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Original Investigation |

Collaborative Care for Adolescents With Depression in Primary Care:  A Randomized Clinical Trial

Laura P. Richardson, MD, MPH1,2; Evette Ludman, PhD3; Elizabeth McCauley, PhD2,4; Jeff Lindenbaum, MD3; Cindy Larison, MA2; Chuan Zhou, PhD1,2; Greg Clarke, PhD5; David Brent, MD6,7; Wayne Katon, MD4
[+] Author Affiliations
1Department of Pediatrics, University of Washington School of Medicine, Seattle
2Seattle Children’s Research Institute Center for Child Health, Behavior, and Development, Seattle
3Group Health Research Institute, Seattle, Washington
4Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
5Kaiser Permanente Center for Health Research, Portland, Oregon
6University of Pittsburgh, Pittsburgh, Pennsylvania
7Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
JAMA. 2014;312(8):809-816. doi:10.1001/jama.2014.9259.
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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

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Figure 1.
Reaching Out to Adolescents in Distress (ROAD) Study Enrollment Flowchart

CRAFFT is a behavioral health screening tool developed to screen adolescents for alcohol and other drug use disorders; its acronym is constructed from key words in the 6 screening questions (car, relax, alone, forget, friends, trouble). PHQ-9 indicates Patient Health Questionnaire 9-item scale.

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Figure 2.
Mean CDRS-R and CIS Scores Over Time in Intervention vs Control Youth

Mean Child Depression Rating Scale–Revised (CDRS-R) and Columbia Impairment Scale (CIS) scores for intervention vs usual care control based on youth survey response data. Error bars indicate 95% confidence intervals.

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