Teenagers and Depression

178897619_medWho knew that depression in teenagers was such a common problem, leading to things like self-harm, obesity, and risk-taking behavior? And that one in five adolescents experience at least one episode of major depression by age 18?  Rick and I both admit to being unaware of the magnitude of the problem on PodMed this week , and were heartened to see results of a study in JAMA showing that a collaborative care model employed in primary care practices is quite beneficial.

Investigators randomized 101 adolescents who screened positive for depression in a primary care setting to either usual care as self-referral to mental health care after receiving a letter from their primary care physician with their screening results or to a 12 month intervention employing follow-up by a master's level clinician with a special interest in depression, so-called 'depression care managers.' The depression care manager was empowered to assess the patient and provide brief cognitive behavioral therapy, medications, or both, after consultation with both the patient and the parents.

Outcomes included changes in a clinician-administered questionnaire on depressive symptoms and another on impairment at baseline and 12 months, and remission. As the paper states, "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)."  Yikes.  These are really big intervention effects. It's worth noting that the outcomes reflect the hands on approach taken by the depression care managers.  Following their initial consult the DCMs followed up every one to two weeks, escalated interventions if the teenager wasn't responding, and changed medications if necessary, all at a cost of about $1400 per patient.

Issues of concern emerged from this study:  the majority of adolescents did not complete the screening assessment, and a large percentage of parents declined consent for their adolescent to participate.  In Rick's opinion, these outcomes underpin a persistent factor underpinning undertreatment of depression: stigma.  Parents did not want to admit that depression might be a problem for their teenager.  Juxtapose that against the fact that the study authors credit participatory parents as a major support in providing good outcomes in their intervention group, and the need for some strategy to overcome bias is apparent. Of course stigma relative to depression is not limited to an adolescent population, but couple that with black box warnings about use of certain antidepressant medications in this age group, resulting in reluctance on the part of primary care docs to even attempt to manage the condition, and things seem dire indeed.  Rick and I agree that the depression care manager model is one well worth exploring and implementing further, and perhaps expanding to other populations in whom depression is common.

Other topics this week include MERS contagiousness in household contacts in NEJM, cardiovascular events in low, middle and high income countries in the same journal, and self-management of high blood pressure in JAMA.  Until next week, y'all live well.

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