Collaborative Care for Mental Health Helps Teens

A care manager can help primary care doctors and mental health specialists collaborate to treat teenagers with problems such as depression and anxiety.

In a common medical scenario, a teen might go to their primary care doctor with complaints of depression. The doctor — concerned, but busy — prescribes an antidepressant, and the teen receives a referral to a mental health specialist and instructions to return in 4 to 6 weeks.

That’s often the end of the story. The teen never seeks follow-up care, despite having a serious medical condition and having been told to take a medication, sometimes with significant side effects.

It’s not exactly setting up the teen or the treatment for success.

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“What we know is that often teens who get started on medications don’t return for follow up or discontinue them after they’re started, or they don’t make it to the mental health specialist appointment,” says Laura Richardson, MD, MPH, a professor of pediatrics at the University of Washington School of Medicine and chief of adolescent medicine at Seattle Children’s Hospital. “Right now, in primary care, our systems for tracking that and supporting patients are not as good as they could be. We leave a lot of it up to the patient and the family to get the next steps in care.”

Richardson and colleagues have found another healthcare model, called collaborative care, can be more effective in treating depression in teens.

Collaborative care is integrated care that treats common mental health conditions that are often persistent, such as depression and anxiety. It specializes in regular follow-up care that may include the expertise of primary care doctors and mental healthcare specialists. A care manager checks in with a patient during the course of care to document any side effects and treatment dosages so the doctor can adjust any medications based on the patient’s progress, preferences, and feedback.

Collaborative care for teen depression

Richardson and colleagues were among the first to examine how well collaborative care works to treat depression in teens. For a study published in JAMA, Richardson and colleagues recruited 101 teens with major and minor depression at primary care clinics in the Seattle area. Half were provided with their depression screening results and assigned to usual care — a referral to a mental health specialist in their network. The other half worked with a depression care manager, who provided educational and brief psychotherapy sessions at the clinic’s offices.

Teens and their families worked with their primary care provider and the care manager to establish a treatment plan. The care managers also followed up with the teens over a period of 12 months, calling or meeting with them every week or two to assess symptoms and their overall health and progress.

After a year, half of teens in the treatment group had achieved remission — no longer having depressive symptoms — compared to one in five in the usual-care group.

Parents and teens both rated the program highly: Eighty-one percent said they were satisfied or very satisfied with the program. Parents also said they appreciated having another caring adult in their teen’s life, while teens said it was important to them to know someone was reaching out and cared about them.

Teens rated the care managers highly, saying they were accessible and helpful, like talking to a friend. But part of the reason for such high satisfaction levels is likely the convenience of getting help at their nearby doctor’s office.

“It’s a lot easier on the family,” says Richardson. “If you think about it, with things like depression, the system is set up in such a way right now where we ask people, when they’re feeling their worst, to jump over a million hurdles to get to care. It’s at a time when they’re already having a hard time coping with what’s going on in their life, so to add a lot of hurdles is not in their best interest.”

Collaborative care avoids those difficulties.

“The whole goal of collaborative care is to break down those barriers and to make sure that when we recommend a treatment, people aren’t just sitting out there thinking, ‘Well, that didn’t work, so there’s nothing that’s going to help me feel better.’ There’s someone reaching out and saying, ‘Hey, wait, you can feel better. Let’s figure this out together.’”

Collaborative care is effective and reduces costs

Research showing the effectiveness of collaborative care is important because standard treatment for depression in adolescents often fails due to lack of follow-up. By the age of 18, more than 15 percent of teenagers experience an episode of major depression — but fewer than half receive treatment. Almost 38 percent of all teens report persistent feelings of sadness, hopelessness, or depression, according to research from the Centers for Disease Control and Prevention. Early episodes increase the risk of recurring depression and other mental health disorders throughout life.  

In recent years, Richardson and colleagues have looked at other ways to expand collaborative care to help adolescents with mental health problems, including the possibility that some schools can become part of collaborative care teams, providing behavioral health services on-site for teens.

“When teens show up with depression,” Richardson notes, “it’s often their first experience. I think there’s a tremendous opportunity to work on making sure that we’re teaching skills to teens and helping them in ways that will reduce the risk for it to become a lifelong problem.”

In all, more than 80 studies have shown the collaborative care model improves health outcomes, reduces costs, and is effective in treating several health problems in addition to teen depression. Such conditions include heart disease and diabetes, both health problems that require frequent medical check-ins and medication management.

Though a number of care systems have adopted the model nationwide and internationally, Richardson says the biggest barrier to wider adoption of collaborative care is the current healthcare model, which bills for services performed rather than more holistic care.

“How do you have a care manager in the clinic if they can’t support their time through billing? This is a new role, and we really have to figure out with healthcare systems how to support it,” she says. “There are some opportunities as the healthcare system moves forward in looking, not just at the number of services we provide, but the quality of outcomes that we have. I think that will create some tremendous opportunities for us to really think about how we organize care.”

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