Follow-up Care Poor for Adolescents With Depression

Jennifer Garcia

February 02, 2016

Follow-up care for adolescents diagnosed with depression is low among primary care physicians, according to a new study published online February 1 in JAMA Pediatrics.

"These findings raise concerns that many adolescents with depression receive an unacceptable level of care, particularly striking because more than half of adolescent suicide completers have chronic, unremitted depression," Briannon C. O'Connor, PhD, from the Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York City, and colleagues write.

The researchers evaluated electronic health records from three large healthcare systems including two large health maintenance organizations in the western United States and a network of community health centers in the Northeast.

Data from 4612 adolescents (aged 12 - 20 years) evaluated between January 1, 2012, and June 30, 2013, were included. Eligible participants had documented symptoms of depression and least one face-to-face visit with a primary care physician. Mean age at index event was 16.0 years, and 66% of patients were female. Data were analyzed for 6 months before and 3 months after the index event. Depression symptoms were assessed using the Patient Health Questionnaire 9, modified for adolescents and teenagers.

The most common diagnosis was major depression (47%; n = 1295), followed by other/unspecified depression (24%; n = 654). The average score on the questionnaire suggested moderately severe symptoms at two of the three locations, with the third location having an average score consistent with moderate symptoms.

Overall, 81% of patients had a follow-up appointment of some kind during the study period. In contrast, 19% (n = 854) of adolescents with clinically significant depression symptoms received no follow-up care at all during the study period.

Once a diagnosis was made, treatment was initiated for 64% (n = 2934) of the study participants, with the most common treatment being psychotherapy alone, followed by antidepressant therapy only, and then by a combination treatment.

Younger age at the time of diagnosis (ages 15 - 17 years), moderate to severe symptom severity, and receiving a diagnosis of major depression were significantly associated with treatment initiation.

The authors found that 40% of the patients who were prescribed antidepressant medications without psychotherapy received no follow-up care (n = 356), despite current black box warnings for antidepressants that describe an increased risk for suicidality and recommend patient monitoring during the initial few months of therapy.

The authors note differences in rates of diagnosis as well as follow-up care between participating sites, suggesting that differences within healthcare systems may also affect care for this patient population.

The researchers acknowledge study limitations such as the reliance on electronic health record data, where "conclusions depend on how information is gathered and recorded." For example, whether follow-up care was provided and simply not recorded or whether the primary care physician referred the patient to a specialist cannot be discerned on the basis of electronic health record data alone. The researchers also note that differences in patient demographics among the participating sites may limit the generalizability of the data.

"Regardless of treatment initiation, symptom monitoring is recommended," write Dr O'Connor and colleagues.

"Given the negative outcomes associated with untreated adolescent depression, greater attention to improving adherence to quality standards is warranted," they conclude.

Funding for this study was provided through a grant from the Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services. The authors have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online February 1, 2016. Abstract

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