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Original Contribution |

Effectiveness of a Quality Improvement Intervention for Adolescent Depression in Primary Care Clinics:  A Randomized Controlled Trial FREE

Joan Rosenbaum Asarnow, PhD; Lisa H. Jaycox, PhD; Naihua Duan, PhD; Anne P. LaBorde, PhD, PsyD; Margaret M. Rea, PhD; Pamela Murray, MD, MHP; Martin Anderson, MD, MPH; Christopher Landon, MD; Lingqi Tang, PhD; Kenneth B. Wells, MD, MPH
[+] Author Affiliations

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).

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JAMA. 2005;293(3):311-319. doi:10.1001/jama.293.3.311.
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Published online

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 States.

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.

Figures in this Article

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.2,59

The treatment literature supports efficacy for cognitive-behavior therapy (CBT),1014 interpersonal psychotherapy,1416 and some selective serotonin reuptake inhibitors,1721 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.2224 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 need2830 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 onset.34,35

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.

Sample and Design

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).

Figure 1. Flow of Patients in the Intervention Trial
Graphic Jump Location

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.

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).

Intervention Conditions

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 elsewhere.46,47

Figure 2. Youth Partners-in-Care Quality Improvement Intervention Flow Chart
Graphic Jump Location

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.

Data Collection

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.

Outcomes Examined

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.

Data Analysis

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.

Table Graphic Jump LocationTable 1. Baseline Patient Characteristics (N = 418)

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 assumptions.5456

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 visit.

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).

Process of 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.

Table Graphic Jump LocationTable 2. Six-Month Intervention Effects on Process of Care (n = 344)*
Clinical Outcomes

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 comparisons.

Table Graphic Jump LocationTable 3. Six-Month Intervention Effects on Depression, Mental Health–Related Quality of Life, and Satisfaction With Mental Health Care (N = 344)*

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.5456 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,6466 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.4951,68 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 (jasarnow@mednet.ucla.edu).

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, Duan, Tang.

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.

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Centers for Disease Control and Prevention.  Youth risk behavior surveillance—United States, 2001. 2002. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.htm. Accessibility verified December 15, 2004
Shaffer D, Pfeffer C.Work Group on Quality Issues.  Practice Parameters for the Assessment and Treatment of Children and Adolescents With Suicidal BehaviorWashington, DC: AACAP Communications Dept; 2000
Weissman M, Wolk S, Goldstein R.  et al.  Depressed adolescents grown up.  JAMA. 1999;281:1707-1713
PubMed   |  Link to Article
Kandel DB, Davies M. Adult sequelae of adolescent depressive symptoms.  Arch Gen Psychiatry. 1986;43:255-262
PubMed   |  Link to Article
Birmaher B, Ryan ND, Brent DA.  et al.  Childhood and adolescent depression.  J Am Acad Child Adolesc Psychiatry. 1996;35:1427-1439
PubMed   |  Link to Article
Kovacs M. Presentation and course of major depressive disorder during childhood and later years of the life span.  J Am Acad Child Adolesc Psychiatry. 1996;35:705-715
PubMed   |  Link to Article
Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent depression.  J Am Acad Child Adolesc Psychiatry. 1999;38:56-63
PubMed   |  Link to Article
Brent DA, Holder D, Kolko D.  et al.  A clinical psychotherapy trial for adolescent depression comparing cognitive, family and supportive therapy.  Arch Gen Psychiatry. 1997;54:877-885
PubMed   |  Link to Article
Lewinsohn PM, Clarke GN, Hops H, Andrews J. Cognitive-behavioral treatment for depressed adolescents.  Behav Ther. 1990;21:385-401
Link to Article
Clarke GN, Rohde P, Lewinsohn PM, Hops H, Seeley JR. Cognitive-behavioral treatment of adolescent depression.  J Am Acad Child Adolesc Psychiatry. 1999;38:272-279
PubMed   |  Link to Article
Wood A, Harrington R, Moore A. Controlled trial of a brief cognitive-behavioural intervention in adolescent patients with depressive disorders.  J Child Psychol Psychiatry. 1996;37:737-746
PubMed   |  Link to Article
Rossello J, Bernal G. Treatment of depression in Puerto Rican adolescents.  J Consult Clin Psychol. 1999;67:734-745
PubMed   |  Link to Article
Mufson L. Weissman MM, Moreau D, Garkinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents.  Arch Gen Psychiatry. 1999;56:573-579
PubMed   |  Link to Article
Mufson L, Dorta KP, Wickramaratne P.  et al.  A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents.  Arch Gen Psychiatry. 2004;61:577-584
PubMed   |  Link to Article
Emslie G, Heiligenstein JH, Wagner KD.  et al.  Fluoxetine for acute treatment of depression in children and adolescents.  J Am Acad Child Adolesc Psychiatry. 2002;41:1205-1215
PubMed   |  Link to Article
Emslie G, Rush JA, Weinberg WA.  et al.  A double-blind, randomized placebo-controlled trial of fluoxetine in depressed children and adolescents.  Arch Gen Psychiatry. 1997;54:1031-1037
PubMed   |  Link to Article
Wagner KD, Ambrosini P, Rynn M.  et al.  Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials.  JAMA. 2003;290:1033-1041
PubMed   |  Link to Article
Wagner KD, Robb AS, Findling RL, Jin J, Gutierrez MM, Heydorn WE. A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolesents.  Am J Psychiatry. 2004;161:1079-1083
PubMed   |  Link to Article
March J, Silva S, Petrycki S.  et al. Treatment for Adolescents With Depression Study (TADS) Group.  Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression.  JAMA. 2004;292:807-820
PubMed   |  Link to Article
Birmaher B, Brent DA, Benson RS.  et al. American Academy of Child and Adolescent Psychiatry.  Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders.  J Am Acad Child Adolesc Psychiatry. 1998;37:1234-1238
PubMed   |  Link to Article
Hughes CW, Emslie GJ, Crismon ML.  et al.  The Texas Children's Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder.  J Am Acad Child Adolesc Psychiatry. 1999;38:1442-1454
PubMed   |  Link to Article
Emslie GJ, Hughes CW, Crimson ML.  et al.  A feasibility study of the childhood depression medication algorithm.  J Am Acad Child Adolesc Psychiatry. 2004;43:519-527
PubMed   |  Link to Article
Whittington CJ, Kendall T, Fonagy P.  et al.  Selective serotonin reuptake inhibitors in childhood depression.  Lancet. 2004;363:1341-1345
PubMed   |  Link to Article
Vitiello B, Swedo S. Antidepressant medications in children.  N Engl J Med. 2004;350:1489-1491
PubMed   |  Link to Article
US Food and Drug Administration.  Public Health Advisory: Suicidality in Children and Adolescents Being Treated With Antidepressant Medications. October 15, 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/default.htm. Accessed November 10, 2004
Kramer T, Garralda M. Psychiatric disorders in adolescents in primary care.  Br J Psychiatry. 1998;173:508-513
PubMed   |  Link to Article
Horwitz SM, Leaf PJ, Leventhal JM, Forsyth B, Speechley KN. Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices.  Pediatrics. 1992;89:480-485
PubMed
US Department of Health and Human Services.  Mental Health: A Report of the Surgeon GeneralRockville, Md: US Dept of Health and Human Services; 1999
Jensen PS, Bhatara VS, Vitiello B.  et al.  Psychoactive medication prescribing practices for U.S. children.  J Am Acad Child Adolesc Psychiatry. 1999;38:557-565
PubMed   |  Link to Article
Weersing VR, Weisz JR. Community clinic treatment of depressed youth.  J Consult Clin Psychol. 2002;70:299-310
PubMed   |  Link to Article
Ziv A, Boulet JR, Slap GB. Utilization of physician offices by adolescents in the United States.  Pediatrics. 1999;104:35-42
PubMed   |  Link to Article
Clarke GN, Hawkins W, Murphy M.  et al.  Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents.  J Am Acad Child Adolesc Psychiatry. 1995;34:312-321
PubMed   |  Link to Article
Gotlib IH, Lewinsohn PM, Seeley JR. Symptoms versus a diagnosis of depression.  J Consult Clin Psychol. 1995;63:90-100
PubMed   |  Link to Article
Asarnow JR, Jaycox L, Duan N.  et al.  Depression and role impairment among adolescents in primary care clinics.  J Adolesc HealthIn press
Society for Adolescent Medicine.  A Position Statement of the Society for Adolescent Medicine.  J Adolesc Health. 1995;16:413
PubMed   |  Link to Article
World Health Organization.  Composite International Diagnostic Interview (CIDI): Core Version 2.1: Interviewer's ManualGeneva, Switzerland: World Health Organization; 1997
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC: American Psychiatric Association; 1994
Radloff LS. The CES-D scale: a self report depression scale for research in the general population.  Appl Psychol Meas. 1977;1:385-401
Link to Article
Berger VW, Christophi CA. Randomization technique, allocation concealment, masking, and susceptibility of trials to selection bias.  J Modern Appl Stat Methods. 2003;2:80-86
Berger VW, Exner DV. Detecting selection bias in randomized clinical trials.  Control Clin Trials. 1999;20:319-327
PubMed   |  Link to Article
Asarnow JR, Carlson G, Schuster M.  et al.  Youth Partners in Care: Clinician Guide to Depression Assessment and Management Among Youth in Primary Care SettingsLos Angeles, Calif: UCLA School of Medicine; 1999. Adapted from: Rubenstein L, Unutzer J, Miranda J, et al. Partners in Care: Clinician Guide to Depression Assessment and Management in Primary Care Settings. Santa Monica, Calif: RAND; 1996
Clarke GN, Lewinsohn PM, Hops H, Seeley JR. Adolescent Coping With Depression Course.  Eugene, Ore: Castalia Press; 1990
Asarnow JR, Jaycox LH, Clarke G.  et al.  Stress and Your Mood: A Manual.  Los Angeles, Calif: UCLA School of Medicine; 1999
Asarnow JR, Jaycox L, Anderson M. Depression among youth in primary care.  Child Adolesc Psychiatr Clin North Am. 2002;11:477-498
PubMed   |  Link to Article
Asarnow JR, Jaycox LH, Tompson MC. Depression in youth: psychosocial inventions.  J Clin Child Psychol. 2001;30:33-47
PubMed   |  Link to Article
Ware JE Jr, Kosinski M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary ScalesBoston, Mass: Health Institute, New England Medical Center; 1995
Ware JE Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey.  Med Care. 1996;34:220-233
PubMed   |  Link to Article
Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection.  Med Care. 1992;30:473-483
PubMed   |  Link to Article
Horwitz SM, Hoagwood K, Stiffman AR.  et al.  Measuring youths’ use of mental health services: reliability of the Services Assessment for Children and Adolescents (SACA).  Psychiatr Serv. 2001;52:1088-1094
PubMed   |  Link to Article
Wells KB, Sherbourne CD, Schoenbaum M.  et al.  Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial.  JAMA. 2000;283:212-220
PubMed   |  Link to Article
Edlund MJ, Young AS, Kung FY, Sherbourne CD, Wells KB. Does satisfaction reflect the technical quality of mental health care?  Health Serv Res. 2003;38:631-645
PubMed   |  Link to Article
Fisher R. The Design of ExperimentsEdinburgh, Scotland: Oliver & Boyd; 1935
Good P. Permutation Tests: A Practical Guide to Resampling Methods for Testing Hypotheses. 2nd ed. New York, NY: Springer-Verlag; 2000
Pitman EJG. Significance tests which may be applied to samples from any populations.  J R Stat Soc [Ser B]. 1937;B4:119-130
Brick JM, Kalton G. Handling missing data in survey research.  Stat Methods Med Res. 1996;5:215-238
PubMed   |  Link to Article
Kalton G. Handling wave nonresponse in panel surveys.  J Off Stat. 1986;2:303-314
StataCorp.  Stata Statistical Software. Release 8.0 ed. College Station, Tex: StataCorp; 2003
Achenbach TM. Manual for the Youth Self Report and 1991 Profile. Burlington: University of Vermont Dept of Psychiatry; 1997
Prins A, Ouimette PC, Kimerling R.  et al.  The primary care PTSD screen (PC-PTSD).  Primary Care Psychiatry. 2003;9:9-14
Link to Article
Rahdert E. The Adolescent Assessment and Referral System ManualRockville, Md: National Institute on Drug Abuse; 1991. DHHS publication (ADM) 91-1735
Unutzer J, Katon W, Callahan CM.  et al.  Collaborative care management of late-life depression in the primary care setting.  JAMA. 2002;288:2836-2845
PubMed   |  Link to Article
Zito JM, Safer DJ, DosReis S.  et al.  Rising prevalence of antidepressants among US youths.  Pediatrics. 2002;109:721-727
PubMed   |  Link to Article
Rushton JL, Whitmire JT. Pediatric stimulant and selective serotonin reuptake inhibitor prescription trends: 1992-1998.  Arch Pediatr Adolesc Med. 2001;155:560-565
PubMed   |  Link to Article
DeBar LL, Clarke GN, O'Connor E, Nichols GN. Treated prevalences, incidence, and pharmacotherapy of child and adolescent mood disorders in an HMO.  Ment Health Serv Res. 2001;3:73-89
PubMed   |  Link to Article
Thompson C, Kinmonth AL, Stevens L.  et al.  Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care.  Lancet. 2000;355:185-191
PubMed   |  Link to Article
Roberts RE, Lewisohn PM, Seeley JR. Screening for adolescent depression: a comparison of depression scales.  J Am Acad Child Adolesc Psychiatry. 1991;30:58-66
PubMed   |  Link to Article
Whooley MA, Stone B, Soghikian K. Randomized trial of case-finding for depression in elderly primary care patients.  J Gen Intern Med. 2000;15:293-300
PubMed   |  Link to Article
Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference?  BMJ. 1995;311:1274-1276
PubMed   |  Link to Article
 US Preventive Services Task Force. Screening for Depression: Recommendations and Rationale. Available at: http://www.ahrq.gov/clinic/3rdupstf/depression/depressrr.pdf. Accessibility verified December 28, 2004.

Figures

Figure 1. Flow of Patients in the Intervention Trial
Graphic Jump Location

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.

Figure 2. Youth Partners-in-Care Quality Improvement Intervention Flow Chart
Graphic Jump Location

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.

Tables

Table Graphic Jump LocationTable 1. Baseline Patient Characteristics (N = 418)
Table Graphic Jump LocationTable 2. Six-Month Intervention Effects on Process of Care (n = 344)*
Table Graphic Jump LocationTable 3. Six-Month Intervention Effects on Depression, Mental Health–Related Quality of Life, and Satisfaction With Mental Health Care (N = 344)*

References

Lewinsohn P. Depression in adolescents. In: Gotlib IH, Hammen CL, eds. Handbook of Depression. New York, NY: Guilford Press; 2002:541-553
Kessler RC. Epidemiology of depression. In: Gotlib I, Hammen CL, eds. Handbook of Depression. New York, NY: Guilford Press; 2002:23-42
Centers for Disease Control and Prevention.  Youth risk behavior surveillance—United States, 2001. 2002. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.htm. Accessibility verified December 15, 2004
Shaffer D, Pfeffer C.Work Group on Quality Issues.  Practice Parameters for the Assessment and Treatment of Children and Adolescents With Suicidal BehaviorWashington, DC: AACAP Communications Dept; 2000
Weissman M, Wolk S, Goldstein R.  et al.  Depressed adolescents grown up.  JAMA. 1999;281:1707-1713
PubMed   |  Link to Article
Kandel DB, Davies M. Adult sequelae of adolescent depressive symptoms.  Arch Gen Psychiatry. 1986;43:255-262
PubMed   |  Link to Article
Birmaher B, Ryan ND, Brent DA.  et al.  Childhood and adolescent depression.  J Am Acad Child Adolesc Psychiatry. 1996;35:1427-1439
PubMed   |  Link to Article
Kovacs M. Presentation and course of major depressive disorder during childhood and later years of the life span.  J Am Acad Child Adolesc Psychiatry. 1996;35:705-715
PubMed   |  Link to Article
Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent depression.  J Am Acad Child Adolesc Psychiatry. 1999;38:56-63
PubMed   |  Link to Article
Brent DA, Holder D, Kolko D.  et al.  A clinical psychotherapy trial for adolescent depression comparing cognitive, family and supportive therapy.  Arch Gen Psychiatry. 1997;54:877-885
PubMed   |  Link to Article
Lewinsohn PM, Clarke GN, Hops H, Andrews J. Cognitive-behavioral treatment for depressed adolescents.  Behav Ther. 1990;21:385-401
Link to Article
Clarke GN, Rohde P, Lewinsohn PM, Hops H, Seeley JR. Cognitive-behavioral treatment of adolescent depression.  J Am Acad Child Adolesc Psychiatry. 1999;38:272-279
PubMed   |  Link to Article
Wood A, Harrington R, Moore A. Controlled trial of a brief cognitive-behavioural intervention in adolescent patients with depressive disorders.  J Child Psychol Psychiatry. 1996;37:737-746
PubMed   |  Link to Article
Rossello J, Bernal G. Treatment of depression in Puerto Rican adolescents.  J Consult Clin Psychol. 1999;67:734-745
PubMed   |  Link to Article
Mufson L. Weissman MM, Moreau D, Garkinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents.  Arch Gen Psychiatry. 1999;56:573-579
PubMed   |  Link to Article
Mufson L, Dorta KP, Wickramaratne P.  et al.  A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents.  Arch Gen Psychiatry. 2004;61:577-584
PubMed   |  Link to Article
Emslie G, Heiligenstein JH, Wagner KD.  et al.  Fluoxetine for acute treatment of depression in children and adolescents.  J Am Acad Child Adolesc Psychiatry. 2002;41:1205-1215
PubMed   |  Link to Article
Emslie G, Rush JA, Weinberg WA.  et al.  A double-blind, randomized placebo-controlled trial of fluoxetine in depressed children and adolescents.  Arch Gen Psychiatry. 1997;54:1031-1037
PubMed   |  Link to Article
Wagner KD, Ambrosini P, Rynn M.  et al.  Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials.  JAMA. 2003;290:1033-1041
PubMed   |  Link to Article
Wagner KD, Robb AS, Findling RL, Jin J, Gutierrez MM, Heydorn WE. A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolesents.  Am J Psychiatry. 2004;161:1079-1083
PubMed   |  Link to Article
March J, Silva S, Petrycki S.  et al. Treatment for Adolescents With Depression Study (TADS) Group.  Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression.  JAMA. 2004;292:807-820
PubMed   |  Link to Article
Birmaher B, Brent DA, Benson RS.  et al. American Academy of Child and Adolescent Psychiatry.  Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders.  J Am Acad Child Adolesc Psychiatry. 1998;37:1234-1238
PubMed   |  Link to Article
Hughes CW, Emslie GJ, Crismon ML.  et al.  The Texas Children's Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder.  J Am Acad Child Adolesc Psychiatry. 1999;38:1442-1454
PubMed   |  Link to Article
Emslie GJ, Hughes CW, Crimson ML.  et al.  A feasibility study of the childhood depression medication algorithm.  J Am Acad Child Adolesc Psychiatry. 2004;43:519-527
PubMed   |  Link to Article
Whittington CJ, Kendall T, Fonagy P.  et al.  Selective serotonin reuptake inhibitors in childhood depression.  Lancet. 2004;363:1341-1345
PubMed   |  Link to Article
Vitiello B, Swedo S. Antidepressant medications in children.  N Engl J Med. 2004;350:1489-1491
PubMed   |  Link to Article
US Food and Drug Administration.  Public Health Advisory: Suicidality in Children and Adolescents Being Treated With Antidepressant Medications. October 15, 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/default.htm. Accessed November 10, 2004
Kramer T, Garralda M. Psychiatric disorders in adolescents in primary care.  Br J Psychiatry. 1998;173:508-513
PubMed   |  Link to Article
Horwitz SM, Leaf PJ, Leventhal JM, Forsyth B, Speechley KN. Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices.  Pediatrics. 1992;89:480-485
PubMed
US Department of Health and Human Services.  Mental Health: A Report of the Surgeon GeneralRockville, Md: US Dept of Health and Human Services; 1999
Jensen PS, Bhatara VS, Vitiello B.  et al.  Psychoactive medication prescribing practices for U.S. children.  J Am Acad Child Adolesc Psychiatry. 1999;38:557-565
PubMed   |  Link to Article
Weersing VR, Weisz JR. Community clinic treatment of depressed youth.  J Consult Clin Psychol. 2002;70:299-310
PubMed   |  Link to Article
Ziv A, Boulet JR, Slap GB. Utilization of physician offices by adolescents in the United States.  Pediatrics. 1999;104:35-42
PubMed   |  Link to Article
Clarke GN, Hawkins W, Murphy M.  et al.  Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents.  J Am Acad Child Adolesc Psychiatry. 1995;34:312-321
PubMed   |  Link to Article
Gotlib IH, Lewinsohn PM, Seeley JR. Symptoms versus a diagnosis of depression.  J Consult Clin Psychol. 1995;63:90-100
PubMed   |  Link to Article
Asarnow JR, Jaycox L, Duan N.  et al.  Depression and role impairment among adolescents in primary care clinics.  J Adolesc HealthIn press
Society for Adolescent Medicine.  A Position Statement of the Society for Adolescent Medicine.  J Adolesc Health. 1995;16:413
PubMed   |  Link to Article
World Health Organization.  Composite International Diagnostic Interview (CIDI): Core Version 2.1: Interviewer's ManualGeneva, Switzerland: World Health Organization; 1997
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC: American Psychiatric Association; 1994
Radloff LS. The CES-D scale: a self report depression scale for research in the general population.  Appl Psychol Meas. 1977;1:385-401
Link to Article
Berger VW, Christophi CA. Randomization technique, allocation concealment, masking, and susceptibility of trials to selection bias.  J Modern Appl Stat Methods. 2003;2:80-86
Berger VW, Exner DV. Detecting selection bias in randomized clinical trials.  Control Clin Trials. 1999;20:319-327
PubMed   |  Link to Article
Asarnow JR, Carlson G, Schuster M.  et al.  Youth Partners in Care: Clinician Guide to Depression Assessment and Management Among Youth in Primary Care SettingsLos Angeles, Calif: UCLA School of Medicine; 1999. Adapted from: Rubenstein L, Unutzer J, Miranda J, et al. Partners in Care: Clinician Guide to Depression Assessment and Management in Primary Care Settings. Santa Monica, Calif: RAND; 1996
Clarke GN, Lewinsohn PM, Hops H, Seeley JR. Adolescent Coping With Depression Course.  Eugene, Ore: Castalia Press; 1990
Asarnow JR, Jaycox LH, Clarke G.  et al.  Stress and Your Mood: A Manual.  Los Angeles, Calif: UCLA School of Medicine; 1999
Asarnow JR, Jaycox L, Anderson M. Depression among youth in primary care.  Child Adolesc Psychiatr Clin North Am. 2002;11:477-498
PubMed   |  Link to Article
Asarnow JR, Jaycox LH, Tompson MC. Depression in youth: psychosocial inventions.  J Clin Child Psychol. 2001;30:33-47
PubMed   |  Link to Article
Ware JE Jr, Kosinski M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary ScalesBoston, Mass: Health Institute, New England Medical Center; 1995
Ware JE Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey.  Med Care. 1996;34:220-233
PubMed   |  Link to Article
Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection.  Med Care. 1992;30:473-483
PubMed   |  Link to Article
Horwitz SM, Hoagwood K, Stiffman AR.  et al.  Measuring youths’ use of mental health services: reliability of the Services Assessment for Children and Adolescents (SACA).  Psychiatr Serv. 2001;52:1088-1094
PubMed   |  Link to Article
Wells KB, Sherbourne CD, Schoenbaum M.  et al.  Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial.  JAMA. 2000;283:212-220
PubMed   |  Link to Article
Edlund MJ, Young AS, Kung FY, Sherbourne CD, Wells KB. Does satisfaction reflect the technical quality of mental health care?  Health Serv Res. 2003;38:631-645
PubMed   |  Link to Article
Fisher R. The Design of ExperimentsEdinburgh, Scotland: Oliver & Boyd; 1935
Good P. Permutation Tests: A Practical Guide to Resampling Methods for Testing Hypotheses. 2nd ed. New York, NY: Springer-Verlag; 2000
Pitman EJG. Significance tests which may be applied to samples from any populations.  J R Stat Soc [Ser B]. 1937;B4:119-130
Brick JM, Kalton G. Handling missing data in survey research.  Stat Methods Med Res. 1996;5:215-238
PubMed   |  Link to Article
Kalton G. Handling wave nonresponse in panel surveys.  J Off Stat. 1986;2:303-314
StataCorp.  Stata Statistical Software. Release 8.0 ed. College Station, Tex: StataCorp; 2003
Achenbach TM. Manual for the Youth Self Report and 1991 Profile. Burlington: University of Vermont Dept of Psychiatry; 1997
Prins A, Ouimette PC, Kimerling R.  et al.  The primary care PTSD screen (PC-PTSD).  Primary Care Psychiatry. 2003;9:9-14
Link to Article
Rahdert E. The Adolescent Assessment and Referral System ManualRockville, Md: National Institute on Drug Abuse; 1991. DHHS publication (ADM) 91-1735
Unutzer J, Katon W, Callahan CM.  et al.  Collaborative care management of late-life depression in the primary care setting.  JAMA. 2002;288:2836-2845
PubMed   |  Link to Article
Zito JM, Safer DJ, DosReis S.  et al.  Rising prevalence of antidepressants among US youths.  Pediatrics. 2002;109:721-727
PubMed   |  Link to Article
Rushton JL, Whitmire JT. Pediatric stimulant and selective serotonin reuptake inhibitor prescription trends: 1992-1998.  Arch Pediatr Adolesc Med. 2001;155:560-565
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