DOI: 10.1542/peds.2005-2086 2006;118;669-682 Pediatrics

Ruth E.K. Stein, Lauren E. Zitner and Peter S. Jensen Interventions for Adolescent Depression in Primary Care

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ARTICLE

Interventions for Adolescent Depression in PrimaryCareRuth E. K. Stein, MDa, Lauren E. Zitner, BAb, Peter S. Jensen, MDb

aDepartment of Pediatrics, Albert Einstein College of Medicine/Children’s Hospital at Montefiore, New York, New York; bCenter for the Advancement of Children’s MentalHealth, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, New York

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

ABSTRACT

BACKGROUND.Depression in adolescents is underrecognized and undertreated despiteits poor long-term outcomes, including risk for suicide. Primary care settings maybe critical venues for the identification of depression, but there is little informationabout the usefulness of primary care interventions.

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

METHODS.Available data on brief psychosocial treatments for adolescent depressionin primary settings were reviewed. Given the paucity of direct studies, we alsodrew on related literature to summarize available evidence whether brief, psycho-social support from a member of the primary care team, with or without medica-tion, might improve depression outcomes.

RESULTS.We identified 37 studies relevant to treating adolescent depression inprimary care settings. Only 4 studies directly examined the impact of primarycare–delivered psychosocial interventions for adolescent depression, but theysuggest that such interventions can be effective. Indirect evidence from otherpsychosocial/behavioral interventions, including anticipatory guidance and effortsto enhance treatment adherence, and adult depression studies also show benefitsof primary care–delivered interventions as well as the impact of provider trainingto enhance psychosocial skills.

CONCLUSIONS. There is potential for successful treatment of adolescent depression inprimary care, in view of evidence that brief, psychosocial support, with or withoutmedication, has been shown to improve a range of outcomes, including adolescentdepression itself. Given the great public health problem posed by adolescent depres-sion, the likelihood that most depressed adolescents will not receive specialtyservices, and new guidelines for managing adolescent depression in primary care,clinicians may usefully consider initiation of supportive interventions in theirprimary care practices.

www.pediatrics.org/cgi/doi/10.1542/peds.2005-2086

doi:10.1542/peds.2005-2086

KeyWordsadolescent depression, primary care,treatment, psychosocial intervention

AbbreviationsPCC—primary care clinicianIPT-A—interpersonal therapy modified fordepressed adolescentsCES-D—Center for Epidemiologic Studies-Depression ScaleQI—quality improvementCBT—cognitive behavioral therapySSRI—selective serotonin reuptakeinhibitorADHD—attention-deficit/hyperactivitydisorderCST—coping skills training

Accepted for publication Mar 2, 2006

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

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of Pediatrics

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ADOLESCENT DEPRESSION IS a serious public healthproblem.1,2 Studies show that �9% of teenagers

meet criteria for depression at any one time, with asmany as 1 in 5 teens having a history of depression atsome point during adolescence.3–5 Adolescent depressionis responsible for �1700 suicides a year among 12- to19-year-olds in the United States and is probably alsoresponsible for many additional deaths that are declaredaccidents.1 Furthermore, depressed youth who go un-treated may have poor long-term outcomes, includingreduced social functioning and deteriorating school per-formance and risk for drug and alcohol use and nicotinedependence.2,6 Thus, early identification and access totreatment is of particular importance for depressed ado-lescents.

Despite recent progress in identifying and treatingchildren’s and adolescents’ mental disorders,7–9 epidemi-ologic studies indicate that only 20% to 35% of youthwho meet full criteria for depression currently receivetreatment.10,11 With so many depressed youth going un-recognized and untreated, it is incumbent on healthprofessionals to seek additional ways of addressing thiswidespread disorder.

One approach is to use venues that are not consideredtraditional mental health sites to identify and treat at riskadolescents. Adolescents visit their primary care clinician2 to 3 times per year on average,12,13 and youth who havemental health issues are more likely than their peers tobe high users of primary care services.12,13 Adolescentsreport many mental health concerns to their primarycare clinicians,14,15 and primary care represents a settingin which parents and adolescents feel relatively comfort-able disclosing mental health problems.16,17 For example,Donovan and McCarthy18 sent letters to all of the 16- to17-year-olds in their practice inviting them to the officeto discuss “any medical or general problems.” More than50% (92) of those invited attended after 1 letter, anddepression was the second most common problem re-ported.

Other factors also may incline both primary care cli-nicians (PCCs) and individual families and youth to pre-fer primary care venues for managing adolescent depres-sion. Rushton et al19 suggest that more than one third ofchildren and youth who are referred to mental healthspecialists do not in fact make contact with the specialtyprovider over the next 6 months. In addition, PCCsgenerally perceive substantial obstacles, including ac-cess, availability, and lack of mental health insuranceparity, that interfere with their likelihood of makingsuch referrals. The pervasive lack of mental health ser-vices,19 continuing stigma associated with mental healthreferral, and families’ expressed preferences for obtain-ing mental health care in the primary care setting,20

together suggest that PCCs are likely to shoulder increas-ing responsibility not only for identifying but also formanaging youth with depression. Tolan and Dodge,21 as

well as others,22 have suggested that primary care siteshave become a major component of the mental healthsystem by default, despite the fact that PCCs are oftennot reimbursed for mental health services.

Furthermore, PCCs are not trained in the use of med-ication treatments for depression, and their use isfraught with substantial concerns about potential ad-verse effects. Moreover, recent evidence suggests thatmost families and doctors alike are reluctant to considermedication as the first choice for managing depression inyouth.17,23 Thus, it is important to understand whetherthe PCC and/or a treatment team based in a primary caresetting can provide an appropriate health care frame-work for the overall management of adolescent depres-sion, not only by possibly offering medications, but alsoby offering psychosocial assistance or other supportiveinterventions for depressed youth.

To identify available evidence that directly addressedthese questions, we conducted a systematic review of theextant literature on the effects of various forms of de-pression management, psychosocial support, and/or for-mal psychotherapeutic treatment of child and adolescentdepression in primary care settings, such as offices andschools, either by the PCCs themselves or by mentalhealth specialists or team members within primary caresettings. This we termed “direct evidence,” describedfurther below. We built on a previous review in 2001 byBower et al24 focused directly on psychosocial interven-tions for children and youth with mental health prob-lems, including but not limited to depression. Of note,because the review by Bower et al24 identified no ran-domized, controlled trials of psychosocial treatment foradolescent depression in primary care, we broadenedour search to identify various forms of “indirect evi-dence,” defined as (1) studies of primary care-deliveredpsychosocial interventions for other types of pediatricbehavioral and emotional problems presenting in pri-mary care settings, (2) studies of the effectiveness ofprimary care-delivered interventions for adults with de-pression, and (3) studies of systematic interventions toimprove PCCs’ skills in these areas. Finally, becausevarious types of counseling, psychoeducational, andsupportive interventions are common components ofpediatric practice, we explored the literature for studiesof the effectiveness of primary care-delivered interven-tions in 2 areas, anticipatory guidance and treatmentadherence, to determine whether pediatric practices inthe management of adolescent depression might be in-formed by these experiences. Taken together, these 5categories formed the basis for a discussion of the indi-rect evidence for the potential benefits of psychosocialinterventions by primary care physicians for adolescentswith depression, as well as to provide initial informationabout whether the incorporation of psychosocial care fordepressed adolescents into primary care sites is feasible.

670 STEIN et al at Columbia University on January 9, 2007 www.pediatrics.orgDownloaded from

METHODS

Electronic searches of Medline, PsycInfo, and the Co-chrane database were conducted in June 2005 for allindexed journals from the years 1999 to June 2005. Thesearch included keywords used in the review by Boweret al,24 plus some additional keywords, resulting in thecombinations of the following keywords: “child or ado-lesc$ or youth,” “primary care or pediatr$ or family prac$or general prac$,” “adherence,” “motivational interview$,”“engagement,” “doctor-patient relationship,” “anticipa-tory guidance,” “adherence,” “counsel$,” “Hawthorne ef-fect,” “preventive counseling,” “therapeutic alliance,” “ed-ucation,” “support,” and “psych$ or mental health.” Thereference lists of all relevant articles were searched forfurther studies. In addition, experts in the field wereconsulted to identify additional studies. Although onlyEnglish language journals were included in the search,the databases used do include major international jour-nals where child mental health research is often cited.For all of the identified titles, abstracts were manuallyreviewed. Given the paucity of randomized, controlledtrials identified earlier in the review by Bower et al,24

studies with simple before and after comparisons wereincluded.

RESULTSA total of 4314 titles and abstracts were identified. Arti-cles that were not related to treatment or psychosocial

support, individual case studies, studies evaluating a par-ticular measure or tool, articles describing purely psy-chopharmacological treatments, and articles irrelevantto our search were eliminated. The remaining 300 werethen carefully examined, and articles that describedadult specialty care treatment studies, long-term treat-ment studies for children and adolescents, and childprimary care studies where no true intervention com-ponent was included were eliminated. We identified afinal total of 37 relevant studies, including the 25 studieson general mental health issues identified in the previ-ous comprehensive review done by Bower et al.24 Arti-cles were included as “direct evidence” (see below forthis definition) if the study included (but was not nec-essarily limited to) children or adolescents in the rangeof 10 to 18 years of age.

Direct Evidence for the Effectiveness of DepressionInterventions in the Primary Care SettingWe identified only 4 studies directly examining the ef-fectiveness of primary care physicians or members oftheir staff in the recognition and treatment of depressionin adolescents (defined as ages 10–18 years; Table1).15,23,25,26 Each study was conducted in a “real-world”primary care setting, either in a primary care healthclinic or in a school-based general health clinic. Like-wise, each sought to compare “treatment as usual” withmore optimal intervention methods, usually as delivered

TABLE 1 Direct Evidence

Source Design Brief Description ofIntervention

Population SampleSize

Length ofFollow-Up

Summary of Results

Mufson et al, 200426 RCT School-based health clinicclinicians administeredinterpersonal therapyfor adolescents vstreatment as usual

Referredadolescents

63 16 wk (4 wk after endof treatment)

Adolescents treated with QI compared withusual care showed greater symptomreduction and improvement in overallfunctioning

Walker et al, 200215 RCT 20-min consultations withpractice nurses todiscuss health concerns

Teenagers invited togeneral practiceconsultations

1516 3 and 12 mo Recognition of possible depression resultedin improved mental health outcomes at3 and 12 months; 97% of attenders saidthey would recommend intervention toa friend

Asarnow et al, 200523 RCT QI intervention in 5primary care clinics,with care managerssupporting PCCs inevaluating andmanaging adolescents’depression

Depressedadolescents

418 6 mo QI adolescents reported significantly fewerdepressive symptoms, higher mentalhealth-related quality of life, and greatersatisfaction with mental health care

Clarke et al, 200525 RCT HMO usual care,(including SSRImedications, pediatricvisits, or mental healthtreatments) vs HMOusual care plus 5–9sessions of CBT

Depressedadolescents in anHMO

152 52 wk At 52-week follow-up there was someadvantage for the CBT condition onsome (but not all) measures. Significantlybetter outcomes among the “severelydepressed” youth receiving the CBTprogram compared to severelydepressed youth receiving only usualcare SSRIs; No differences among lessdepressed youth.

HMO indicates health maintenance organization.

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by staff employed by the clinic rather than by researchclinicians. In the first study, Mufson et al26 examinedinterpersonal therapy delivered by social workers andpsychologists to depressed adolescents (n � 63) referredfor a mental health intake visit in 5 school-based healthclinics. Adolescents were randomized to either interper-sonal therapy modified for depressed adolescents(IPT-A) or “whatever psychological treatments the ado-lescents would have received in the school-based clinic ifthe study had not been in place” for 16 weeks.26 IPT-A isa time-limited manualized treatment that focuses onimproving interpersonal functioning in any of 4 areas(grief, role disputes, role transitions, and interpersonaldeficits) and developing strategies for addressing theseproblems.26 The nonintervention treatments varied butclosely resembled supportive counseling. Adolescentstreated with IPT-A showed significantly fewer clinician-reported depression symptoms on the Hamilton Depres-sion Rating Scale, significantly better functioning on theClinician’s Global Assessment Scale, significant improve-ment in social functioning on the Social AdjustmentScale-Self Report, and significantly greater clinical im-provement compared with supportive counseling, thusdemonstrating marked effectiveness of IPT-A for adoles-cent depression in school-based health clinics.

Another study of note evaluated the effectiveness ofinviting teens to general practice consultations to discusshealth behavior concerns.15 In this study, 1516 teensfrom 8 general practices completed questionnaires abouta variety of behaviors, as well as a Center for Epidemi-ologic Studies-Depression Scale (CES-D) for children toassess mental health. Youth completing questionnaireswere invited to attend a consultation, and those whoattended were randomly assigned to either a nurse con-sultation intervention (n � 304) or “standard care.” Theintervention consisted of a 20-minute consultation witha nurse, aimed at improving self-efficacy for behaviorchange. Analyses revealed that at 3 months and 1 year offollow-up, teenagers identified as depressed who re-ceived the consultation from the medical practice nursehad significantly lower CES-D for children scores com-pared with depressed youth not receiving the consulta-tion. Moreover, the intervention was very well received,with 97% of attendees saying that they would recom-mend the intervention to a friend. This study suggeststhat a relatively simple primary care-based interventioncan improve outcomes of depressed adolescents.

More recently, Asarnow et al23 conducted a carefullyexecuted, randomized and controlled study in 5 healthcare organizations with 418 adolescent primary care pa-tients. All of the adolescents had current depressivesymptoms as measured by the Composite InternationalDiagnostic Interview and a score of 16 or greater on theCES-D at baseline. Patients were randomly assigned toeither the “usual care” condition or a quality improve-

ment (QI) intervention. Usual care was a slightly en-hanced modification of the standard care of the prac-tices, in that the PCCs were trained in depressionevaluation and treatment. The QI intervention includedteams of experts at each site, as well as care managerswho supported PCCs with patient evaluation, education,evidence-based psychosocial treatment, medicationwhen desired, and linkage with specialty mental healthservices. Care managers were psychotherapists withmasters-level or doctoral degrees in mental health ornursing. Care managers followed up with patients overthe 6-month intervention period, coordinated care withthe PCC, and delivered the manualized cognitive behav-ioral therapy (CBT) treatment.

Importantly, most adolescents in the QI interventiongroup, after being advised about both medication andpsychosocial treatments, did not select or receive medi-cation treatment (87.5%). Key differences between theQI group versus the usual care group seemed to lie in thelikelihood that QI patients received either CBT or theassistance of a care manager, neither of which wereavailable to the usual care patients. At 6-month follow-up, adolescents in the QI arm had significantly lowermean CES-D scores, as well as a significantly lower rateof severe depression. Patients receiving the QI interven-tion reported higher mental health-related quality of lifeand greater satisfaction with mental health care. Thisstudy is the first to demonstrate that depression in ado-lescents can be improved in primary care office settings.

Clarke et al25 conducted a randomized effectivenesstrial of a 5–9 session CBT program with depressed ado-lescents in a health maintenance organization. All of theadolescents in the trial had already been taking selectiveserotonin reuptake inhibitors (SSRIs), prescribed by apediatrician, and both the intervention and controlgroups continued on the SSRIs for the duration of thestudy. Although there were no significant differencesbetween groups in the acute phase of the study, trendsfor an emerging advantage for the CBT interventionpatients were found on some measures by the 52-weekfollow-up point. In addition, among the “severely de-pressed” youth, there were significantly better outcomesin the CBT group compared with SSRIs only. The au-thors attribute the lack of significant difference in theacute phase to the general phenomenon of rapid recov-ery from index major depression episodes among ado-lescents in both arms of the study. Additional follow-upinterviews will be completed at 18 and 24 months.

Taken as a group, these studies provide some evi-dence for direct efficacy of psychosocial interventions fordepression management delivered in primary care.Nonetheless, given the diversity of the interventions, theevidence is still somewhat sparse, and more research isneeded.

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Indirect Evidence: Psychosocial Interventions in Primary Carefor Adult DepressionWhereas some may question the inclusion of psycho-social interventions in primary care for adult depres-sion in an article on adolescent depression, we includeit here for several reasons. First and perhaps most im-portantly, large numbers of adolescents receive theirprimary care in the adult-based service system or familypractices, where it is the usual practice to treat them asif they were adults. Second, such adult-based practices,like those in pediatrics, are often based on high volumesand short visits. The evidence of feasibility in other set-tings that share these characteristics is important tothe generalizability of the findings to pediatric and ado-lescent medicine practices. Table 2 lists search-identifiedstudies in which treatment for depression was givenby the primary care team to adults.27–32 Some studieshave examined psychosocial interventions deliveredby the PCC, whereas others have looked at supportprovided by nurses, social workers, or psychologists inprimary care. Four of these studies focus on benefitsfor the adults,27–29,31 and 2 studies of postpartum motherswith depression focus on the mother-child relation-ship.30,32 The former show strongly positive results, re-gardless of the intervention provided, whereas thosefocusing on the mother-child relationship are moremodest in their impact, with one showing some benefitsand the other not.

Mynors-Wallis et al29 conducted a randomized, con-trolled trial with 3 treatment arms, brief problem solvingtreatment, amitriptyline, and drug placebo, to treat adultmajor depression in primary care. The problem solvingtreatment was delivered by general practitioners in 6sessions over 3.5 hours. Problem solving was signifi-cantly superior to placebo at both 6 and 12 weeks on 3different outcome measures.29 Mynors-Wallis et al28 latercompared problem solving treatment, antidepressantmedication, or combination treatment of adults in pri-mary care delivered by either a general practitioner or apractice nurse. Patients receiving problem-solving treat-ment alone had a mean number of 4.6 treatment ses-sions (range: 1–7), with the first session lasting 1 hourand subsequent sessions lasting 30 minutes. The resultsshowed that problem solving treatment produced a 62%recovery rate at 52 weeks when delivered by the generalpractitioner (n � 39) and a 56% recovery rate whendelivered by the practice nurse (n � 41), thus suggestingthat problem-solving treatment can be an effective treat-ment for adult depressive disorders in primary care.

These studies demonstrate that relatively modest psy-chosocial interventions can improve adult depressionoutcomes and yield gains in patient satisfaction. Alsonotable among these studies is the finding of comparableeffects of psychosocial treatments and medication.28 Thisis especially important given many people’s reluctancein taking antidepressant medications. Taken together,

the evidence of benefit of psychosocial interventions fortreating adult depression in primary care settings plusthe substantial evidence of efficacy of psychosocial treat-ments for child and adolescent depression when deliv-ered in specialty care settings7,9 do not replace the needfor additional formal studies of psychosocial interven-tions for depressed youth in primary care settings. In themeantime, however, for PCCs who must deal now withdepressed youth who cannot or will not access specialtymental health, these data provide cautious hope thatsimilar psychosocial interventions, if delivered in pri-mary care by members of the primary care team, mightyield similar benefits among depressed youth.

Interventions in Pediatric Primary Care for Other PsychosocialProblemsDepression is only one of a long list of behavioral healthconditions that pediatricians may deal with in the pri-mary care setting. “Other psychosocial problems” iscomposed of mental health problems that are seen mostcommonly in children and adolescents. These includeinternalizing symptoms, such as anxiety problems andeating disorders, as well as externalizing symptoms, in-cluding attention-deficit/hyperactivity disorder (ADHD)and conduct problems. As found previously by Bower etal,24 this portion of the review revealed much variabilityin the interventions, problems treated, and outcomes inthe available studies. In addition, as Bower et al24 noted,most of these studies either lacked a control group orused a controlled before and after design. Even amongthose that were randomized, controlled trials, most didnot provide enough information to judge the quality ofthe randomization or the methods. Table 3 outlines 9studies33–42 in which treatment was given by the primarycare team to children and adolescents for various psy-chosocial problems. Among the most salient of thesestudies, one examined the effects of preventive interven-tion with parents by a PCC in a community sample (n �246) and found some differences in behavior and rela-tionships in the intervention group,34 some of whichlasted for up to 20 to 30 years.35 However, it is question-able whether these results could be replicated more gen-erally, because they involved a longitudinal cohort fol-lowed by a single general practitioner over a generation.More recently, Tutty et al42 evaluated the impact of an8-week behavioral and social skills program delivered ina primary care setting to children with ADHD who werealso simultaneously initiating medication treatment.Findings indicated that among the 59 children and fam-ilies receiving the skills program, fewer ADHD behaviorproblems and increased parenting skills were noted com-pared with the 41 children receiving medication only. Inanother study, Stewart-Brown et al41 assessed the impactof a general practice-based parenting program using arandomized, controlled trial design across 4 generalpractices; parents of children 2 to 8 years of age with

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TABLE2

IndirectEviden

ce:Interventions

inPrim

aryCa

reforA

dultDep

ression

Stud

yDesign

BriefD

escriptio

nofInterventio

nPopu

latio

nSampleSize

Leng

thof

Follow-Up

SummaryofResults

CooperandMurray,

1997

27a

RCT

CounselingvsCBTvsdynamictherapy

(1specialist,1generalistproviding

each)vsroutineprimarycare

Motherssufferingfrom

postpartu

mdepressio

n191

18mo

Smallimprovem

entsinmother-child

interactionover

time,notrelated

toreceiptoftreatment;No

relationshipbetweencognitive

developm

entand

receiptoftreatment;Norelationshipbetween

behaviorproblemsand

receiptoftreatment

Mynors-Wallisetal,19952

9RCT

Problem-solving

treatment(6sessions

over3mo)vsam

itriptylinevsusual

care,conducted

by2GP

sand

1psychiatrist

Adultswith

majordepressio

nrecruitedfromgeneral

practice

776and12

wk

Problem-solving

treatmentw

assig

nificantly

superior

toplaceboat6and12

wk

Mynors-Wallisetal,20002

8RCT

Problemsolvingby

research

GPor

research

practicenursevs

antidepressantvscom

bination

Adultswith

majordepressio

nrecruitedfromgeneral

practice

116

6and12

and52

wk

Patientsinallgroupsshowed

aclearimprovem

ent

over12

wk;Nodifferenceinoutcom

eirrespective

ofwho

delivered

theproblemsolvingtreatment.

Oxm

anetal,20013

0RCT

2–4hofproblem-solving

treatmentvs

paroxetinevsplaceboinprimary

care

Adultswith

minordepressio

nordysthymia

330

3mo,25

wk

76%recoveryform

inordepressio

n,68%for

dysthymiaat3mo;Nogroupdifferencesreported.

Richards

etal,20033

1RCT

Self-helpinterventionby

practice

nursesofup

to3appointm

entsvs

usualcare

Adultpatientsp

resentingto

theirG

Pwith

mild

tomoderateanxiety/

depressio

n

139

1and3mo

Interventiongrouppatientsw

eremorelikelytobe

belowclinicalthresholdvsusualcaregroupand

weremoresatisfied

Seeley

etal,19963

2aSBA

Training

indetectionand

managem

entofpostnatal

depressio

n(useofcounseling/CBT

skills)

HVs

andpostnatally

depressedwom

en46

HVs,num

berof

patients

unclear

�Nosig

nificantdifference

inchange

inmothers’

experienceofinfantcare.Rateofmother-baby

relationshipproblemslow

eratfollow-upin

interventiongroup

Stew

art-Brow

netal,

2004

41

RCT

10-wkgeneralpractice-based

parentingprogramby

HVs

vswait-

listcontro

l

Parentso

fchildrenaged

2-8

with

behaviorproblems

116parents

Immediate,6

and

12mo

Children’sb

ehaviorimproved

significantly

morethan

controlchildren,bothimmediatelyandat6-mo

follow-up;Nosig

nificantdifference

at12

mo

RCTindicatesrandomized,contro

lledtrial;GP,generalpractitioner;CBT,cognitive-behavioraltherapy;SBA,sim

plebeforeandafterstudy;HV,healthvisitor.

aStudiesaretakenfromBoweretal.24

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behavior problems were randomly assigned to either the10-week group-based intervention or a wait-list control.Findings indicated that among the parents receiving theintervention, children’s behavior improved significantlymore than control children, both immediately and at6-month follow-up. Notably, this intervention was de-livered by “health visitors,” an additional staff personavailable within general practices in the United Kingdombut not usually in the United States. Regardless, at leastin some situations, some evidence suggests that evenmodest interventions can be useful when delivered inprimary care settings by primary care staff.

Table 4 lists studies of interventions delivered in pri-mary care by a mental health care specialist who wascolocated in the primary care setting (S. Martin, unpub-lished work 1988).43–51 In one study, Finney et al49 re-ported that externalizing and internalizing scores weresignificantly reduced at 12 months of follow-up afterbehavior therapy was provided to children with psycho-logical problems (n � 186) by psychologists located inprimary care. However, there was no comparison group

on these measures, so these results must be interpretedwith caution.

In a more rigorously designed study, Beardslee et al43

conducted an efficacy trial of 2 manual-based preventiveintervention programs for children of depressed parents,designed to be used by a wide range of practitioners froma variety of disciplines, including pediatricians, inter-nists, nurses, and mental health clinicians. The “lecturecondition” consisted of 2 separate group meetings withparents only. The “clinician-facilitated condition” con-sisted of 6 to 11 sessions, including separate meetingswith parents and children, as well as a family meeting. Itwas found that parents in both conditions reported sig-nificant change in child-related behaviors and attitudesbut 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-re-lated qualities in these at-risk children. This study dem-onstrates that a brief, simple intervention does haveenduring positive effects on families’ ability to problemsolve around parental illness.

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

Study Design Brief Description ofIntervention

Population SampleSize

Length ofFollow-Up

Summary of Results

Crawford et al, 198933a SBA Behavior therapy Children with sleepdisorders

9 7 wk All patients reduced number of problemincidents pre- to postassessment

Cullen, 197634, Cullen andCullen, 199635a

RCT Brief pre-school interviewswith parents(psychological healthpromotion) vs control

Communitysample

246 6 and 20 y Some differences in behavior andrelationships favoring theintervention group, but no differencebetween groups in terms of schoolperformance; Some differencesendured for up to 20–30 y (eg,neurotic symptoms)

Galbraith et al, 199336a SBA Behavior therapy Children with sleepdisturbances

45 34 wk Time to settle and mean wakingsreduced significantly over time; Atdischarge, 73% of parents weresatisfied with the treatment

Hewitt, 199137a CBA Two parent educationalinterventions(educational leafletsplus 2 schedules of HVcontact) vs control

9-mo to 2-y-olds 132 9 mo and 2 y Parents in first intervention groupreported more potentiallyproblematic behavior at 9 mo and2 y; No difference in reports of actualproblem behavior at either point; Nodifferences between secondintervention and controls at 9months.

Houtzager et al, 200138 SBA 5-session support group Siblings of childrenwith cancer

24 Unclear: “After groupparticipation”

Siblings experience less anxiety afterparticipating in the group

Oliansky, 199739a RCT Educational interventionby nurses vs control

Adolescents at riskfor substanceuse

25 1 and 3 mo Self-reported alcohol use lower inintervention group at 1 and 2 mo

Scott and Richards,199040a

RCT Researcher acting insupportive capacityplus booklet vs bookletalone vs control

Children under 18mo with nightwaking

90 12 wk No significant differences in nightwaking measures between the 2intervention groups and controls

Tutty et al, 200342 RCT 8-wk behavioral and socialskill class in an HMOserving primary care/specialty care needs

Children newlydiagnosed withADHD

100 3 and 6 mo Intervention group reportedsignificantly lower parent-ratedADHD symptoms, and the trainingwas well-accepted

RCT indicates randomized, controlled trial; CBA, controlled before and after study; SBA, simple before and after study; HV, health visitor; HMO, health maintenance organization.a Studies are taken from Bower et al.24

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TABLE4

Man

agem

entb

ySp

ecialistsinPrim

aryCa

re

Stud

yDesign

BriefD

escriptio

nof

Interventio

nPopu

latio

nSampleSize

Leng

thof

Follow-Up

SummaryofResults

Beardsleeetal,20034

3RCT

Eithera2-meetinglecture

(parentsonly)ora

6–11

sessionclinician-

facilitated

intervention

Relativelyhealthychildren

aged

8–15

ofparents

with

mooddisorder

andtheirparents

93families(121

children)

12and24

mo

Bothinterventions

prom

oted

resilience-relatedqualities

intheseat-risk;Long-standing

positiveeffectsinhow

familiesproblemsolvearound

parentalillness.

Benson

andTurk,19884

4aRCT

Grouptherapyby

psychologist/GPvs

routineprimarycare

Frequentattenders

1717

mo

Familyconsultations

significantly

reducedinintervention

group6moafterinterventioncompleted

Blakey,19864

5aCBA

Behaviortherapyvs

routineprimarycare

Patientsw

ithpsychological

problems

178

3y

Rateso

fservice

useininterventiongroupwerehigher

pretreatment,reducedposttreatmentbutincreased

againovertim

eCoverleyetal,19954

6aSBA

Psychiatric

evaluationby

child

psychiatrist

Mothersofchildrenwith

psychiatric

disorders

2612

mo

12-m

oclinicattendance

reducedfrom6.5to2.8,and

maternalcoincidence

increasedpostintervention

DavisandSpurr,1998

47a

CBA

Parentcounselingby

trained

HVs

vscontrol

Familiesreferredtoa

parentadvisorservice

(HVs,GPs,nursery)or

voluntary,self-referrals

9316

wk

Improvem

entw

ithininterventiongroupsig

nificantin

relationtoperceptions

offamilyrelationships,child

behaviorandcontactswith

primarycareprofessio

nals;

Between-groupanalysesofchange

scoressig

nificant

forfam

ilyrelationships

Finney

etal,19914

9aCBA

Behaviortherapyby

psychologistsversus

routinecare

Childrenwith

psychological

problems

186

12months

Externalizingandinternalizingscoresreduced

significantly

(withininterventiongrouponly).HMO

medicalencounterssig

nificantly

lowerpost-

interventionininterventiongroupcomparedwith

controls

Finney

etal,19894

8aCBA

Behaviortherapyby

psychologistsvs

routinecare

Childrenwith

recurrent

abdominalpain

3242

wk

Schoolabsencereduced(withininterventiongrouponly);

Significantreductioninmedicalvisitsw

ithin

interventiongroup,no

change

incontrols

GravesandHastru

p,1981

50a

CBA

Patientstreated

bypsychologistsvs

controls

Childrenwith

mental

healthproblems

6312

mo

Significantreductions

inmedicalvisitsinintervention

group,no

significantchangeincontrols

Martin,1988(unpublished

thesis)

a

CBA

Behaviortherapyby

psychologistsvs

routinecare

Childrenwith

mental

healthproblems

6512

wk

Treatm

entw

asassociated

with

asig

nificantdropin

intensity

ofproblems,butnotthenumberreported

Nicoletal,19935

1aRCT

Intensivehealthvisitingvs

familytherapy(by

socialworkers)vs

motherand

toddler’s

groups

(socialw

orkers

andHVs)vscontro

l

Preschoolchildrenwith

emotionaland

behavioralproblems

260

1and3y

At1y,sig

nificantdifference

indevelopm

entalquotient,

with

familytherapylowerthan

otherthree

groups;No

differenceintotalchildbehavior;At3

y,none

ofthe

majoroutcom

evariablesshow

edatreatmenteffect

RCTindicatesrandomized,contro

lledtrial;GP,generalpractitioner;CBA

,contro

lledbeforeandafterstudy;SBA

,simplebeforeandafterstudy;HV,healthvisitor;HMO,health

maintenance

organization.

aStudiesaretakenfromBoweretal.24

676 STEIN et al at Columbia University on January 9, 2007 www.pediatrics.orgDownloaded from

Taken together, although not focused on adolescentdepression per se, the higher quality studies (random-ized, controlled trials) presented in Tables 3 and 4 sug-gest that intensive psychosocial interventions can bebeneficial when delivered in primary care settings, al-though caution is warranted, because the general pat-tern seen across these studies seems to suggest thatgreater treatment “intensity” (eg, 8–12 sessions) seemsto characterize those interventions where effects havebeen most apparent. Although treatments of that inten-sity may be outside the scope of the realities of practicefor most physicians, with sufficient support, training,and staffing, such interventions might be feasibly deliv-ered by other members of the primary care team.

Improving Skills of PCCsPediatricians have repeatedly reported that they believethat they are inadequately trained in mental health is-sues.52–56 However, evidence shows that training primarycare physicians improves their willingness to addresspatients’ behavioral health issues,57 which increases con-fidence, and decreases discomfort in exploring mentalhealth issues. Lustig et al57 conducted a study examiningthe impact of skills-based training workshops on PCCscreening and counseling practices with adolescents andfound significant increases in counseling on multiplemeasures identified to be relevant for adolescent preven-tive health care, including tobacco use and sexual be-havior. This study offers support for the benefit of train-ing for PCCs to increase their counseling behaviors.

Training clinicians in specific behavioral issues hasalso been shown to improve patient-doctor communica-tion. Gielen et al58 found that pediatricians trained ininjury prevention provided significantly more injuryprevention counseling than the control group, and par-ents were significantly more satisfied with the help thattheir physicians provided on safety topics than controlgroup parents.

Overall, educational studies involving members of theprimary care team suggest that short courses for primarycare professionals may be associated with changes insubjective outcomes, such as physician confidence andknowledge, actual increases in the physicians’ expectedbehaviors (counseling), changes in parents/patients’knowledge, and, in a few instances, changes in patients’symptoms and emotional distress (See Table 5; P. Apple-ton, P. Pritchard, A. Pritchard, unpublished work,1988).37,59–64

Anticipatory GuidanceAnticipatory guidance, that is, the provision of develop-mentally appropriate information and support in antic-ipation of issues that may arise in the near future, hasbeen a cornerstone of pediatric practice and is one of thefundamental underpinnings of the work that pediatri-cians do in their offices during health care maintenance

visits. Key principles of this approach are incorporatedinto Bright Futures in Practice.65 To a large extent, antici-patory guidance is the backbone of prevention. Remark-ably, we were able to locate very few randomized, con-trolled trials of anticipatory guidance with adolescentsand, as a result, no evidence-based reviews. Nonethe-less, anticipatory guidance is not wholly without sup-port, and among the few studies that have actually ex-amined its effects, several have demonstrated benefit.Studies by Guteilus et al66 and Adam et al67 both showedpositive effects of anticipatory guidance on early childrearing practices and actually changed parental behav-iors. More recently, Nelson et al68 reviewed the evidencefor effectiveness of anticipatory guidance and showedpositive impact on parent-child interaction, sleep pat-terns, injury prevention, and reading. Although thesestudies are not directly relevant to the management ofadolescent depression in primary care, they offer someevidence that anticipatory guidance strategies mightprove useful.

In the related area of injury prevention, Bass et al69

reviewed injury prevention counseling in primary caresettings, finding 18 studies showing positive effects ofinjury prevention counseling, including increasedknowledge, improved behavior, and decreased injuryoccurrence for both motor vehicle and nonmotor vehicleinjuries. Similar benefits have been seen with regard toother topics as well, suggesting that advice giving andeducational counseling in the area of adolescent depres-sion are not without precedent in other areas of pediatricpractice and are likely to be more beneficial than doingnothing.

Psychosocial Interventions for Improved AdherenceResearch in other types of primary care interventionsdemonstrates the usefulness of the health care practitio-ner in changing patient behavior and improving out-comes, especially with respect to adherence to therapeu-tic regimens for longer-term management of ongoinghealth conditions. Research on adherence to therapeuticregimens generally focuses on a wide range of chronicconditions and, therefore, has saliency for the chronicnature of many types of depression. Such research hasrepeatedly demonstrated the importance of a relation-ship between the clinician and the patient and has em-phasized the importance of communication skills andthat even in the absence of medication, a strong positiverelationship with the health care provider is a motivatorof many different types of behavioral changes on thepart of patients. For example, in the pediatric asthmaliterature, as demonstrated in a review by Lemanek etal,70 both educational and behavioral strategies havebeen shown to be “promising” according to Chamblesscriteria in improving adherence to therapeutic regi-mens.70 Cognitive behavioral strategies seem equally

PEDIATRICS Volume 118, Number 2, August 2006 677 at Columbia University on January 9, 2007 www.pediatrics.orgDownloaded from

TABLE5

Educationa

lStudies

InvolvingthePrim

aryCa

reTeam

Stud

yDesign

BriefD

escriptio

nof

Interventio

nStud

yPopu

latio

nSampleSize

SummaryofResults

P.Ap

pleton,P.Pritchard,A.Pritchard,

unpublish

edwork,1988

a

SBA

Behavioralinterventionmethods;

3-dayinductionfollowed

by3

follow-updays,plusaccessto

specialistH

V

HVs

13HVs

and72

families

Significantreductions

inmothers’perceptionoftheseverity

oftheproblemandmothers’and

fathers’GH

Qscores

pre-andpostintervention

Bernardetal,19996

0aSBA

Preparatoryreadingandsin

gle

structured

teaching

sessions

usingeithervignetteso

rvideo

GPtrainees

61GP

sand

174

patients

Scoresin5/6attitude/competencequestions

increased

post-training;Sm

allbutsig

nificantincreasein

know

ledgequizscores;Significantincreaseindiagnostic

accuracy

insubsam

pleofGP

sBowleretal,1984

61a

SBA

3-dayworkshopandfollow-up

session6wklater

HVs

6HVs

5/6HVs

increasedscoreson

casevignettes;Averagescore

pretraining,10.2;posttraining,18.7

Davisetal,19976

2aCBA

Parentadvisortrainingvsno

training

HVs

andCM

Os

6HVs

and3CM

Os

Significantchangesincounselingknow

ledge,perceptionof

selfascounselor,self-esteem

,overallcounselingability

andattendingbehavior

Hew

ittetal,19913

7aSBA

2-daybehavioralworkshopon

managingchildren’s

behavioralproblems;

Additionalinvivo

case

supervision

andtraining

HVs

9HVs

Significantincreaseinratings

ofappropriateness

post-training;Nodifferencesinratings

ofdifficulty

indealingwith

problemsp

ost-training;Noeffectoftraining

onmethods

ofcaseidentification

Roteretal,1995

63RCT

One

of2communication-skills

trainingcoursesd

esignedto

helpphysicians

address

patients’em

otionaldistressvs

no-trainingcontrol

PCCs

andtheirpatients

69PCCs,648

patients

Trainedphysicians

reportedmorepsychosocialproblems,

engagedinmorestrategiesform

anagingem

otional

problemsw

ithactualpatients,scored

higherinclinical

proficiency

with

simulated

patients;Patientso

ftrained

physicians

reportedreductioninem

otionaldistressforas

long

as6months.

Stevensonetal,19886

4aRCT

12-sessio

ninterventionusing

behaviormodification

techniquesvsdelayed

HVs

andfamilieson

theircaseload

14HVs

and205families

Fewchangesinchild

behaviorineitheranalysis,although

thosechangesthatw

eresig

nificantsuggested

thatthe

delaygroupwerelesseffectivepost-training;No

differencesinresolutionoftargetbehaviors;No

significantchangesinmaternalGHQscore.

Weirand

Dinnick,19886

5aCBA

Instructioninbehavior

modification(m

anualized)and

groupmeetings

HVs

andchildrenwith

sleep

problems

Num

berofH

Vsunclear,

51children

Fewdifferencesinoutcom

esbetweeninterventionand

control,usingeitherclinicalorhealthvisitorratings,

although

morechildrenincontrolgroup

referredto

otheragencies(8%

vs41%)

SBAindicatessimplebeforeandafterstudy;HV,healthvisitor;GP,generalpractitioner;GHQ,generalhealthquestionnaire;CBA

,contro

lledbeforeandafterstudy;CMO,com

munity

medicalofficer;RCT,randomized.contro

lledtrial.

aStudiesaretakenfromBoweretal.24

678 STEIN et al at Columbia University on January 9, 2007 www.pediatrics.orgDownloaded from

promising in improving adherence to type 1 diabetestreatment regimens.71

One example of a study examining adherence ran-domly assigned diabetic adolescents to either copingskills training (CST) in conjunction with intensive insu-lin therapy or to intensive insulin therapy alone.71 CSTentailed a series of small group meetings to teach ado-lescents social problem solving, conflict resolution, andsocial skills. Adolescents who received CST from a nursepractitioner had lower hemoglobin A1C levels (indicat-ing better long-term control of their diabetes) and betterdiabetes self-efficacy and were less upset about copingwith diabetes than control group adolescents. In addi-tion, adolescents who received CST experienced less of anegative impact of diabetes on their quality of life.71

Although additional studies are needed, availabledata suggest that the PCC who provides modest levels ofsupport can affect meaningful change in behavioral andpsychosocial dimensions with adolescents, even withbrief interventions consisting of as few as 1 to 3 meet-ings.70 Although the recent review of regimen adherenceby Lemanek et al70 does not consider these interventionsto meet criteria for “well-established” therapy, there issubstantial evidence that they are “probably efficacious.”

DISCUSSIONIn considering our overall findings, several caveatsshould be noted. First, our review of the literature re-vealed that very few studies have directly tested thebenefits of treating adolescent depression in primarycare settings. Given their very small number, we did notattempt to use meta-analytic procedures to systemati-cally rate the quality of the direct studies, although wehave noted the strengths and limitations of these studies.In addition, our review was limited by the choice ofdates, key words, and available databases. Despite theselimitations, available evidence has increased substan-tially over the last few years, and several compellinglines of evidence support the possible benefits of primarycare interventions for depressed youth. Moreover, ourreview suggests that the primary care setting is a practi-cal, realistic, and feasible setting in which to addressadolescent depression, with several lines of evidencesuggesting the merits of this approach.

First, adolescent depression is a relatively commonoccurrence, with inadequate resources in most commu-nities to refer all depressed adolescents to mental healthprofessionals. In fact, many adolescents experience thesesymptoms transiently and may not need specialized care.Even in carefully executed, randomized, controlled trialslasting 6 to 8 weeks, upward of 60% of adolescentsubjects may improve substantially on placebo,72 sug-gesting that supportive interactions and active problemsolving with a caring health care professional is not aninactive treatment and might, in fact, benefit manyyouth much more than a never-ending waiting list or a

referral that is not followed through to completion. Inaddition, a host of logistic, social, and financial issuesmay impede the likelihood of mental health referral,even if it were the universally recommended strate-gy.73,74

Second, although few primary care studies directlyassessing adolescent depression meet our highest stan-dard of evidence, the great need for services for de-pressed adolescents warrants primary care providers’ fo-cused attention. The information presented in this articlesuggests the usefulness of primary care interventions,particularly in view of the strong likelihood that manyadolescents will not get care elsewhere for their depres-sion.

Not surprisingly, then, the increasingly prevailing rec-ommendation (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 necessaryguidance to support their management of mental healthproblems within their setting. To address this problem, asteering committee consisting of 27 primary care experts(including pediatricians, family physicians, and nursepractitioners), depression researchers (child psychiatryand psychology), guideline development experts, policy-makers, and family organization representatives havemet over the last 2 years to develop the Guidelines forAdolescent Depression in Primary Care (A. Cheung, MD, R.Zuckerbrot, MD, and P. S. J., unpublished manuscript).In addition, liaison representatives from each of themajor US and Canadian primary care and specialty men-tal professional associations and family advocacy orga-nizations provided formal input to the recommenda-tions.

To augment the process of consensus development,an extensive survey of optimal methods for depressionmanagement was also conducted among 80 PCCs anddepression experts. In addition, rigorous literature re-views (including this review) were completed of all ev-idence pertaining to primary care adolescent depressionmanagement: depression screening/identification, as-sessment and diagnosis, treatment, maintenance, andmental health system coordination (R. Zuckerbrot, MD,A. Cheung, MD, K. Ghalib, MD, and P. S. J., unpublisheddata). The final guidelines (now nearing completion)and accompanying literature reviews will be published,and an associated tool kit will be made available at nocost online (www.kidsmentalhealth.org/GLAD-PC.html). The guidelines are intended for ultimate dissem-ination to PCCs in the United States and Canada, includ-ing clinicians in pediatrics, family medicine, nursing, andinternal medicine.

These guidelines should be an important first step inimproving the ability of PCCs to address these issues. Inaddition, however, PCCs are often not reimbursed formental health services nor are they equipped to developand maintain linkages with the community resources

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needed to provide a continuum of care for these youth.Evidence from a national cross-sectional survey of 280pediatricians suggests that whereas most feel responsiblefor recognizing adolescent depression, they do not feelresponsible for treating even uncomplicated adolescentdepression. Only 35% expressed motivation to changetheir current depression recognition and treatment prac-tices.32 More recently, Stein et al56 reported on the resultsof an American Academy of Pediatrics Periodic Surveythat indicated that among practicing pediatricians, 84%think they should be responsible for identifying depres-sion, but only 53% actually report that they usuallyinquire about depression among their patients. Only20% report that they believe that they should treatdepression.

Clearly, there is a compelling need for more researchto determine the best ways to improve primary caretreatment of adolescents with depression. However, de-spite the limited direct evidence for effectiveness of pri-mary care physicians’ capacity to reduce depressedyouths’ symptoms with psychosocial support, the pri-mary care setting has shown itself to be a practical,realistic, and useful setting in which to address a range ofchild and adolescent health issues. Although more re-search is clearly needed, PCCs should not assume that“there is nothing I can do” to assist depressed youth andtheir families. To do so is to inadvertently withhold thelikely benefits of empathy, support, and education thatmay alleviate the suffering of as many as half of theseyouth, particularly for those families faced with longmental health treatment waiting lists or other barriers tocare.

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DOI: 10.1542/peds.2005-2086 2006;118;669-682 Pediatrics

Ruth E.K. Stein, Lauren E. Zitner and Peter S. Jensen Interventions for Adolescent Depression in Primary Care

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