Follow-up primary care for adolescents with depression is extremely poor, with 19% overall and 40% of those given antidepressants receiving no follow up at all, according to an analysis of electronic health records for 4,612 patients attending three large and highly regarded primary-care settings, which was published online Feb. 1 in JAMA Pediatrics.
“Current standards of care recommend that adolescents identified with depression symptoms receive further assessment, initiate antidepressant medication and/or psychotherapy treatment, and are monitored for changes in symptoms, especially following an antidepressant prescription. Evidence from this study suggests that quality of care in routine practice diverges from these standards,” said Briannon C. O’Connor, Ph.D., of New York University Child Study Center, and her associates.
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They analyzed EHR data from two unnamed health maintenance organizations in the western United States and a large network of community health centers in the Northeast. The researchers identified 4,612 adolescents with moderately severe symptoms of depression. At the index visit to their primary care physicians, 47% of these patients were diagnosed as having major depression and 24% as having other/unspecified depression. The most frequently used screen for depression was the Patient Health Questionnaire.
During the 3 months following these index visits, symptom monitoring was documented in 32% (1,486) of the adolescents overall. This means that two-thirds of patients had no symptom monitoring, which is considered basic care even for patients with mild depressive symptoms.
In addition, 19% of adolescents with newly identified depression had no follow-up visits at all with their primary care physicians.
“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, unremitting depression,” the investigators said (JAMA Pediatr. 2016 Feb 1. doi: 10.1001/jamapediatrics.2015.4158).Treatment was initiated in 64% of the adolescents: antidepressants only in 19%, psychotherapy only in 29%, and combined antidepressants and psychotherapy in 16%. Fully 40% of the nearly 900 adolescents who were prescribed antidepressants showed no follow-up visits at all during the 3 months after the index visit. “Current black box warnings highlight the risk for increased suicidality for youth prescribed antidepressants and recommend patients are ‘monitored appropriately and observed closely … especially during the initial few months,’ ” Dr. O’Connor and her associates noted.
These findings are particularly troubling because the participating sites “are often looked to as leaders in cutting-edge care that routinely use quality-improvement initiatives focused on adolescent behavioral health care. Thus, [the study results], as discouraging as they are, may overstate the quality of care in other settings,” the investigators added.
This study was supported by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. Dr. O’Connor and her associates reported having no relevant financial disclosures.