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Original Investigation | Pediatric Quality Measures

Usual Care for Adolescent Depression From Symptom Identification Through Treatment Initiation

Briannon C. O’Connor, PhD1; R. Eric Lewandowski, PhD1; Stephanie Rodriguez, BS2; Aldo Tinoco, MD, MPH, MS3; William Gardner, PhD4; Kimberly Hoagwood, PhD1; Sarah Hudson Scholle, MPH, DrPH1
[+] Author Affiliations
1New York University Child Study Center, Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York
2National Committee for Quality Assurance, Washington, DC
3Evolent Health, Arlington, Virginia
4Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
JAMA Pediatr. 2016;170(4):373-380. doi:10.1001/jamapediatrics.2015.4158.
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Importance  Published guidelines describing effective adolescent depression care in primary care settings include screening, assessment, treatment initiation, and symptom monitoring. It is unclear the extent to which these steps are documented in patient health records.

Objective  To determine rates of appropriate follow-up care for adolescents with newly identified depression symptoms in 3 large health systems.

Design, Setting, and Participants  In this analysis conducted from March to September 2014, structured data retrospectively extracted from electronic health records were analyzed for 3 months following initial symptom identification to determine whether the patient was followed up and, if so, whether treatment was initiated and/or symptoms were monitored. Records were collected from 2 large health maintenance organizations in the western United States and a network of community health centers in the Northeast. The study group included adolescents (N = 4612) with newly identified depression symptoms, defined as an elevated score on the Patient Health Questionnaire (≥10) and/or a diagnosis of depression.

Main Outcomes and Measures  Rates of treatment initiation, symptom monitoring, and follow-up care documented within 3 months of initial symptom identification.

Results  Among the 4612 participants, the mean (SD) age at index event was 16.0 (2.3) years, and 3060 were female (66%). Treatment was initiated for nearly two-thirds of adolescents (79% of those with a diagnosis of major depression; n = 1023); most received psychotherapy alone or in combination with medications. However, in the 3 months following identification, 36% of adolescents received no treatment (n = 1678), 68% did not have a follow-up symptom assessment (n = 3136), and 19% did not receive any follow-up care (n = 854). Further, 40% of adolescents prescribed antidepressant medication did not have any documentation of follow-up care for 3 months (n = 356). Younger age (ages 15-17 years: odds ratio [OR], 0.78; 95% CI, 0.67-0.92 and ages 18-20 years: OR, 0.83; 95% CI, 0.70-0.99; P = .008), more severe initial symptoms (moderate: OR, 0.99; 95% CI, 0.82-1.21; moderate to severe: OR, 1.46; 95% CI, 1.19-1.80; and severe: OR, 2.14; 95% CI, 1.65-2.79; P < .001), and receiving a diagnosis (major depression/dysthymia: OR, 2.65; 95% CI, 2.20-3.20 and unspecified depression/adjustment disorder: OR, 1.75; 95% CI, 1.43-2.14; P < .001) were significantly associated with treatment initiation. Differences in rates of follow-up care were evident between sites (site 2: OR, 1.77; 95% CI, 1.45-2.16 and site 3: OR, 2.10; 95% CI, 1.72-2.57), suggesting that differences within health systems may also affect care received.

Conclusions and Relevance  Most adolescents with newly identified depression symptoms received some treatment, usually including psychotherapy, within the first 3 months after identification. However, follow-up care was low and substantial variation existed between sites. These results raise concerns about the quality of care for adolescent depression.

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Adolescents With 3-Month Follow-up Care

aOther visits included any documented visit that did not include a behavioral health treatment or antidepressant medication such as an ill visit or well child visit.

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