Treatment of Youth Depression

In this issue of the Journal, Asarnow and colleagues (1) report on the 12- and 18-month outcomes of their landmark Youth Partners in Care study, which broke new ground as the first multisite effectiveness trial for youth depression in primary care settings. A previous report on the 6-month outcomes (2) showed significant advantages from the study’s quality improvement intervention, which is designed to improve access to evidence-based cognitive-behavioral therapy (CBT) and antidepressant medication relative to usual care augmented only by education of primary care clinicians. Findings at 6 months included significantly better access to evidence-based depression treatment, reductions in depressive symptom severity, improvements in mental-health-related quality of life, and greater family satisfaction with mental health services for the quality improvement group compared to the usual-care group. Although Youth Partners in Care results at 6, 12, and 18 months provide some degree of encouragement for the field, they are also sobering, leaving open the question of whether the study’s findings suggest that the public health glass is half empty or half full.

The pessimists among us will note that participation in any mental health treatment was disappointing in Youth Partners in Care, regardless of group assignment, and that observed improvements in depressive symptoms and quality of life were modest and poorly sustained at best. The vast majority of youths in the study did not receive any mental health services (68% of those in the quality improvement intervention group and 83% of those in the usual-care group). Observed differences between the groups with regard to access to care were accounted for entirely by higher rates of participation in psychotherapy in the quality improvement group, but even youths who opted for psychotherapy in that group often received fewer treatment sessions than recommended by existing guidelines.

Also troubling is the fact that the quality improvement intervention did not improve participation in antidepressant treatment or antidepressant treatment combined with psychotherapy. Recent evidence suggests a favorable risk-benefit profile with second-generation antidepressants in the treatment of youth depression (3), and the combination of antidepressants and CBT is likely superior to either individual treatment alone (4, 5) . Even though the Youth Partners in Care study was completed prior to broadly publicized warnings about pediatric antidepressant safety, only 12% of participants in the quality improvement intervention and 16% of those in the usual-care group received any antidepressant medication, and the percentages of those receiving combination treatment were even lower (2) . These results are at variance with those from studies that have tested quality improvement interventions for depressed adults, where the use of antidepressants increased in comparison with usual care (6, 7) . This raises questions as to whether the Youth Partners in Care results correctly reflect differences in patient and family beliefs and preferences in the primary care management of depression in youths, particularly minority youths, or whether the study’s quality improvement intervention was wanting with regard to educating, problem solving, and implementing antidepressant treatment.

The importance of individual health beliefs and stigma cannot easily be dismissed. A recent study (8) that examined the beliefs of parents of children and adolescents in specialty mental health care found that psychotherapy was perceived as beneficial and having few risks in the treatment of depression, whereas antidepressant treatment was perceived as both beneficial and risky. Greater perceived benefits from antidepressants predicted future medication management appointments, suggesting that careful discussion of the potential benefits of antidepressant treatment as well as the risks may be especially relevant in creating truly informed consumers of care.

Finally, although there was a 55% reduction in suicidality in the quality improvement intervention group compared to an 18% reduction in the usual-care group at the 6-month follow-up (2), the between-group differences were not statistically significant and were even less pronounced at 12 and 18 months. Population-based evidence suggests that access to health and mental health services may reduce the risk of suicide (9, 10), highlighting the potential importance of public health strategies focused on improving access to care for depressed youths, a group clearly at heightened risk for suicide. Interventions designed to improve access to evidence-based diagnosis and treatment for adults with depressive disorders in primary care have proved successful in decreasing both suicidality and depressive symptoms (11, 12) .

The optimists among us may find great hope in knowing that the Youth Partners in Care intervention was superior to usual care in reducing depressive symptoms, increasing mental-health-related quality of life, and enhancing satisfaction with care at the 6-month evaluation. Although between-group differences were quite modest and were not maintained at the 12- and 18-month evaluations, there was a trend suggesting superiority of the quality improvement intervention with regard to depressive symptoms at 18 months, a full year after the intervention phase was completed. The investigators also report that path analysis showed that the intervention was associated with significantly greater “indirect” treatment effects at 18 months. What is perhaps most encouraging is that the intervention appears so promising despite low rates of participation in mental health treatment, as well as markedly low rates of antidepressant treatment, without differential effects between the groups.

Whereto after Youth Partners in Care? Several ideas come to mind. One must wonder whether the symptomatic and diagnostic thresholds used for study entry were excessively low. Indeed, one out of four youths screened for the study was eligible for participation, yet only 43% of the enrolled sample met criteria for a diagnosis of major depression or dysthymic disorder, while the majority of participants suffered from a subsyndromal depressive disorder. A more symptomatic and impaired sample might increase the likelihood of detecting treatment effects, including for secondary outcomes, such as suicidality.

With regard to the intervention itself, it is tantalizing to speculate about the potential impact of Youth Partners in Care had it resulted in higher rates of participation in mental health treatment. Future studies would do well to pay careful attention to the psychoeducation offered to patients and families and might productively emphasize the relatively favorable risk-benefit profile of antidepressant treatment for depressed youths (3) . In addition, better attention to patient and family health beliefs and the power of stigma has the potential to improve participation in care. The development of briefer, more potent, and readily disseminated psychotherapeutic interventions tailored to youths presenting in the primary care setting (13) should also be explored, as should other novel methods to improve the effect size of a multifaceted yet focused intervention. These might include the application of novel technology to aid in patient tracking, care coordination, and safety monitoring, as well as aggressive identification and referral of depressed parents and caretakers, given recent findings that parental treatment can have beneficial effects on depression in youths (14) .

Youth Partners in Care is indeed a landmark study that points the way toward and highlights the need for public-health-oriented clinical research targeting youth depression.