Depression among youth in primary care: Models for delivering mental health services

The high costs of health care and the need to extend service capacity have resulted in primary care providers serving as gatekeepers to specialty care, including specialty mental health care. Consistent with the priority placed on promoting mental health in Healthy People 2010, recommendations from the United States Public Health Service call for a review of children’s mental health in routine pediatric examinations [1–3]. This increased emphasis on the role of the primary care provider has stimulated efforts to develop and test models for delivering mental health services through primary care; however, are primary care providers ready to meet this challenge? This article focuses specifically on the knowledge and tools available to the primary care provider to treat depression in youth. Depressive disorders are common: it is estimated that roughly 20% of the youth in the United States experience a depressive episode by the age of 18 years [4]. Moreover, depression is associated with significant current and future disability. The Global Burden of Disease Study predicts that major depression will become the second leading cause of disability in the world by the year 2010 [5]. Although depressive disorders are associated with significant risk of dysfunction, there are psychosocial and pharmacologic treatments with demonstrated efficacy [6–9]. Current treatments can be improved, and additional data are needed on treatment efficacy and effectiveness in real-world practice settings. There is also a critical need to improve access to efficacious treatments. Because most youth in the United States have contact with primary care providers, efforts within the primary care setting have great potential for improving access to high quality care for depression in youth. To guide this review and discussion, we first present a heuristic model to guide the delivery of effective care for depression in youth seen in primary care