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Project Tag: Program Design

The Need for a Pediatric Treatment Resistant Depression Center of Excellence

SUMMARY – Treatment resistant depression is a growing problem for children in Texas and the United States. Twenty percent of children experience an episode of major depression before adulthood and rates of reported depression symptoms among children and youth grew to over 40% during the pandemic (receding in the years since to approximately 30%). Unfortunately, only about one third of these children receive needed care, and as many as 40% receive no treatment at all. Research demonstrates that untreated depression is the largest driver of suicide, which is the second and third leading cause of death in youth ages 10–14 and 15–24 in the United States, respectively. However, current models of care are inadequate to provide effective treatment, especially for children aged 12 and under. In this report, made possible by generous support from the Bette Rathjen Foundation for Emotional Health, the Meadows Institute lays out the programmatic elements necessary to implement a pediatric treatment resistant depression Center of Excellence, including indepth examination of services, staffing, and related expenses.

Children & Youth Collaborative Care Collaborative Problem Solving P-TRD Program Design

Providing effective care for pediatric treatment resistant depression (P-TRD) requires a coordinated and comprehensive array of treatment modalities, most of which have been inadequately studied in children and youth. This dilemma is generally true for the practice of child and adolescent psychiatry, necessitating “off-label” adult practices to be frequently applied to children. In designing a P-TRD Center of Excellence (CoE) with the best care continuum possible, we began by incorporating the relevant evidence base for children and then extrapolated best practices from adult and adolescent care to fill gaps. Our framework for the P-TRD CoE is a comprehensive care model that includes a full diagnostic evaluation, longitudinal treatment, individual and family therapeutic support, skill building, family educational supports, and care coordination, with health equity and family navigation as central and guiding elements.

Key Findings

Every child’s care should start with a comprehensive interdisciplinary evaluation that includes the child suffering from P-TRD along with their family and caregivers. Receiving an evaluation that yields a clear problem statement, diagnosis (or multiple diagnoses), and plan for care over the short and longer term is the cornerstone of our proposed CoE model.
A team approach to care is imperative. Each team member (psychiatrist, psychologist, social worker, nurse) provides services at the top of their license and thoughtfully coordinates care in weekly meetings.
Cultural humility and health equity are critical components of the interdisciplinary evaluation. In the proposed CoE, there is a designated clinician who conducts a cultural assessment to gain deeper insights into the child, family, and their perspectives on development, values, preferences, and beliefs about mental health treatment. These learnings are continuously shared and discussed with the interdisciplinary team.
Strong support networks are critical to treatment success. The CoE will facilitate family and caregiver connections with care teams to promote treatment linkage, attendance, retention, and completion.
All stakeholders stressed the significance of school coordination within the CoE. This unanimous agreement among experts underscores the pivotal role of schools in the comprehensive care of children with P-TRD. There is an important role of neuropsychological and educational assessment early in the treatment process and it is critical to have the infrastructure to support the coordination of care to ensure that these educational supports are being delivered in the school setting.
Children with complex care needs and their families experience better health outcomes if they have access to a person-centered system that is achieved through the comprehensive delivery of quality services across the lifespan, designed according to the multidimensional needs of the individual, and delivered by a coordinated team of providers working across disciplines, settings, levels of care, and sectors. This includes close coordination with a child’s pediatric primary care provider.