Dysthymia
without another mood disorder was rare (<1% [3/418]), as was bipolar disorder
without a past-year depressive episode (1.7% [7/418]). Comorbid mental health
symptoms were common: 28% of youth reported significant externalizing symptoms
or conduct problems (eg, disobedient, stealing, aggression),60 22%
screened positive for posttraumatic stress disorder,61 25%
endorsed 1 or more indicators of problematic substance use,62 27%
reported suicidal ideation,60 and 13% reported
suicide attempts or deliberate self-harm (defined as some suicidal ideation
plus some suicide attempt or deliberate self-harm during the previous 6 months
on the Youth Self Report).60 About 22% reported
specialty mental health care and psychotherapy/counseling in the past 6 months,
and 16% reported medication treatment in the past 6 months. Medication treatment
was more common in youth with depressive disorders vs those with subsyndromal
depression (OR, 4.55; 95% confidence interval [CI], 2.54 to 8.16; P<.001). Depression was detected at the index primary care visit
in 19% of youth, based on youth report of depression counseling during this
There were no significant differences between the quality improvement
and usual care groups at baseline. Most differences were far from being statistically
significant, except for a near-significant trend for MCS-12 score (P = .08). The Berger-Exner test for selection bias was insignificant
for all outcome measures (P = .52 for CES-D
score, P = .48 for MCS-12 score, and P = .35
for satisfaction with mental health care).
At 6-month follow-up, patients receiving the quality improvement intervention
reported significantly higher rates of mental health care than did those receiving
usual care (32% vs 17%; OR, 2.8; 95% CI, 1.6 to 4.9; P<.001)
(Table 2). This was due to increased
rates of psychotherapy in the intervention group, as the difference for medication
treatment was small and statistically nonsignificant (Table 2). Rates of combined medication and psychotherapy were similar
for quality improvement (10%) and usual care (12%) patients. No between-group
differences were found in rates of combined treatment vs monotherapy (medication
or psychotherapy, OR, 1.4; 95% CI, 0.6 to 3.6; P = .43)
or in rates of combined treatment vs no treatment (OR, 1.5; 95% CI, 0.6 to
3.4; P = .40). Quality improvement patients
had a higher rate of monotherapy (23% quality improvement vs 14% usual care)
vs no treatment (OR, 2.1; 95% CI, 1.1 to 3.8; P = .02),
again due to a higher rate of psychotherapy in the quality improvement group.
Quality improvement patients reported more psychotherapy sessions than did
patients receiving usual care, but relatively few patients reported 12 or
more sessions (Table 2). Medication
treatment was more common among youth with depressive disorders (OR, 3.1;
95% CI, 1.6 to 6.0; P<.001). Similar rates of
mental health care from primary care clinicians at baseline and follow-up
indicated that the intervention primarily affected use of a care manager or
mental health services (Table 2). These
self-report data were consistent with chart-review data indicating higher
rates of care manager/CBT contacts vs medication in quality improvement patients
(44% vs 13%); 34% of quality improvement patients received in-person CBT based
on chart review.
At the 6-month follow-up, quality improvement patients had significantly
lower mean (SD) CES-D scores compared with usual care patients (19.0 [11.9]
vs 21.4 [13.1], P = .02) (Table 3). This improvement among intervention patients was also
reflected in a significantly lower rate of severe depression (CES-D score
≥24) in the quality improvement group (31% vs 42%; OR, 0.6; 95% CI, 0.4
to 0.9; P = .02). Quality improvement patients
reported higher mental health–related quality of life (measured as mean
[SD] MCS-12 score) compared with usual care patients (44.6 [11.3] vs 42.8
[12.9], P = .03), as well as greater satisfaction
with mental health care (3.8 [0.9] vs 3.5 [1.0], P = .004).
The P value combining the results for CES-D score,
MCS-12 score, and satisfaction, using multivariate analysis of variance, was.004,
indicating that these findings are not of spurious significance due to multiple
We conducted a number of sensitivity analyses on the specifications
for the analytic approach. First, we used a design-based nonparametric method,
the permutation test, to ascertain whether our findings are sensitive to model
assumptions.54- 56 Results
were similar to those reported above (P = .02
for CES-D score, P = .03 for MCS-12 score,
and P = .003 for satisfaction with mental
health care). Second, we examined unweighted analyses without incorporating
attrition weights; results were similar to the analyses reported above (P = .02 for CES-D score, P = .02 for CES-D severe range, P = .03
for MCS-12 score, and P = .008 for satisfaction
with mental health care). Third, we examined weighted analyses that incorporated
attrition weights and enrollment weights (based on the probabilities of screening
and enrollment) to account for nonresponse that occurred before baseline/randomization.
Results were again similar (P = .02 for
CES-D score, P = .02 for CES-D severe range, P = .05 for MCS-12 score, and P = .03 for satisfaction with mental health care). Thus,
our findings appear robust using parametric and nonparametric analyses and
weighted and unweighted analyses.
Due to current questions regarding the impact of treatment on youth
suicidality, we conducted exploratory analyses examining intervention effects
on youth-reported suicidal ideation and suicide attempts or deliberate self-harm.
There were no significant intervention effects on either measure. The number
of patients reporting suicide attempts or deliberate self-harm declined from
14.2% at baseline to 6.4% at 6 months in the quality improvement group and
from 11.6% to 9.5% in the usual care group. However, the difference between
quality improvement vs usual care at 6 months is statistically nonsignificant
(OR, 0.55; 95% CI, 0.23 to 1.34; P = .19).
This is an important subject for future studies with larger samples powered
specifically to address this question.
This is the first demonstration that depression and quality-of-life
outcomes can be improved through a quality improvement intervention for depressed
adolescents in primary care settings. Building on prior demonstrations of
improved outcomes from quality improvement interventions for adult and late-life
depression,52,63 our results indicate
that this approach can be adapted successfully for younger populations with
similar outcomes. Both the YPIC study and the adult Partners-in-Care Study52 achieved a roughly 10 percentage-point difference
in the percentage of patients falling in the clinically significant range
on the CES-D as well as achieving clinically meaningful improvements in mental
health-related quality of life. Because evidence supporting depression treatments
is less established for adolescents than for adults, it is noteworthy that
similarly designed quality improvement interventions are effective in youth,
adults, and elderly persons.52,63
Despite increases in youth antidepressant use and primary care clinician
prescriptions for antidepressant medications in the past decade,64- 66 our
results indicate that when both psychotherapy and medication were available
options within primary care, psychotherapy (the more difficult option) was
generally preferred. Unlike adult studies in which medication rates were higher
and increased with quality improvement interventions,52,63 our
intervention did not increase medication rates, despite intervention support
of medication treatment. Because the study preceded recent warnings regarding
use of antidepressant medications among adolescents,27 our
findings were not due to this public controversy and suggest a developmental
difference. This reinforces the importance of resources to enable evidence-based
psychotherapy in quality improvement programs for adolescent depression in
primary care settings.
Our intervention replicated key features of routine community practices:
specialties usually treating adolescents (pediatrics, family medicine, adolescent
medicine), diverse patients seen in clinics, and patient and clinician choice
of treatment. Under these naturalistic conditions, patients and clinicians
elected relatively low levels of treatment, with most patients receiving care
manager follow-up or low doses of CBT. This led to modest reductions in depression,
compared with efficacy studies that tested more intensive interventions with
restricted patient populations under controlled conditions. However, our effects
were similar to those in other quality improvement effectiveness trials.52 Intervention effects were also averaged across the
entire quality improvement group (including untreated patients), and patients
in the usual care group were free to receive “usual care” treatments,
likely attenuating intervention effects.
What can be accomplished with a quality improvement demonstration vs
a clinical efficacy study in which treatments are assigned? Our quality improvement
study asks: what can primary care practices accomplish by making it easier
for clinicians and patients to understand and select evidence-based depression
treatments? The YPIC study provided resources and information to encourage
patients and clinicians to select evidence-based treatments. Using standardized
effect sizes, outcome effects are small compared with those from efficacy
studies; in absolute magnitude, however, observed differences were similar
to 6-month intervention effects in the adult Partners-in-Care Study52 and are of public health significance given the prevalence
and morbidity of adolescent depression.
A portion of the targeted sample was lost during screening/recruitment/enrollment
procedures, compromising the generalizability of study findings. To some extent,
incorporating enrollment weights to account for preenrollment sample loss
can mitigate this limitation. Our sensitivity analyses that incorporated enrollment
weights yielded results similar to those from our primary analyses (both analyses
incorporated attrition weights for postrandomization sample loss). To the
extent that enrollment weights capture differences between the enrolled sample
and nonenrolled eligible youth, this supports the generalizability of our
findings to similar primary care practice. However, enrollment weights may
not capture all differences; for instance, participation may have been higher
for youth with a preference for psychotherapy due to generally more limited
access to psychotherapy vs medication.
The study had other limitations. Because primary care clinician training
in care of depression was common to all patients, the YPIC study tests the
marginal benefit of the full quality improvement intervention vs usual care
“enriched” by primary care clinician education. Although prior
research suggests minimal impact for clinician education alone,67 this
provides a conservative test of the intervention. Primary care clinicians
may also learn from experiences with their quality improvement patients and
carry this learning over to patients in the usual care group, again resulting
in a conservative estimate of the intervention effect. We selected sites to
represent a range of practice conditions, but sites were not selected at random.
Although our sample is diverse and includes large numbers of minority youths,
results may not be generalizable across all ethnic groups, geographic locations,
and practice settings. Assessments emphasized youth self-report but with established
reliable measures.49- 51,68 Data
on longer-term outcomes are needed to clarify the sustainability of intervention
effects after discontinuing intervention resources. Despite significant intervention
effects, almost a third of quality improvement patients continued to show
severe depressive symptoms. The availability of psychotherapy may have led
to substitution of psychotherapy for medication, and emphasizing combined
psychotherapy and medication might have led to improved outcomes.21 Our effectiveness design, which encouraged but did
not require treatment fidelity or adherence, likely weakened intervention
effects. Because the study supported screening, primary care practices would
have to screen patients to implement the intervention independently. The intervention
effect included the effect of improved detection, although the literature
suggests that detection without additional practice resources to support mental
health care has little impact on outcomes.69,70
Since our goal was to improve access to care with patients choosing
a range of specific treatments, the study does not provide information on
the effects of specific treatments (CBT, medication). The fact that our intervention
impacted rates of psychotherapy but not medication use suggests that psychosocial
interventions contributed to improved patient outcomes. However, it could
be that even with low medication rates, allowing patients and clinicians to
select preferred treatments contributed to improved matching of patients to
treatments that were most likely to be effective for them. This is consistent
with our finding that youth with depressive disorder, the group with greatest
need, was most likely to receive medication treatment.
In conclusion, the present results demonstrate that quality improvement
interventions for adolescent depression are feasible in primary care settings
and associated with benefits on measures of depression, quality of life, and
satisfaction with mental health treatment. Our quality improvement model and
results are consistent with the recommendation of the US Preventive Services
Task Force71 that depression screening in primary
care is effective when combined with access to treatments such as those provided
in the YPIC trial.
Corresponding Author: Joan Rosenbaum Asarnow,
PhD, UCLA Neuropsychiatric Institute, David Geffen School of Medicine at UCLA,
760 Westwood Plaza, Los Angeles, CA 90024-1759 (email@example.com).
Financial Disclosures: Independent of this
study, Dr Asarnow has consulted on cognitive-behavior therapy and cognitive-behavior
therapy for depression, Dr Jaycox has consulted on cognitive-behavior therapy
for anxiety, and Dr Rea has consulted on cognitive-behavior therapy for depression.
Dr Jaycox has received an unrestricted grant from Pfizer unrelated to the
study herein. Dr Asarnow consults on this grant. Dr Murray is a member of
the Behavioral Health Committee of Highmark (a Pittsburgh-based insurer).
Author Contributions: Dr Asarnow had full access
to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analyses.
Study concept and design: Asarnow, Jaycox,
Duan, Murray, Anderson, Tang, Wells.
Acquisition of data: LaBorde, Rea, Landon.
Analysis and interpretation of data: Asarnow,
Duan, Tang, Wells.
Drafting of the manuscript: Asarnow, Jaycox,
Critical revision of the manuscript for important
intellectual content: Asarnow, Duan, LaBorde, Rea, Murray, Anderson,
Landon, Tang, Wells.
Statistical analysis: Asarnow, Duan, Tang.
Obtained funding: Asarnow, Jaycox, Wells.
Administrative, technical, or material support:
Asarnow, Jaycox, LaBorde, Rea, Murray, Anderson, Landon, Tang, Wells.
Study supervision: Asarnow, Duan, Rea, Murray,
Anderson, Landon, Tang, Wells.
Funding/Support: The study was supported by
grant HS09908 from the Agency for Health Care Research and Quality. Additional
support for data analysis and for Drs Duan, Tang, and Wells was provided by
grant MH068639 from the National Institute of Mental Health.
Role of the Sponsor: The agencies funding this
study had no role in the design and conduct of the study; the collection,
management, analysis, and interpretation of the data; or the preparation,
review, or approval of the manuscript.
Acknowledgment: We thank the participating
sites and their clinicians, staff, and patients whose commitment to the project
made the study possible. Participating sites include Kaiser Permanente Medical
Center Los Angeles, the Venice Family Clinic, Ventura County Medical Center
(with behavioral health provided by staff from Ventura County Behavioral Health),
Children's Hospital Pittsburgh (with behavioral health provided by staff
from Western Psychiatric Institute and Clinics), and the UCLA Department of
Pediatrics (with behavioral health provided by staff from the Department of
Psychiatry). We also acknowledge the consultants and members of our advisory
boards who provided guidance and expertise regarding conception and design
throughout the course of the project: David Brent, Gabrielle Carlson, Greg
Clarke, Donald Guthrie, Kelly Kelleher, Mary Jane Rotheram-Borus, John Weisz,
and Frances Wren. Thanks also to Donald Guthrie, Diana Liao, Xulei Liu, Ari
Stern, Beth Tang, and Lily Zhang for their contributions to data analysis.
We thank Charlotte Mullican for her support and wisdom, and the team contributing
to intervention development and implementation: Angela Albright, Janeen Armm,
Gabrielle Carlson, Emily McGrath, Jeanne Miranda, Mark Schuster, James McCracken,
and Bonnie Zima. Thanks also to the members of the YPIC group for assistance
with data acquisition and project administration, including Geoff Collins,
Samantha Fordwood, Eunice Kim, James McKowen, Diana P. Huizar, and Rochelle
Noel, and thanks to Nicole Janowicz for her assistance with manuscript preparation.