Treatment and Outcomes Among North Carolina Medicaid-Insured Youth With Depression

Objective: Youth depression is increasing and is associated with adverse concurrent and long-term outcomes. Understanding receipt of depression treatment and outcomes is critical for population-level efforts to address youth depression. This study aimed to understand treatment patterns and their association with depression-related outcomes.

Method: North Carolina Medicaid claims were used to conduct a retrospective cohort study of treatment and depression-related outcomes in pediatric Medicaid beneficiaries. The sample included 34,623 youth ages 5 to 21 years with an incident depression diagnosis. Psychotherapy and antidepressant medication were assessed for 6 months following diagnosis. Depression-related outcomes including suicidal or self-harming behaviors, emergency department use, and psychiatric hospitalization were analyzed using Cox proportional hazards models to calculate hazard ratios.

Results: Among youth with depression, 86% received treatment (39% psychotherapy, 16% medication, 31% combined), but few youth received guideline-recommended treatment duration. At 6 and 18 months, youth who received combined treatment had higher risk of adverse outcomes compared with the other groups. The untreated group had lower risk of outcomes other than all-cause emergency department visits. Single-session psychotherapy and inconsistent medication fills were also associated with poor outcomes; however, more psychotherapy sessions were associated with lower risk of all-cause emergency department visits.

Conclusion: These data show that the majority of youth who received depression treatment had suboptimal adherence to recommended guidelines. Youth who received combined treatment (both medication and therapy) had more adverse depression outcomes. As claims records do not include clinical data, the effect of treatment type, dose, depression severity, or a combination of these factors cannot be readily disentangled; therefore, these findings do not support a conclusion that combined treatment leads to poor outcomes. Rather, it is possible that youth with a more severe clinical profile are more likely to be prescribed combined treatment or to have poor adherence and thus worse outcomes. Understanding how to improve adherence in real-world settings is needed. Results suggest that many youth continue to struggle despite receipt of mental health care, indicating a call for enhancing existing treatment strategies. Research should aim to better understand population-level care for depression and to promote receipt of and adherence to recommended treatment duration across modalities.

Diversity & inclusion statement: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.