EMERALD extends collaborative care model to adolescents with depression

An innovative care team model at Mayo Clinic that includes a psychiatrist, registered nurse, behavioral health manager and social worker is designed to help primary care physicians become more comfortable in identifying and diagnosing depression in adolescent patients and in managing their care.

In the Early Management and Evidence-Based Recognition of Adolescents Living With Depression (EMERALD) pilot program, a behavioral health manager acts as an integrated care coordinator, contacting the patient and the patient's family and primary care physician weekly and discussing the patient's progress with a child and adolescent psychiatrist, as determined by clinical status. The psychiatrist does not see the patient unless there is a need.

In the EMERALD model, a multidisciplinary team works with adolescents and those within their support system to facilitate the following efforts:

  • Monitor symptoms of depression
  • Monitor medications and adverse effects
  • Set behavioral activation goals
  • Assist with internal and external referrals to wellness resources
  • Develop a relapse prevention plan

EMERALD is based on the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) collaborative care program for adults. Both EMERALD and DIAMOND translate evidence-based practice into general care through the consistent use of a measurement tool, the Patient Health Questionnaire for Adolescents (PHQ-A), and an external registry. These two components allow the team to accomplish the following:

  • Assess patients in the context of their other health care concerns
  • Monitor the effectiveness of the treatments chosen
  • Maintain a record of each patient's depression as the situation evolves
  • Monitor all participants to measure depression remission rates over time

John E. Huxsahl, M.D., with the departments of Pediatric and Adolescent Medicine and Psychiatry and Psychology at Mayo Clinic in Rochester, Minn., and the principal investigator for EMERALD, notes, "This program provides resources that help primary care physicians provide effective care for their adolescent patients with depression. We're a support network. With our support, primary care physicians should feel comfortable providing treatment, and especially prescribing antidepressants, to their patients without the psychiatrist in the room."

Adolescent patients remain in the EMERALD program until their PHQ-A scores are less than 5 and are maintained at that level for three months. "Some patients reach that goal as early as four or five months," says Dr. Huxsahl. "There is, however, a distinction between how long patients are in the program and how long they may continue to take medications prescribed by their primary care physicians."

Enrollment increases, program expands

When the pilot program began in July 2011, 28 patients had been screened and four were enrolled. "Adolescents — or their parents — don't always want to be seen for case management," notes Dr. Huxsahl. The program's current active enrollment is 18 patients, with two more patients who are ready to participate. One patient completed the program in July.

In 2012, the program was expanded to involve all physicians in the Division of Community Pediatric and Adolescent Medicine at Mayo Clinic in Rochester and, eventually, physicians in the Department of Family Medicine.

"We will continue to enroll patients under the current guidelines, with expansion into other Mayo specialties that see children in this age range," says Dr. Huxsahl. "The EMERALD program provides a format that will allow primary care physicians to be more skillful and comfortable in being able to both identify and treat kids with depressive illness."