Reducing Health Risk Behaviors and Improving Depression in Adolescents: A Randomized Controlled Trial in Primary Care Clinics.

Objective: Primary care (PC) is a major service delivery setting that can provide preventive behavioral health care to youths. To explore the hypothesis that reducing health risk behaviors (HRBs) would lower depressive symptoms, and that health risk and depression can be efficiently targeted together in PC, this study (1) evaluates an intervention designed to reduce HRBs among adolescent PC patients with depressive symptoms and (2) examines prospective links between HRBs and depressive symptoms. Method: A Randomized controlled trial was conducted comparing a behavioral health intervention with enhanced Usual PC (UC+). Participants were 187 adolescents (ages 13-18 years) with past-year depression, assessed at baseline, 6 months, and 12 months. Primary outcome was the Health Risk Behavior Index (HRBI), a composite score indexing smoking, substance use, unsafe sex, and obesity risk. Secondary/exploratory outcomes were an index of the first three most correlated behaviors (HRBI-S), each HRB, depressive symptoms, and satisfaction with mental health care. Results: Outcomes were similar at 6 and 12 months, with no significant between-group differences. HRBI, HRBI-S, and depressive symptoms decreased, and satisfaction with mental health care increased across time in both groups. HRBI, HRBI-S, and smoking predicted later severe depression. Conversely, severe depression predicted later HRBI-S and substance use. Conclusions: UC+ and the behavioral health intervention yielded similar benefits in reducing HRBs and depressive symptoms. Findings underscore the bidirectional links between depression and HRBs, supporting the importance of monitoring for HRBs and depression in PC to allow for effective intervention in both areas.

Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial.

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.

Long-term benefits of short-term quality improvement interventions for depressed youths in primary care.

OBJECTIVE: Quality improvement programs for depressed youths in primary care settings have been shown to improve 6-month clinical outcomes, but longer-term outcomes are unknown. The authors examined 6-, 12-, and 18-month outcomes of a primary care quality improvement intervention. METHOD: Primary care patients 13-21 years of age with current depressive symptoms were randomly assigned to a 6-month quality improvement intervention (N=211) or to treatment as usual enhanced with provider training (N=207). The quality improvement intervention featured expert leader teams to oversee implementation of the intervention; clinical care managers trained in cognitive-behavioral therapy for depression to support patient evaluation and treatment; and support for patient and provider choice of treatments. RESULTS: The quality improvement intervention, relative to enhanced treatment as usual, lowered the likelihood of severe depression (Center for Epidemiological Studies Depression Scale score > or =24) at 6 months; a similar trend at 18 months was not statistically significant. Path analyses revealed a significant indirect intervention effect on long-term depression due to the initial intervention improvement at 6 months. CONCLUSIONS: In this randomized effectiveness trial of a primary care quality improvement intervention for depressed youths, the main effect of the intervention on outcomes was to decrease the likelihood of severe depression at the 6-month outcome assessment. These early intervention-related improvements conferred additional long-term protection through a favorable shift in illness course through 12 and 18 months.

Adolescent primary care patients' preferences for depression treatment.

Despite efficacious treatments for depression in youth, current data indicate low rates of care. To better understand reasons for these low rates of care, we examined treatment preferences for depression treatment. Adolescents (N=444) who screened positive for depression at a primary care visit completed measures of predisposing, enabling, and need characteristics thought to be related to help seeking. Results indicated a strong tendency for adolescents to prefer active treatment (72%) versus watchful waiting (28%), and for youth to prefer counseling (50%) versus medication (22%). Female gender, prior treatment experience, and current depression and anxiety were related to preference for active treatment over watchful waiting. In multivariable analyses, female gender and current anxiety symptoms remained significant predictors of preference for active treatment. Ethnicity, attitudes about depression care, prior treatment experience, and anxiety symptoms were related to preference for medication over counseling. In multivariable analyses, those with negative attitudes about depression treatment generally, with positive attitudes about treatment via medication, or with current anxiety symptoms were more likely to prefer medication. Youth preference for counseling over medication may contribute to low adherence to medication treatment and underscores the importance of patient education aimed at promoting positive expectations for treatments.

Depression and role impairment among adolescents in primary care clinics.

PURPOSE: To evaluate the association between depression and role impairment in a primary care sample, with and without controlling for the effects of general medical conditions. METHODS: Cross-sectional survey of consecutive primary care patients, ages 13-21 years (n = 3471), drawn from six sites including public health, managed care, and academic health center clinics. We assessed probable depressive disorder, depressive symptoms, and common medical problems using youth self-report on a brief screening questionnaire. Main outcome measures were two indicators of role impairment: (a) decrement in productivity/role activity, defined as not in school or working full time; and (b) low educational attainment, defined as more than 2 years behind in school or > or = 20 years of age and failed to complete high school. RESULTS: Adolescents screening positive for probable depressive disorder had elevated rates of productivity/role activity decrements (19% vs. 13%; OR 1.69; 95% confidence interval [CI] 1.39-2.06; p < 0.001) and low educational attainment (20% vs. 15%; OR 1.47; 95% CI 1.21-1.78; p < 0.001). Probable depressive disorder made a unique contribution to the prediction of these impairment indicators after adjusting for the effect of having a general medical condition; controlling for depression, the presence of a general medical condition did not contribute to role impairment. CONCLUSIONS: Adolescent primary care patients screening positive for depression are at increased risk for impairment in school/work productivity and educational attainment. These findings emphasize the importance of primary care clinicians' attention to depression and role limitations.