New care pathway to improve treatment of adolescent depression

By Anne Harding

NEW YORK (Reuters Health) - Care for adolescents with depression in the U.S. is "suboptimal," but the authors of a new care pathway based on a review of research literature and practice guidelines are hoping their work can help turn the tide.

The Agency for Healthcare Research and Quality (AHRQ) is funding the development of this care pathway and accompanying quality indicators (QIs), which the authors describe in Pediatrics, online September 16.

"We're sort of mid-stream in developing these measures," lead author Dr. R. Eric Lewandowski of the New York University School of Medicine in New York City told Reuters Health. "Generally there are important gaps in what we need to know to be able to do this at a systemic level with the kind of rigor that is typically required for quality indicators for other conditions."

The AHRQ grant was made available under the Children's Health Insurance Program Reauthorization Act, Dr. Lewandowski explained.

The report lays out an 11-step care pathway for the identification and management of adolescents with depression, with QIs for each step. For each QI, Dr. Lewandowski and his colleagues have included evidence from studies in adolescents on best practices.

The QIs are in the following areas: depression screening; assessment to confirm diagnosis; suicide risk assessment; brief supportive counseling; treatment initiation (antidepressant medication or psychotherapy); communication and documentation; adequacy of treatment course: antidepressant medication; adequacy of treatment course: psychotherapy; symptom reassessment; remission; and treatment adjustment.

"We're a little bit short of what we need to know to make clear and precise recommendations for quality indicators based directly on evidence," Dr. Lewandowski said. "There's a call to the field to get going and fill the gaps."

"I agree with the idea and I think most if not all of the recommendations they made are pretty standard," Dr. David Brent, a professor of psychiatry and academic chief of child and adolescent psychiatry at the University of Pittsburgh Medical Center, told Reuters Health.

The biggest challenge, he added, will be to find a way to provide adolescents with depression care without further burdening pediatricians. "The average pediatrician has eight minutes with a patient, so who's going to do the supportive counseling? I think that many pediatricians don't feel comfortable using antidepressants, especially since the black box warning," Dr. Brent said.

In the Pittsburgh region, he added, most pediatric practices have adopted a collaborative model of care, in which a mental health practitioner works on-site, and a psychiatrist provides backup for a given number of practices. "It really works well," he said. "I think people are getting care that they wouldn't otherwise."

"The ideas are good, the quality indicators are good," Dr. Brent said of the new document. "I'm not sure that it's really realistic to implement without some of these other changes also taking place."

SOURCE: http://bit.ly/18Oruzl

Pediatrics 2013.