Of 115 youth who were identified as possible candidates for the study, 82 met eligibility criteria (). The most common reason for exclusion was that the depression was felt to be too severe for primary care treatment either because the patient was already seeing a psychiatrist (n = 11), had been hospitalized in an inpatient mental health facility within the prior year (n = 4) or had psychiatric comorbidity that required mental health specialty care (n = 3). Additional reasons for exclusion were being outside of study age range by the time of initial contact, not meeting criteria for major or minor depression, or having plans to leave the primary care practice. Fifty-eight percent (N = 48) of youth who were contacted and did not meet exclusion criteria agreed to participate in the study. The remainder were either unreachable (N = 11) or refused to participate (N = 23). Most of the families who refused to participate indicated that their child was already receiving the help that he or she needed. Eight of the youth who agreed to participate did not show for intake interviews despite multiple scheduling attempts, resulting in a final enrollment of 40 subjects (49% of eligible).
Intervention Enrollment Flowchart
Among the 40 youth enrolled in the study, participants were between 12 and 18 years old with an average age of 15 years (). The majority of participants were female and White. Fifty-five percent of participants were taking at least one psychotropic medication at study baseline, the most common types being antidepressants and stimulants. The mean PHQ-9 was 14 (SD = 4.5), indicating moderate severity of major depression.
Ten youth received medication treatment only, 12 received psychotherapy only, and 16 received both types of treatment during the study (8 youth who were already receiving one type of therapy, including 4 on antidepressant medications, and 4 in psychotherapy were provided a second treatment at the start of the study; 8 others had a second treatment added during the study due to persistent depressive symptoms). Two youth withdrew prior to selecting or starting any treatment. Over the 6 month treatment period, youth had an average of 9 contacts with the DCM (SD=3.2, Range=2 to 17). Most of these contacts were in person (mean = 6.8 per youth (SD=3.5, Range=1 to 16)) with fewer by phone (mean = 3.1 per youth (SD=2.3, Range= 0 to 9)).
There was a significant improvement in depression scores and functional impairment from baseline to six month follow-up (). Seventy-four percent of youth with an assessment at 6 months (n=35) had a greater than 50% decrease in depressive symptoms on the PHQ-9 between their baseline to their final follow-up assessment with the DCM. On written MFQ-SF assessments at baseline and six months, 52% of youth who completed the 6 month survey (n=31) demonstrated a 50% or greater reduction in depressive symptoms. There was a significant decrease in the mean CIS score from 22.5 (SD = 7.76) at baseline to 15.3 (SD = 8.99) at 6-month follow-up (p<0.001), which represents a 32% decrease in functional impairment symptoms. At baseline, 82.5% of youth had CIS scores of 15 or higher, indicating a “need for services”, compared to 50% at the 6-month assessment.
Pre and Post Intervention Depression and Functional Impairment
Both parents and youth reported high levels of satisfaction with the intervention. On a scale of 1 to 7, 81% of youth completing satisfaction surveys (N=31) and 81% of parents who completed satisfaction surveys (n=26) reported that they were satisfied or very satisfied with the intervention.
Semi-structured exit interviews were completed with 16 youth and 21 parents. In exit interviews, youth and parents again expressed high levels of satisfaction with the intervention. Youth particularly appreciated that the DCM was “non-judgmental”, “cared about” them, was “available” and took the time to listen to their concerns, communicated concern by calling to check in with them and remembering what they had discussed, and made practical suggestions that they felt they could apply in their every day lives. As one youth stated in comparing the DCM to her doctor:
“She was more I felt a counselor, like someone I could cry to or… kind of more personal and I could ask her anything and told her my drug history and everything… It was just really open. And she didn’t judge me - she just gave me honest facts. She was more like a friend.”
In addition to meetings with the DCM, about two-thirds of youth interviewed also felt that group sessions with other teens would be helpful so that they did not “feel so alone”.
Youth and parents appreciated that the care took place in their primary care physician’s office and felt that it was easy to arrange appointments. Parents felt that their children benefited from having “another adult” to relate to and appreciated that regular visits with the DCM encouraged them to keep underlying issues “on the table” and helped their children to “learn to take care of themselves.” Parents’ main request was that they would have liked more information about what tasks their children were working on with the DCM. Although a few youth indicated that they would be upset if their parents were more involved, most thought that it would be alright if their parents learned more about what tasks they were working on as long as confidentiality regarding specific details of what the youth was sharing were preserved.
A final theme that arose related to concern about the timing of the intervention. For a few youth the intervention ended at a particularly bad time - during a relationship break-up or at the beginning or end of the school year. These youth had particularly difficult transitions off of the study and reported an increase in their depressive symptoms in the months following study completion.