Published online August 1, 2006
PEDIATRICS Vol. 118 No. 2 August 2006, pp. 669-682 (doi:10.1542/peds.2005-2086)
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ARTICLE

Interventions for Adolescent Depression in Primary Care

Ruth E.K. Stein, MDa, Lauren E. Zitner, BAb and Peter S. Jensen, MDb

a Department of Pediatrics, Albert Einstein College of Medicine/Children's Hospital at Montefiore, New York, New York
b Center for the Advancement of Children's Mental Health, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, New York


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND. Depression in adolescents is underrecognized and undertreated despite its poor long-term outcomes, including risk for suicide. Primary care settings may be critical venues for the identification of depression, but there is little information about the usefulness of primary care interventions.

OBJECTIVE. We sought to examine the evidence for the treatment of depression in primary care settings, focusing on evidence concerning psychosocial, educational, and/or supportive intervention strategies.

METHODS. Available data on brief psychosocial treatments for adolescent depression in primary settings were reviewed. Given the paucity of direct studies, we also drew on related literature to summarize available evidence whether brief, psychosocial support from a member of the primary care team, with or without medication, might improve depression outcomes.

RESULTS. We identified 37 studies relevant to treating adolescent depression in primary care settings. Only 4 studies directly examined the impact of primary care–delivered psychosocial interventions for adolescent depression, but they suggest that such interventions can be effective. Indirect evidence from other psychosocial/behavioral interventions, including anticipatory guidance and efforts to enhance treatment adherence, and adult depression studies also show benefits of primary care–delivered interventions as well as the impact of provider training to enhance psychosocial skills.

CONCLUSIONS. There is potential for successful treatment of adolescent depression in primary care, in view of evidence that brief, psychosocial support, with or without medication, has been shown to improve a range of outcomes, including adolescent depression itself. Given the great public health problem posed by adolescent depression, the likelihood that most depressed adolescents will not receive specialty services, and new guidelines for managing adolescent depression in primary care, clinicians may usefully consider initiation of supportive interventions in their primary care practices.

Key Words: adolescent depression • primary care • treatment • psychosocial intervention

Abbreviations: PCC—primary care clinician • IPT-A—interpersonal therapy modified for depressed adolescents • CES-D—Center for Epidemiologic Studies-Depression Scale • QI—quality improvement • CBT—cognitive behavioral therapy • SSRI—selective serotonin reuptake inhibitor • ADHD—attention-deficit/hyperactivity disorder • CST—coping skills training

Adolescent depression is a serious public health problem.1,2 Studies show that ≤9% of teenagers meet criteria for depression at any one time, with as many as 1 in 5 teens having a history of depression at some point during adolescence.3–5 Adolescent depression is responsible for >1700 suicides a year among 12- to 19-year-olds in the United States and is probably also responsible for many additional deaths that are declared accidents.1 Furthermore, depressed youth who go untreated may have poor long-term outcomes, including reduced social functioning and deteriorating school performance and risk for drug and alcohol use and nicotine dependence.2,6 Thus, early identification and access to treatment is of particular importance for depressed adolescents.

Despite recent progress in identifying and treating children's and adolescents' mental disorders,7–9 epidemiologic studies indicate that only 20% to 35% of youth who meet full criteria for depression currently receive treatment.10,11 With so many depressed youth going unrecognized and untreated, it is incumbent on health professionals to seek additional ways of addressing this widespread disorder.

One approach is to use venues that are not considered traditional mental health sites to identify and treat at risk adolescents. Adolescents visit their primary care clinician 2 to 3 times per year on average,12,13 and youth who have mental health issues are more likely than their peers to be high users of primary care services.12,13 Adolescents report many mental health concerns to their primary care clinicians,14,15 and primary care represents a setting in which parents and adolescents feel relatively comfortable disclosing mental health problems.16,17 For example, Donovan and McCarthy18 sent letters to all of the 16- to 17-year-olds in their practice inviting them to the office to discuss "any medical or general problems." More than 50% (92) of those invited attended after 1 letter, and depression was the second most common problem reported.

Other factors also may incline both primary care clinicians (PCCs) and individual families and youth to prefer primary care venues for managing adolescent depression. Rushton et al19 suggest that more than one third of children and youth who are referred to mental health specialists do not in fact make contact with the specialty provider over the next 6 months. In addition, PCCs generally perceive substantial obstacles, including access, availability, and lack of mental health insurance parity, that interfere with their likelihood of making such referrals. The pervasive lack of mental health services,19 continuing stigma associated with mental health referral, and families' expressed preferences for obtaining mental health care in the primary care setting,20 together suggest that PCCs are likely to shoulder increasing responsibility not only for identifying but also for managing youth with depression. Tolan and Dodge,21 as well as others,22 have suggested that primary care sites have become a major component of the mental health system by default, despite the fact that PCCs are often not reimbursed for mental health services.

Furthermore, PCCs are not trained in the use of medication treatments for depression, and their use is fraught with substantial concerns about potential adverse effects. Moreover, recent evidence suggests that most families and doctors alike are reluctant to consider medication as the first choice for managing depression in youth.17,23 Thus, it is important to understand whether the PCC and/or a treatment team based in a primary care setting can provide an appropriate health care framework for the overall management of adolescent depression, not only by possibly offering medications, but also by offering psychosocial assistance or other supportive interventions for depressed youth.

To identify available evidence that directly addressed these questions, we conducted a systematic review of the extant literature on the effects of various forms of depression management, psychosocial support, and/or formal psychotherapeutic treatment of child and adolescent depression in primary care settings, such as offices and schools, either by the PCCs themselves or by mental health specialists or team members within primary care settings. This we termed "direct evidence," described further below. We built on a previous review in 2001 by Bower et al24 focused directly on psychosocial interventions for children and youth with mental health problems, including but not limited to depression. Of note, because the review by Bower et al24 identified no randomized, controlled trials of psychosocial treatment for adolescent depression in primary care, we broadened our search to identify various forms of "indirect evidence," defined as (1) studies of primary care-delivered psychosocial interventions for other types of pediatric behavioral and emotional problems presenting in primary care settings, (2) studies of the effectiveness of primary care-delivered interventions for adults with depression, and (3) studies of systematic interventions to improve PCCs' skills in these areas. Finally, because various types of counseling, psychoeducational, and supportive interventions are common components of pediatric practice, we explored the literature for studies of the effectiveness of primary care-delivered interventions in 2 areas, anticipatory guidance and treatment adherence, to determine whether pediatric practices in the management of adolescent depression might be informed by these experiences. Taken together, these 5 categories formed the basis for a discussion of the indirect evidence for the potential benefits of psychosocial interventions by primary care physicians for adolescents with depression, as well as to provide initial information about whether the incorporation of psychosocial care for depressed adolescents into primary care sites is feasible.


   METHODS
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 METHODS
RESULTS
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Electronic searches of Medline, PsycInfo, and the Cochrane database were conducted in June 2005 for all indexed journals from the years 1999 to June 2005. The search included keywords used in the review by Bower et al,24 plus some additional keywords, resulting in the combinations of the following keywords: "child or adolesc$ or youth," "primary care or pediatr$ or family prac$ or general prac$," "adherence," "motivational interview$," "engagement," "doctor-patient relationship," "anticipatory guidance," "adherence," "counsel$," "Hawthorne effect," "preventive counseling," "therapeutic alliance," "education," "support," and "psych$ or mental health." The reference lists of all relevant articles were searched for further studies. In addition, experts in the field were consulted to identify additional studies. Although only English language journals were included in the search, the databases used do include major international journals where child mental health research is often cited. For all of the identified titles, abstracts were manually reviewed. Given the paucity of randomized, controlled trials identified earlier in the review by Bower et al,24 studies with simple before and after comparisons were included.


   RESULTS
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 METHODS
 RESULTS
DISCUSSION
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A total of 4314 titles and abstracts were identified. Articles that were not related to treatment or psychosocial support, individual case studies, studies evaluating a particular measure or tool, articles describing purely psychopharmacological treatments, and articles irrelevant to our search were eliminated. The remaining 300 were then carefully examined, and articles that described adult specialty care treatment studies, long-term treatment studies for children and adolescents, and child primary care studies where no true intervention component was included were eliminated. We identified a final total of 37 relevant studies, including the 25 studies on general mental health issues identified in the previous comprehensive review done by Bower et al.24 Articles were included as "direct evidence" (see below for this definition) if the study included (but was not necessarily limited to) children or adolescents in the range of 10 to 18 years of age.

Direct Evidence for the Effectiveness of Depression Interventions in the Primary Care Setting
We identified only 4 studies directly examining the effectiveness of primary care physicians or members of their staff in the recognition and treatment of depression in adolescents (defined as ages 10–18 years; Table 1). 15,23,25,26 Each study was conducted in a "real-world" primary care setting, either in a primary care health clinic or in a school-based general health clinic. Likewise, each sought to compare "treatment as usual" with more optimal intervention methods, usually as delivered by staff employed by the clinic rather than by research clinicians. In the first study, Mufson et al26 examined interpersonal therapy delivered by social workers and psychologists to depressed adolescents (n = 63) referred for a mental health intake visit in 5 school-based health clinics. Adolescents were randomized to either interpersonal therapy modified for depressed adolescents (IPT-A) or "whatever psychological treatments the adolescents would have received in the school-based clinic if the study had not been in place" for 16 weeks.26 IPT-A is a time-limited manualized treatment that focuses on improving interpersonal functioning in any of 4 areas (grief, role disputes, role transitions, and interpersonal deficits) and developing strategies for addressing these problems.26 The nonintervention treatments varied but closely resembled supportive counseling. Adolescents treated with IPT-A showed significantly fewer clinician-reported depression symptoms on the Hamilton Depression Rating Scale, significantly better functioning on the Clinician's Global Assessment Scale, significant improvement in social functioning on the Social Adjustment Scale-Self Report, and significantly greater clinical improvement compared with supportive counseling, thus demonstrating marked effectiveness of IPT-A for adolescent depression in school-based health clinics.


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  		TABLE 1 Direct Evidence

 
Another study of note evaluated the effectiveness of inviting teens to general practice consultations to discuss health behavior concerns.15 In this study, 1516 teens from 8 general practices completed questionnaires about a variety of behaviors, as well as a Center for Epidemiologic Studies-Depression Scale (CES-D) for children to assess mental health. Youth completing questionnaires were invited to attend a consultation, and those who attended were randomly assigned to either a nurse consultation intervention (n = 304) or "standard care." The intervention consisted of a 20-minute consultation with a nurse, aimed at improving self-efficacy for behavior change. Analyses revealed that at 3 months and 1 year of follow-up, teenagers identified as depressed who received the consultation from the medical practice nurse had significantly lower CES-D for children scores compared with depressed youth not receiving the consultation. Moreover, the intervention was very well received, with 97% of attendees saying that they would recommend the intervention to a friend. This study suggests that a relatively simple primary care-based intervention can improve outcomes of depressed adolescents.

More recently, Asarnow et al23 conducted a carefully executed, randomized and controlled study in 5 health care organizations with 418 adolescent primary care patients. All of the adolescents had current depressive symptoms as measured by the Composite International Diagnostic Interview and a score of 16 or greater on the CES-D at baseline. Patients were randomly assigned to either the "usual care" condition or a quality improvement (QI) intervention. Usual care was a slightly enhanced modification of the standard care of the practices, in that the PCCs were trained in depression evaluation and treatment. The QI intervention included teams of experts at each site, as well as care managers who supported PCCs with patient evaluation, education, evidence-based psychosocial treatment, medication when desired, and linkage with specialty mental health services. Care managers were psychotherapists with masters-level or doctoral degrees in mental health or nursing. Care managers followed up with patients over the 6-month intervention period, coordinated care with the PCC, and delivered the manualized cognitive behavioral therapy (CBT) treatment.

Importantly, most adolescents in the QI intervention group, after being advised about both medication and psychosocial treatments, did not select or receive medication treatment (87.5%). Key differences between the QI group versus the usual care group seemed to lie in the likelihood that QI patients received either CBT or the assistance of a care manager, neither of which were available to the usual care patients. At 6-month follow-up, adolescents in the QI arm had significantly lower mean CES-D scores, as well as a significantly lower rate of severe depression. Patients receiving the QI intervention reported higher mental health-related quality of life and greater satisfaction with mental health care. This study is the first to demonstrate that depression in adolescents can be improved in primary care office settings.

Clarke et al25 conducted a randomized effectiveness trial of a 5–9 session CBT program with depressed adolescents in a health maintenance organization. All of the adolescents in the trial had already been taking selective serotonin reuptake inhibitors (SSRIs), prescribed by a pediatrician, and both the intervention and control groups continued on the SSRIs for the duration of the study. Although there were no significant differences between groups in the acute phase of the study, trends for an emerging advantage for the CBT intervention patients were found on some measures by the 52-week follow-up point. In addition, among the "severely depressed" youth, there were significantly better outcomes in the CBT group compared with SSRIs only. The authors attribute the lack of significant difference in the acute phase to the general phenomenon of rapid recovery from index major depression episodes among adolescents in both arms of the study. Additional follow-up interviews will be completed at 18 and 24 months.

Taken as a group, these studies provide some evidence for direct efficacy of psychosocial interventions for depression management delivered in primary care. Nonetheless, given the diversity of the interventions, the evidence is still somewhat sparse, and more research is needed.

Indirect Evidence: Psychosocial Interventions in Primary Care for Adult Depression
Whereas some may question the inclusion of psychosocial interventions in primary care for adult depression in an article on adolescent depression, we include it here for several reasons. First and perhaps most importantly, large numbers of adolescents receive their primary care in the adult-based service system or family practices, where it is the usual practice to treat them as if they were adults. Second, such adult-based practices, like those in pediatrics, are often based on high volumes and short visits. The evidence of feasibility in other settings that share these characteristics is important to the generalizability of the findings to pediatric and adolescent medicine practices. Table 2 lists search-identified studies in which treatment for depression was given by the primary care team to adults.27–32 Some studies have examined psychosocial interventions delivered by the PCC, whereas others have looked at support provided by nurses, social workers, or psychologists in primary care. Four of these studies focus on benefits for the adults,27–29,31 and 2 studies of postpartum mothers with depression focus on the mother-child relationship.30,32 The former show strongly positive results, regardless of the intervention provided, whereas those focusing on the mother-child relationship are more modest in their impact, with one showing some benefits and the other not.


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  		TABLE 2 Indirect Evidence: Interventions in Primary Care for Adult Depression

 
Mynors-Wallis et al29 conducted a randomized, controlled trial with 3 treatment arms, brief problem solving treatment, amitriptyline, and drug placebo, to treat adult major depression in primary care. The problem solving treatment was delivered by general practitioners in 6 sessions over 3.5 hours. Problem solving was significantly superior to placebo at both 6 and 12 weeks on 3 different outcome measures.29 Mynors-Wallis et al28 later compared problem solving treatment, antidepressant medication, or combination treatment of adults in primary care delivered by either a general practitioner or a practice nurse. Patients receiving problem-solving treatment alone had a mean number of 4.6 treatment sessions (range: 1–7), with the first session lasting 1 hour and subsequent sessions lasting 30 minutes. The results showed that problem solving treatment produced a 62% recovery rate at 52 weeks when delivered by the general practitioner (n = 39) and a 56% recovery rate when delivered by the practice nurse (n = 41), thus suggesting that problem-solving treatment can be an effective treatment for adult depressive disorders in primary care.

These studies demonstrate that relatively modest psychosocial interventions can improve adult depression outcomes and yield gains in patient satisfaction. Also notable among these studies is the finding of comparable effects of psychosocial treatments and medication.28 This is especially important given many people's reluctance in taking antidepressant medications. Taken together, the evidence of benefit of psychosocial interventions for treating adult depression in primary care settings plus the substantial evidence of efficacy of psychosocial treatments for child and adolescent depression when delivered in specialty care settings7,9 do not replace the need for additional formal studies of psychosocial interventions for depressed youth in primary care settings. In the meantime, however, for PCCs who must deal now with depressed youth who cannot or will not access specialty mental health, these data provide cautious hope that similar psychosocial interventions, if delivered in primary care by members of the primary care team, might yield similar benefits among depressed youth.

Interventions in Pediatric Primary Care for Other Psychosocial Problems
Depression is only one of a long list of behavioral health conditions that pediatricians may deal with in the primary care setting. "Other psychosocial problems" is composed of mental health problems that are seen most commonly in children and adolescents. These include internalizing symptoms, such as anxiety problems and eating disorders, as well as externalizing symptoms, including attention-deficit/hyperactivity disorder (ADHD) and conduct problems. As found previously by Bower et al,24 this portion of the review revealed much variability in the interventions, problems treated, and outcomes in the available studies. In addition, as Bower et al24 noted, most of these studies either lacked a control group or used a controlled before and after design. Even among those that were randomized, controlled trials, most did not provide enough information to judge the quality of the randomization or the methods. Table 3 outlines 9 studies33–42 in which treatment was given by the primary care team to children and adolescents for various psychosocial problems. Among the most salient of these studies, one examined the effects of preventive intervention with parents by a PCC in a community sample (n = 246) and found some differences in behavior and relationships in the intervention group,34 some of which lasted for up to 20 to 30 years.35 However, it is questionable whether these results could be replicated more generally, because they involved a longitudinal cohort followed by a single general practitioner over a generation. More recently, Tutty et al42 evaluated the impact of an 8-week behavioral and social skills program delivered in a primary care setting to children with ADHD who were also simultaneously initiating medication treatment. Findings indicated that among the 59 children and families receiving the skills program, fewer ADHD behavior problems and increased parenting skills were noted compared with the 41 children receiving medication only. In another study, Stewart-Brown et al41 assessed the impact of a general practice-based parenting program using a randomized, controlled trial design across 4 general practices; parents of children 2 to 8 years of age with behavior problems were randomly assigned to either the 10-week group-based intervention or a wait-list control. Findings indicated that among the parents receiving the intervention, children's behavior improved significantly more than control children, both immediately and at 6-month follow-up. Notably, this intervention was delivered by "health visitors," an additional staff person available within general practices in the United Kingdom but not usually in the United States. Regardless, at least in some situations, some evidence suggests that even modest interventions can be useful when delivered in primary care settings by primary care staff.


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  		TABLE 3 Indirect Evidence: Treatment of Other Problems by the Primary Care Team

 
Table 4 lists studies of interventions delivered in primary care by a mental health care specialist who was colocated in the primary care setting (S. Martin, unpublished work 1988).43–51 In one study, Finney et al49 reported that externalizing and internalizing scores were significantly reduced at 12 months of follow-up after behavior therapy was provided to children with psychological problems (n = 186) by psychologists located in primary care. However, there was no comparison group on these measures, so these results must be interpreted with caution.


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  		TABLE 4 Management by Specialists in Primary Care

 
In a more rigorously designed study, Beardslee et al43 conducted an efficacy trial of 2 manual-based preventive intervention programs for children of depressed parents, designed to be used by a wide range of practitioners from a variety of disciplines, including pediatricians, internists, nurses, and mental health clinicians. The "lecture condition" consisted of 2 separate group meetings with parents only. The "clinician-facilitated condition" consisted of 6 to 11 sessions, including separate meetings with parents and children, as well as a family meeting. It was found that parents in both conditions reported significant change in child-related behaviors and attitudes but that more change was reported in the clinician-facilitated program at 12 and 24 months of follow-up. This intervention was found to promote resilience-related qualities in these at-risk children. This study demonstrates that a brief, simple intervention does have enduring positive effects on families' ability to problem solve around parental illness.

Taken together, although not focused on adolescent depression per se, the higher quality studies (randomized, controlled trials) presented in Tables 3 and 4 suggest that intensive psychosocial interventions can be beneficial when delivered in primary care settings, although caution is warranted, because the general pattern seen across these studies seems to suggest that greater treatment "intensity" (eg, 8–12 sessions) seems to characterize those interventions where effects have been most apparent. Although treatments of that intensity may be outside the scope of the realities of practice for most physicians, with sufficient support, training, and staffing, such interventions might be feasibly delivered by other members of the primary care team.

Improving Skills of PCCs
Pediatricians have repeatedly reported that they believe that they are inadequately trained in mental health issues.52–56 However, evidence shows that training primary care physicians improves their willingness to address patients' behavioral health issues,57 which increases confidence, and decreases discomfort in exploring mental health issues. Lustig et al57 conducted a study examining the impact of skills-based training workshops on PCC screening and counseling practices with adolescents and found significant increases in counseling on multiple measures identified to be relevant for adolescent preventive health care, including tobacco use and sexual behavior. This study offers support for the benefit of training for PCCs to increase their counseling behaviors.

Training clinicians in specific behavioral issues has also been shown to improve patient-doctor communication. Gielen et al58 found that pediatricians trained in injury prevention provided significantly more injury prevention counseling than the control group, and parents were significantly more satisfied with the help that their physicians provided on safety topics than control group parents.

Overall, educational studies involving members of the primary care team suggest that short courses for primary care professionals may be associated with changes in subjective outcomes, such as physician confidence and knowledge, actual increases in the physicians' expected behaviors (counseling), changes in parents/patients' knowledge, and, in a few instances, changes in patients' symptoms and emotional distress (See Table 5; P. Appleton, P. Pritchard, A. Pritchard, unpublished work, 1988).37,59–64


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  		TABLE 5 Educational Studies Involving the Primary Care Team

 
Anticipatory Guidance
Anticipatory guidance, that is, the provision of developmentally appropriate information and support in anticipation of issues that may arise in the near future, has been a cornerstone of pediatric practice and is one of the fundamental underpinnings of the work that pediatricians do in their offices during health care maintenance visits. Key principles of this approach are incorporated into Bright Futures in Practice.65 To a large extent, anticipatory guidance is the backbone of prevention. Remarkably, we were able to locate very few randomized, controlled trials of anticipatory guidance with adolescents and, as a result, no evidence-based reviews. Nonetheless, anticipatory guidance is not wholly without support, and among the few studies that have actually examined its effects, several have demonstrated benefit. Studies by Guteilus et al66 and Adam et al67 both showed positive effects of anticipatory guidance on early child rearing practices and actually changed parental behaviors. More recently, Nelson et al68 reviewed the evidence for effectiveness of anticipatory guidance and showed positive impact on parent-child interaction, sleep patterns, injury prevention, and reading. Although these studies are not directly relevant to the management of adolescent depression in primary care, they offer some evidence that anticipatory guidance strategies might prove useful.

In the related area of injury prevention, Bass et al69 reviewed injury prevention counseling in primary care settings, finding 18 studies showing positive effects of injury prevention counseling, including increased knowledge, improved behavior, and decreased injury occurrence for both motor vehicle and nonmotor vehicle injuries. Similar benefits have been seen with regard to other topics as well, suggesting that advice giving and educational counseling in the area of adolescent depression are not without precedent in other areas of pediatric practice and are likely to be more beneficial than doing nothing.

Psychosocial Interventions for Improved Adherence
Research in other types of primary care interventions demonstrates the usefulness of the health care practitioner in changing patient behavior and improving outcomes, especially with respect to adherence to therapeutic regimens for longer-term management of ongoing health conditions. Research on adherence to therapeutic regimens generally focuses on a wide range of chronic conditions and, therefore, has saliency for the chronic nature of many types of depression. Such research has repeatedly demonstrated the importance of a relationship between the clinician and the patient and has emphasized the importance of communication skills and that even in the absence of medication, a strong positive relationship with the health care provider is a motivator of many different types of behavioral changes on the part of patients. For example, in the pediatric asthma literature, as demonstrated in a review by Lemanek et al,70 both educational and behavioral strategies have been shown to be "promising" according to Chambless criteria in improving adherence to therapeutic regimens.70 Cognitive behavioral strategies seem equally promising in improving adherence to type 1 diabetes treatment regimens.71

One example of a study examining adherence randomly assigned diabetic adolescents to either coping skills training (CST) in conjunction with intensive insulin therapy or to intensive insulin therapy alone.71 CST entailed a series of small group meetings to teach adolescents social problem solving, conflict resolution, and social skills. Adolescents who received CST from a nurse practitioner had lower hemoglobin A1C levels (indicating better long-term control of their diabetes) and better diabetes self-efficacy and were less upset about coping with diabetes than control group adolescents. In addition, adolescents who received CST experienced less of a negative impact of diabetes on their quality of life.71

Although additional studies are needed, available data suggest that the PCC who provides modest levels of support can affect meaningful change in behavioral and psychosocial dimensions with adolescents, even with brief interventions consisting of as few as 1 to 3 meetings.70 Although the recent review of regimen adherence by Lemanek et al70 does not consider these interventions to meet criteria for "well-established" therapy, there is substantial evidence that they are "probably efficacious."


   DISCUSSION
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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In considering our overall findings, several caveats should be noted. First, our review of the literature revealed that very few studies have directly tested the benefits of treating adolescent depression in primary care settings. Given their very small number, we did not attempt to use meta-analytic procedures to systematically rate the quality of the direct studies, although we have noted the strengths and limitations of these studies. In addition, our review was limited by the choice of dates, key words, and available databases. Despite these limitations, available evidence has increased substantially over the last few years, and several compelling lines of evidence support the possible benefits of primary care interventions for depressed youth. Moreover, our review suggests that the primary care setting is a practical, realistic, and feasible setting in which to address adolescent depression, with several lines of evidence suggesting the merits of this approach.

First, adolescent depression is a relatively common occurrence, with inadequate resources in most communities to refer all depressed adolescents to mental health professionals. In fact, many adolescents experience these symptoms transiently and may not need specialized care. Even in carefully executed, randomized, controlled trials lasting 6 to 8 weeks, upward of 60% of adolescent subjects may improve substantially on placebo,72 suggesting that supportive interactions and active problem solving with a caring health care professional is not an inactive treatment and might, in fact, benefit many youth much more than a never-ending waiting list or a referral that is not followed through to completion. In addition, a host of logistic, social, and financial issues may impede the likelihood of mental health referral, even if it were the universally recommended strategy.73,74

Second, although few primary care studies directly assessing adolescent depression meet our highest standard of evidence, the great need for services for depressed adolescents warrants primary care providers' focused attention. The information presented in this article suggests the usefulness of primary care interventions, particularly in view of the strong likelihood that many adolescents will not get care elsewhere for their depression.

Not surprisingly, then, the increasingly prevailing recommendation (refs 19, 75, and 76; A. Cheung, MD, R. Zuckerbrot, MD, and P. S. J., unpublished data), is that, as a minimum, PCCs should be provided the necessary guidance to support their management of mental health problems within their setting. To address this problem, a steering committee consisting of 27 primary care experts (including pediatricians, family physicians, and nurse practitioners), depression researchers (child psychiatry and psychology), guideline development experts, policy-makers, and family organization representatives have met over the last 2 years to develop the Guidelines for Adolescent Depression in Primary Care (A. Cheung, MD, R. Zuckerbrot, MD, and P. S. J., unpublished manuscript). In addition, liaison representatives from each of the major US and Canadian primary care and specialty mental professional associations and family advocacy organizations provided formal input to the recommendations.

To augment the process of consensus development, an extensive survey of optimal methods for depression management was also conducted among 80 PCCs and depression experts. In addition, rigorous literature reviews (including this review) were completed of all evidence pertaining to primary care adolescent depression management: depression screening/identification, assessment and diagnosis, treatment, maintenance, and mental health system coordination (R. Zuckerbrot, MD, A. Cheung, MD, K. Ghalib, MD, and P. S. J., unpublished data). The final guidelines (now nearing completion) and accompanying literature reviews will be published, and an associated tool kit will be made available at no cost online (www.kidsmentalhealth.org/GLAD-PC.html). The guidelines are intended for ultimate dissemination to PCCs in the United States and Canada, including clinicians in pediatrics, family medicine, nursing, and internal medicine.

These guidelines should be an important first step in improving the ability of PCCs to address these issues. In addition, however, PCCs are often not reimbursed for mental health services nor are they equipped to develop and maintain linkages with the community resources needed to provide a continuum of care for these youth. Evidence from a national cross-sectional survey of 280 pediatricians suggests that whereas most feel responsible for recognizing adolescent depression, they do not feel responsible for treating even uncomplicated adolescent depression. Only 35% expressed motivation to change their current depression recognition and treatment practices.32 More recently, Stein et al56 reported on the results of an American Academy of Pediatrics Periodic Survey that indicated that among practicing pediatricians, 84% think they should be responsible for identifying depression, but only 53% actually report that they usually inquire about depression among their patients. Only 20% report that they believe that they should treat depression.

Clearly, there is a compelling need for more research to determine the best ways to improve primary care treatment of adolescents with depression. However, despite the limited direct evidence for effectiveness of primary care physicians' capacity to reduce depressed youths' symptoms with psychosocial support, the primary care setting has shown itself to be a practical, realistic, and useful setting in which to address a range of child and adolescent health issues. Although more research is clearly needed, PCCs should not assume that "there is nothing I can do" to assist depressed youth and their families. To do so is to inadvertently withhold the likely benefits of empathy, support, and education that may alleviate the suffering of as many as half of these youth, particularly for those families faced with long mental health treatment waiting lists or other barriers to care.


   FOOTNOTES
 
Accepted Mar 2, 2006.

Address correspondence to Ruth E. K. Stein, MD, Albert Einstein College of Medicine/Children's Hospital at Montefiore, 111 E. 210 St, Bronx, NY 10467. E-mail: rstein{at}aecom.yu.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


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