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Youth Partners in Care--Depression Treatment Quality Improvement (YPIC/DTQI)

Youth Partners in Care--Depression Treatment Quality Improvement (YPIC/DTQI) is a 6-month quality improvement intervention to improve depression outcomes among adolescents by increasing access to depression treatments, primarily cognitive behavioral therapy (CBT) and antidepressants, in primary care settings. Like Partners in Care for adults (reviewed previously by NREPP), YPIC/DTQI is a collaborative care model in which mental health is integrated with primary care. The main elements of the YPIC/DTQI model are teamwork between specialists and generalists, case management by care managers, and patient education and empowerment. Organizations implementing the program receive professional development and training, as well as manuals for clinicians and care managers to improve coordination and guide treatment planning and delivery. Patient education brochures are also provided for participating youth and their families.

YPIC/DTQI emphasizes the role of the care manager in coordinating mental health services. The care manager is a psychotherapist, psychologist, social worker, or nurse who works with the referring primary care clinician to evaluate youth and provide treatment or referrals as needed. If a patient screens positive for depression, the care manager presents an educational model for understanding depression and treatment options and supports the patient in deciding whether to pursue treatment for depression. If the patient chooses treatment, the care manager helps to select the preferred treatment, finalizes the treatment plan with input from the primary care clinician and the patient, delivers manualized CBT and/or assists with medication management, and provides patient monitoring and follow-up. Treatment algorithms are used to ensure that the most appropriate options are presented given the patient's individual preferences and needs. For patients choosing "watchful waiting" rather than active treatment, the care manager generally provides follow-up by telephone.

Program materials include a care manager guide and clinician guide, individual and group CBT manuals, a quick reference guide for clinicians, and patient education brochures. To implement the program, the organization first selects a leadership team to manage the project and develop an implementation plan. The leadership team educates staff about YPIC/DTQI, hires and trains care managers, and provides the necessary space, support, and monitoring to conduct the program. The developer provides 1-3 days of training on CBT and separate trainings for clinicians and care managers. Clinicians receive training on best practices for evaluating and treating depression in adolescents, development of treatment plans (when to consider medication, psychotherapy/counseling, watchful waiting/monitoring, specialty consultation), and medication management. Care managers receive training on how to support primary care providers in patient evaluation, treatment, and monitoring, as well as training in CBT for depression.

Though originally developed for primary care settings, YPIC/DTQI has since been adapted for implementation within county mental and behavioral health systems, mental health clinics, and in-home services and to serve youths receiving care through school, juvenile justice, and child welfare systems.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: June 2012
1: Depression symptoms
2: Mental health-related quality of life
3: Utilization of mental health care
Outcome Categories Mental health
Quality of life
Ages 13-17 (Adolescent)
18-25 (Young adult)
Genders Male
Female
Races/Ethnicities Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
School
Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History YPIC/DTQI was first implemented in an effectiveness trial involving 418 primary care patients drawn from five health care organizations in California and Pennsylvania. Adaptations of the program for mental health clinics and other settings have been used across Michigan and in 13 counties in California, serving an estimated additional 500-1,000 people.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations The CBT workbook and handouts are available in Spanish. CBT handouts for parents are also available in Chinese. The Clinician Guide includes a section on cultural adaptation for specific groups.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: June 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Asarnow, J. R., Jaycox, L. H., Duan, N., LaBorde, A. P., Rea, M. M., Murray, P., … Wells, K. B. (2005). Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial. Journal of American Medical Association, 293(3), 3, 311-319.  Pub Med icon

Asarnow, J. R., Jaycox, L. H., Tang, L., Duan, N., LaBorde, A. P., Zeledon, L. R., … Wells K. B. (2009). Long-term benefits of short-term quality improvement interventions for depressed youths in primary care. American Journal of Psychiatry, 166(9), 1002-10.  Pub Med icon

Supplementary Materials

Ngo, V. K., Asarnow, J. R., Lange, J., Jaycox, L. H., Rea, M. M., Landon, C., … Miranda, J. (2009). Outcomes for youths from racial-ethnic minority groups in a quality improvement intervention for depression treatment. Psychiatric Services, 60(10), 1357-1364.  Pub Med icon

Quality Assurance Protocol

Outcomes

Outcome 1: Depression symptoms
Description of Measures Depression symptoms were assessed using the Center for Epidemiological Studies-Depression Scale (CES-D). The CES-D is a 20-item, self-report questionnaire that asks respondents to report the frequency of various depression symptoms over the past week, rating each item on a 4-point scale. Response options range from "rarely or none of the time" (0) to "most or all of the time" (3). A total score ranging from 0 to 60 is tabulated by summing item scores (some positively phrased items are reverse-scored). Items address physical symptoms such as changes in sleep and appetite ("I did not feel like eating; my appetite was poor" and "My sleep was restless") as well as emotional symptoms of a depressed mood ("I felt sad," "I felt lonely," and "I felt that everything I did was an effort").
Key Findings Primary care patients 13-21 years of age with current symptoms of depression were randomly assigned to the intervention condition or to a comparison condition that consisted of treatment as usual enhanced with provider training. Data were collected at baseline and 6-, 12-, and 18-month follow-up.

At 6-month follow-up, patients in the intervention group had significantly reduced symptoms of depression as indicated by total CES-D scores (p = .02) and a significantly reduced rate of severe depression, defined as a CES-D total score of 24 or higher (p = .02), compared with youth receiving usual care.

At 12- and 18-month follow-up, no significant differences in depression symptoms were found between the intervention and control groups. However, significant indirect intervention effects were found at 12- and 18-month follow-ups through intervention effects at 6 months on both depression (p = .023) and severe depression (p = .027). This finding suggests that initial clinical improvement resulting from the intervention had an indirect effect on depression symptoms at subsequent follow-ups.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 2: Mental health-related quality of life
Description of Measures Mental health-related quality of life was measured using the Mental Health Summary Score Short Form (MCS SF-12). The range of possible scores is 0 to 100, with lower scores reflecting poorer mental health. The 12-item scale asks about mental health-related impairment during the past 4 weeks. Examples of items include:

  • "During the past 4 weeks, have you accomplished less than you would like as a result of any emotional problems, such as feeling depressed or anxious?"
  • "During the last 4 weeks, did you have trouble doing work or other activities as carefully as usual as a result of an emotional problem, such as feeling depressed or anxious?"
Key Findings Primary care patients 13-21 years of age with current symptoms of depression were randomly assigned to the intervention condition or to a comparison condition that consisted of treatment as usual enhanced with provider training. Data were collected at baseline and 6-, 12-, and 18-month follow-up.

At 6-month follow-up, patients in the intervention group had significantly improved mental health-related quality of life (p = .03) relative to patients who received usual care.

At 12- and 18-month follow-up, no significant differences in mental health-related quality of life were found between the intervention and control groups. However, significant indirect intervention effects were found at 12- and 18-month follow-ups through intervention effects at 6 months (p = .023). This finding suggests that initial clinical improvement resulting from the intervention had an indirect effect on mental health-related quality of life at subsequent follow-ups.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 3: Utilization of mental health care
Description of Measures Utilization of mental health care was assessed using the Service Assessment for Children and Adolescents (SACA), a questionnaire that asks the child or a parent to report on the frequency, duration, and type of help or services the child has received for behavioral or emotional problems. In the YPIC study, child reports were collected using a shortened form of the SACA that included items from the Partners in Care survey on mental health treatment in primary care. Examples of items include:

  • "Did you receive help in the last 6 months from a mental health specialist? By that I mean, a psychologist, psychiatrist, social worker, or counselor."
  • "In the last 6 months, have you received therapy or counseling?"
  • "In the past 6 months, did you take any prescription medicines to help with emotions, behavior, thinking, sleep, or for a problem with alcohol or drugs? Do not count birth control pills, vitamins, or antibiotics."
Key Findings

Primary care patients 13-21 years of age with current symptoms of depression were randomly assigned to the intervention condition or to a comparison condition that consisted of treatment as usual enhanced with provider training. Data were collected at baseline and 6-, 12-, and 18-month follow-up.

At 6-month follow-up, patients in the intervention group had significantly increased rates of utilization of any specialty mental health care (p < .001) relative to patients receiving usual care, as well as significantly increased rates of utilization of any psychotherapy/counseling (p < .01). In addition, the intervention group also reported a significantly greater increase in the number of psychotherapy/counseling sessions at 6-month follow-up (p < .01) relative to the comparison group.

No significant between-group differences in mental health care utilization were found at 12- and 18-month follow-up.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult) 		78% Female
22% Male 		56% Hispanic or Latino
17% Race/ethnicity unspecified
13% Black or African American
13% White
1% Asian

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Depression symptoms 3.9 4.0 2.0 3.8 3.0 4.0 3.4
2: Mental health-related quality of life 3.9 4.0 2.0 3.8 3.0 4.0 3.4
3: Utilization of mental health care 3.9 3.0 2.0 3.8 3.0 4.0 3.3

Study Strengths

The outcome measures had strong psychometric properties. A training workshop was conducted, and a detailed manual was provided. Consultations were conducted by care managers who were psychotherapists with degrees in the mental health field or nursing. Follow-up rates did not differ by condition. The study used a randomized controlled design. Assessments were conducted by interviewers who were masked to group assignment. Careful attention was paid to the statistical analyses performed, including intent-to-treat analyses. Appropriate techniques were used to account for attrition and missing data.

Study Weaknesses

The selection of the five sites participating in the studies was purposive rather than random. Results of the fidelity measures were not provided, so it is not known how many clinicians adhered to the structure of the CBT sessions or other treatment modalities. Only self-report measures were used.
Readiness for Dissemination
Review Date: June 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Albright, A., & Asarnow, J. (1999). Youth Partners in Care: Guidelines and resources for the care manager. (Adapted from Partners in Care: Guidelines and resources for the depression nurse specialist, 1996, by L. V. Rubenstein, J. Unützer, J. Miranda, B. Simon, W. J. Katon, M. Jackson-Triche, K. Minnium, & K. Wells.)

Asarnow, J., Carlson, G., Schuster, M., Miranda, J., Jackson-Triche, J., & Wells, K. (1999). Youth Partners in Care: Clinician guide to depression assessment and management among youth in primary care setting. (Adapted from Partners in Care: Clinician guide to depression assessment and management in primary care settings, 1996, by L. V. Rubinstein, J. Unützer, J. Miranda, W. J. Katon, M. Wieland, M. Jackson-Triche, K. Minnium, C. Mulrow, & K. B. Wells.)

Asarnow, J., Jaycox, L., Clarke, G., Lewinsohn, P., Hops, H., & Rohde, P. (1999). Stress and your mood: Teen and young adult workbook.

Asarnow, J., Jaycox, L., Clarke, G., Lewinsohn, P., Hops, H., Rohde, P., & Rea, M. (1999). Stress and your mood: A manual for groups.

Asarnow, J., Jaycox, L., Clarke, G., Lewinsohn, P., Hops, H., Rohde, P., & Rea, M. (2010). Stress and your mood: A manual for individuals.

Guidelines for YPIC Depression Quality Improvement Intervention: Implementation Planning

PowerPoint slides:

  • Cognitive-Behavior Therapy for Depression in Adolescents
  • Cognitive-Behavior Therapy for Depression in Adolescents: Social Module
  • Cognitive-Behavior Therapy for Depression in Adolescents: Thoughts Module
  • Depression Quality Improvement: The YPIC Model for Improving Care for Depression in Youth
  • DTQI Booster: Trouble-Shooting the Intervention
  • Session I--Beginning the Program: Education About CBT Model
  • Youth Partners in Care: Depression Quality Improvement

Quality Assurance Protocol

Quick Reference Guide [Brochure]

Stress and Your Mood: A Guide for Teens, Young Adults, and Family Members [Brochure]

Training Videos (October 2011)

Train-the-Trainer Protocol for CBT Component

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

The clinician and care manager guides are detailed and logically organized to follow the stages in the intervention process or the order of sessions. Pictorial algorithms lead staff through treatment choices and explain responsibilities at each stage of screening, assessment, treatment planning, and delivery of CBT or pharmaceutical treatment. The clinician guide also discusses program adaptations for culturally diverse families. The developer provides a variety of consultation and training options, including a training for trainers to promote program sustainability. The developer works with organizations to select standardized clinical tools for collecting outcome data and assists with the aggregation of client outcome data for use in quality assurance. Review and rating of taped CBT or care manager sessions is offered as an optional service.

Dissemination Weaknesses

No weaknesses were identified by reviewers.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Implementation materials (clinician guide, care manager guide, patient education brochures, CBT manual and workbook) Included with consultation and training Yes
Consultation at start-up Varies depending on organization's needs; see Additional Information below Yes
2-hour, on-site training for primary care clinicians and/or psychiatrists $50 per person for groups of 25-50 participants, plus trainer travel expenses; cost may be reduced by using a Webinar format Yes
1-day, on-site training for care managers $200 per person for groups of 25-30 participants, plus trainer travel expenses Yes
1- to 3-day, on-site training on CBT $200 per person per day for groups of 25-30 participants, plus trainer travel expenses Yes
Consultation by telephone on CBT $50 per person per hour for groups of 6-8 participants Yes
Technical assistance/consultation on program evaluation $300 per hour No
Tape review and fidelity ratings $200 per tape No

Additional Information

All costs above are estimates; actual costs will vary. Consultation costs at start-up are estimated at $3,000, but actual costs will vary depending on the organization's needs, number of individuals participating, and implementation plan. As part of consultation, the developer provides assistance in developing the implementation plan, establishing a leadership team, troubleshooting implementation, and planning for program evaluation, as well as ongoing work to address the needs of clinicians, supervisors, and organizations throughout implementation.
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation or research, contact:
Joan R. Asarnow, Ph.D.
(310) 825-0408
jasarnow@mednet.ucla.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.