Implementation of Behavioral Activation within a Care Pathway for Adolescent Depression at an Academic Medical Center
This paper describes the implementation of Behavioral Activation (BA) as the core psychotherapy treatment within a broader clinician-led effort to establish a care pathway for adolescent depression in an academic medical center that served public and private hospital systems. This quality improvement effort required a standardized yet flexible approach to psychotherapy to be used by clinicians with a range of experience and training backgrounds while serving diverse clinical populations in child psychiatry and pediatric clinics. This paper highlights implementation of BA in treating adolescent depression across these varying systems. In particular, the paper emphasizes the application of BA as a principle-driven, treatment that enables flexibility across settings while remaining rooted in scientific evidence. The paper also reviews lessons learned from this effort that may support efforts to implement BA in other clinical settings and systems.
Behavioral Activation as a Principle-Based Treatment: Developments from a Multi-Site Collaboration to Advance Adolescent Depression Treatment
Adolescent depression is a serious and debilitating disorder associated with lifelong negative outcomes, including heightened risk for recurrence into adulthood, psychiatric comorbidities, and suicide. Among evidence-based treatments for adolescents, psychotherapies for depression have the smallest effect sizes of all psychiatric conditions studied. Advancing care for depression in adolescents is complex due to the heterogeneity in etiology and co-occurring difficulties among youth presenting with depression symptoms. This and a companion paper (Lewandowski et al., 2022) draw on a recent multisite collaboration that focused on implementing depression treatment for adolescents within clinical and research contexts. Specifically, this paper will review our work adapting behavioral activation (BA) as a principle-based framework to improve effectiveness and efficiency of depression treatment used within clinical and research settings in academic medical centers. Piloted adaptations include the use of BA principles to address idiographic drivers of depression and in-session BA "exposures" to illustrate BA principles. Case vignettes illustrate these adaptations of BA to address adolescent depression in the context of co-occurring difficulties.
Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey
BACKGROUND:Climate change has important implications for the health and futures of children and young people, yet they have little power to limit its harm, making them vulnerable to climate anxiety. This is the first large-scale investigation of climate anxiety in children and young people globally and its relationship with perceived government response. METHODS:We surveyed 10â€ˆ000 children and young people (aged 16-25 years) in ten countries (Australia, Brazil, Finland, France, India, Nigeria, Philippines, Portugal, the UK, and the USA; 1000 participants per country). Invitations to complete the survey were sent via the platform Kantar between May 18 and June 7, 2021. Data were collected on participants' thoughts and feelings about climate change, and government responses to climate change. Descriptive statistics were calculated for each aspect of climate anxiety, and Pearson's correlation analysis was done to evaluate whether climate-related distress, functioning, and negative beliefs about climate change were linked to thoughts and feelings about government response. FINDINGS/RESULTS:Respondents across all countries were worried about climate change (59% were very or extremely worried and 84% were at least moderately worried). More than 50% reported each of the following emotions: sad, anxious, angry, powerless, helpless, and guilty. More than 45% of respondents said their feelings about climate change negatively affected their daily life and functioning, and many reported a high number of negative thoughts about climate change (eg, 75% said that they think the future is frightening and 83% said that they think people have failed to take care of the planet). Respondents rated governmental responses to climate change negatively and reported greater feelings of betrayal than of reassurance. Climate anxiety and distress were correlated with perceived inadequate government response and associated feelings of betrayal. INTERPRETATION/CONCLUSIONS:Climate anxiety and dissatisfaction with government responses are widespread in children and young people in countries across the world and impact their daily functioning. A perceived failure by governments to respond to the climate crisis is associated with increased distress. There is an urgent need for further research into the emotional impact of climate change on children and young people and for governments to validate their distress by taking urgent action on climate change. FUNDING/BACKGROUND:AVAAZ.
Screening for and Diagnosis of Depression Among Adolescents in a Large Health Maintenance Organization
OBJECTIVE: The aim of this analysis was to determine changes in patterns of depression screening and diagnosis over three years in primary and specialty mental health care in a large health maintenance organization (HMO) as part of a project to develop quality measures for adolescent depression treatment. METHODS: Two series of aggregate data (2010-2012) were gathered from the electronic health records of the HMO for 44,342 unique adolescents (ages 12 to 21) who had visits in primary and mental health care. Chi square tests assessed the significance of changes in frequency and departmental location of Patient Health Questionnaire-9 (PHQ-9) administration, incidence of depression symptoms, and depression diagnoses. RESULTS: There was a significant increase in PHQ-9 use, predominantly in primary care, consistent with internally generated organizational recommendations to increase screening with the PHQ-9. The increase in PHQ-9 use led to an increase in depression diagnoses in primary care and a shift in the location of some diagnoses from specialty mental health care to primary care. The increase in PHQ-9 use was also linked to a decrease in the proportion of positive PHQ-9 results that led to formal depression diagnoses. CONCLUSIONS: The rate of depression screening in primary care increased over the study period. This increase corresponded to an increase in the number of depression diagnoses made in primary care and a shift in the location in which depression diagnoses were made, from the mental health department to primary care. The frequency of positive PHQ-9 administrations not associated with depression diagnoses also increased.
Usual Care for Adolescent Depression From Symptom Identification Through Treatment Initiation
Importance: Published guidelines describing effective adolescent depression care in primary care settings include screening, assessment, treatment initiation, and symptom monitoring. It is unclear the extent to which these steps are documented in patient health records. Objective: To determine rates of appropriate follow-up care for adolescents with newly identified depression symptoms in 3 large health systems. Design, Setting, and Participants: In this analysis conducted from March to September 2014, structured data retrospectively extracted from electronic health records were analyzed for 3 months following initial symptom identification to determine whether the patient was followed up and, if so, whether treatment was initiated and/or symptoms were monitored. Records were collected from 2 large health maintenance organizations in the western United States and a network of community health centers in the Northeast. The study group included adolescents (N = 4612) with newly identified depression symptoms, defined as an elevated score on the Patient Health Questionnaire (>/=10) and/or a diagnosis of depression. Main Outcomes and Measures: Rates of treatment initiation, symptom monitoring, and follow-up care documented within 3 months of initial symptom identification. Results: Among the 4612 participants, the mean (SD) age at index event was 16.0 (2.3) years, and 3060 were female (66%). Treatment was initiated for nearly two-thirds of adolescents (79% of those with a diagnosis of major depression; n = 1023); most received psychotherapy alone or in combination with medications. However, in the 3 months following identification, 36% of adolescents received no treatment (n = 1678), 68% did not have a follow-up symptom assessment (n = 3136), and 19% did not receive any follow-up care (n = 854). Further, 40% of adolescents prescribed antidepressant medication did not have any documentation of follow-up care for 3 months (n = 356). Younger age (ages 15-17 years: odds ratio [OR], 0.78; 95% CI, 0.67-0.92 and ages 18-20 years: OR, 0.83; 95% CI, 0.70-0.99; P = .008), more severe initial symptoms (moderate: OR, 0.99; 95% CI, 0.82-1.21; moderate to severe: OR, 1.46; 95% CI, 1.19-1.80; and severe: OR, 2.14; 95% CI, 1.65-2.79; P < .001), and receiving a diagnosis (major depression/dysthymia: OR, 2.65; 95% CI, 2.20-3.20 and unspecified depression/adjustment disorder: OR, 1.75; 95% CI, 1.43-2.14; P < .001) were significantly associated with treatment initiation. Differences in rates of follow-up care were evident between sites (site 2: OR, 1.77; 95% CI, 1.45-2.16 and site 3: OR, 2.10; 95% CI, 1.72-2.57), suggesting that differences within health systems may also affect care received. Conclusions and Relevance: Most adolescents with newly identified depression symptoms received some treatment, usually including psychotherapy, within the first 3 months after identification. However, follow-up care was low and substantial variation existed between sites. These results raise concerns about the quality of care for adolescent depression.
Predictors of Positive Outcomes in Offspring of Depressed Parents and Non-depressed Parents Across 20 Years
Understanding differences in factors leading to positive outcomes in high-risk and low-risk offspring has important implications for preventive interventions. We identified variables predicting positive outcomes in a cohort of 235 offspring from 76 families in which one, both, or neither parent had major depressive disorder. Positive outcomes were termed resilient in offspring of depressed parents, and competent in offspring of non-depressed parents, and defined by two separate criteria: absence of psychiatric diagnosis and consistently high functioning at 2, 10, and 20 years follow-up. In offspring of depressed parents, easier temperament and higher self-esteem were associated with greater odds of resilient outcome defined by absence of diagnosis. Lower maternal overprotection, greater offspring self-esteem, and higher IQ were associated with greater odds of resilient outcome defined by consistently high functioning. Multivariate analysis indicated that resilient outcome defined by absence of diagnosis was best predicted by offspring self-esteem; resilient outcome defined by functioning was best predicted by maternal overprotection and self-esteem. Among offspring of non-depressed parents, greater family cohesion, easier temperament and higher self-esteem were associated with greater odds of offspring competent outcome defined by absence of diagnosis. Higher maternal affection and greater offspring self-esteem were associated with greater odds of competent outcome, defined by consistently high functioning. Multivariate analysis for each criterion indicated that competent outcome was best predicted by offspring self-esteem. As the most robust predictor of positive outcomes in offspring of depressed and non-depressed parents, self-esteem is an important target for youth preventive interventions.
What family support specialists do: examining service delivery
This study describes services provided by family support specialists (FSS), peer advocates in programs for children with serious psychiatric conditions, to delineate differences between recommended components of FSS services and services actually provided. An analysis of qualitative interview and observational data and quantitative survey data from 63 staff at 21 mental health programs in New York identified that FSS and other staff have generally similar ideas about FSS services, and that these perceptions of activities are generally congruent with what FSS actually did. Implications of findings are discussed in the context of developing competencies and quality indicators for FSS.
Scaling up Evidence-Based Practices for Children and Families in New York State: Toward Evidence-Based Policies on Implementation for State Mental Health Systems
Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the children's mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.
Evidence for the Management of Adolescent Depression
Adolescent depression is a prevalent and disabling condition resulting in emotional suffering and social and educational dysfunction. Care for adolescent depression is suboptimal and could be improved through the development and use of quality indicators (QIs). This article reports on the development of a care pathway and QIs for the primary and specialty care management of adolescent depression from case identification through symptom remission. It presents evidence from a review of adolescent clinical practice guidelines and research literature to support QIs at critical nodes in the pathway, and describes implications for practice based on existing evidence. Barriers to measure development are identified, including gaps in empirical evidence, and a research agenda is suggested.
Group Interpersonal Psychotherapy for depressed youth in IDP camps in Northern Uganda: adaptation and training
This article reviews the use of Interpersonal Psychotherapy (IPT) with depressed youth living in Internally Displaced Persons (IDP) camps in North Uganda. This youth has been exposed to severe losses and disruptions in relationships with caregivers, family, and community members; limited access to formal education; exposure to malnutrition and infections; and pressure to prematurely assume adult family roles. The process of adaptation to the content and training of IPT for these youth is presented and illustrated with case examples.