Most Adolescents With Depression Do Not Receive Follow Up Care

Briannon O'Connor PhD New York University Child Study Center Department of Child and Adolescent Psychiatry New York University School of Medicine, New York

Dr. Briannon O’Connor

MedicalResearch.com Interview with:
Briannon O’Connor PhD
New York University Child Study Center
Department of Child and Adolescent Psychiatry
New York University School of Medicine
New York

Medical Research: What is the background for this study? What are the main findings?

Dr. O’Connor: a. As the health care system continues to emphasize accountability for providing high quality care, the development of meaningful quality standards is critical. This study came from NCQA’s work to develop these quality measures for adolescent depression care. Prior to this study, little was known about what routine care looked like for adolescents who showed up at their primary care visits with significant symptoms of depression.

This study looked at follow up care documented in an electronic health record in the three months after an adolescent was first identified with significant symptoms of depression.

Medical Research: What is the background for this study? What are the main findings?

Dr. O’Connor: Key findings from this study include:

  1. Most adolescents (nearly two-thirds) with newly prescribed depression symptoms received some treatment, usually including psychotherapy, within the first 3 months after depression symptoms were first identified.
  2. Among those adolescents who were prescribed antidepressant medications, 40% had no other follow up care in three months, which is quite concerning since current black box warnings highlight the risk for increased suicidality for youth prescribed antidepressants and clearly recommend close monitoring in the few months following initial prescription.
  3. There were low rates of other follow up care events in the three month follow up period: 19% of adolescents did not receive any follow up care at all, 36% did not receive any treatment, and the majority (68%) lacked documentation that symptoms were monitored or re-assessed using a valid questionnaire
  4. The sites that participated in the study are highly regarded health care institutions, often looked to as leaders in cutting-edge care. Thus, results from this study, discouraging as they are, may overstate the quality of care in other settings.

Medical Research: What should clinicians and patients take away from your report?

Dr. O’Connor: a. Our work highlights the magnitude of the problem-even though there are a number of professional standards and guidelines that outline appropriate care for adolescent depression, clearly the quality of care in routine practice diverges from these standards. There are a lot of issues to that contribute to this problem (how and where care is documented, ensuring that providers have adequate training and ample time to provide behavioral health care, long wait lists for getting into treatment and access to specialists, adolescents not attending follow up appointments), and there’s a lot of great work being done by providers, policy makers, and others to change it, but it’s a system-wide problem and we have a long way to go.

Importantly, there are a number of professional guidelines and tools available to support effective assessment and treatment of adolescent depression for primary care providers that go into far greater detail than I am able to here. In short, since we know that receiving effective treatment early is the best predictor of positive outcomes, these guidelines first recommend using a well-studied, validated screening questionnaire for adolescent depression to increase early identification of symptoms and catch the problem before it worsens. If depression is suspected, a critical next step is to conduct a thorough assessment to determine the diagnosis and severity of symptoms, including suicidality, and use these pieces of information to identify an evidence-based treatment plan. For adolescents with mild depression, brief supportive counseling by the provider (education about depression, support, advice, problem solving) may be sufficient. For adolescents with moderate or severe depression, it is recommended that providers initiate evidence based treatments, which consist of cognitive behavioral or interpersonal psychotherapy, antidepressant medication, and a combination of psychotherapy and medication. Most often, these treatments require specialist care. In these cases, the primary care provider plays a critical role in monitoring and following up with adolescents to ensure that they have been successfully linked with specialist services, to monitor how they are doing while waiting for appointments, and to provide support and continuity of care that helps keep adolescents engaged in their own health care.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. O’Connor: Since lack of appropriate follow up care was a key finding of our study, future research should identify what the barriers to follow up care may be from the perspective of providers, patients, and the health care system more broadly. Then, methods to address these barriers, such as models of collaborative care that facilitate continuity of care and integrate physical and behavioral health care to improve patient outcomes should continue to be developed and evaluated.

Medical Research: Is there anything else you would like to add?

Response: Improving care for depression will require action from families and from the healthcare system. The primary care setting is where most symptoms of depression and other mental health concerns are first identified, and, often, treated. Efforts to integrate high quality mental health care in these settings can make accessing necessary treatments easier for adolescents and their families. Primary care providers, mental health providers and the plans and payers that arrange and pay for care have a lot they can do to help adolescents get the care they need. NCQA has incorporated a new measure into health plan quality reporting to encourage better care for depression for adolescents and adults. This measure (Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults) encourages routine monitoring of depression symptoms and will improve the ability to measure patient outcomes. Other measures will be implemented in subsequent years – See more at:http://www.ncqa.org/HEDISQualityMeasurement/HEDISLearningCollaborative/HEDISDepressionMeasures.aspx#sthash.vhYcMAv5.dpuf

Citation:

O’Connor BC, Lewandowski R, Rodriguez S, et al. Usual Care for Adolescent Depression From Symptom Identification Through Treatment Initiation. JAMA Pediatr.Published online February 01, 2016. doi:10.1001/jamapediatrics.2015.4158.

Briannon O’Connor PhD (2016). Most Adolescents With Depression Do Not Receive Follow Up Care