ABSTRACT
Reducing suicide deaths and premature mortality among youth with depression has been identified as a
national priority and important goal for health systems. Effective, evidence-based pharmacological and
psychosocial therapies exist to treat pediatric depression and clinical practice guidelines, quality indicators, and
medication algorithms have been developed in an effort to apply evidence-based practices to its real-world
management. Unfortunately, little is known about the degree to which the depression care delivered to publicly
insured youth meets existing quality standards, and these widely accepted standards have not been properly
validated, meaning that the impact of care meeting quality standards on important patient outcomes such as
recurrence of depression, self-harm, suicide, and overall mortality is essentially unknown. Relatedly, although
the landmark Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility and mandated
that mental health services be included as basic Medicaid services, whether expanded insurance coverage for
Medicaid enrolled youth has improved depression care quality and/or outcomes is unknown. Specific aims of
this proposed study are three-fold: 1) to identify patient, provider, community and system factors associated
with guideline concordant care for youth with major depressive disorder (MDD); 2) to determine whether
guideline concordant care is associated with depression recurrence, self-harm, suicide, and all-cause mortality;
and 3) to determine the effect of state Medicaid expansion under ACA on access to and quality of care for
Medicaid enrolled youth with MDD. We propose to conduct a retrospective longitudinal cohort study using
national Medicaid data linked with National Death Index records of all youth aged 10-17 (N= 350,00) with new
episodes of MDD between 2015 and 2019. These youth will be followed for up to 24 months up until 2019. Cox
regression models will be used to examine the association between 12 -month mortality and 5 patient-level
quality measures, while risk-adjusting for patient characteristics using propensity score methods. Quality
measures include: 1) effective antidepressant management during the acute phase; 2) effective antidepressant
management during the continuation phase; 3) adequate antidepressant dosage; 4) optimal provider contacts
among those taking antidepressants; and 5) adequate dose of psychotherapy. The contribution of the
proposed research is expected to be an increased understanding of factors that impact adherence to quality of
care treatment guidelines for depression. In addition, the proposed study will help narrow the gap between
community practice and optimal care by determining which recommended clinical practice guidelines improve
critical outcomes for youth with MDD. This contribution will be significant because understanding factors
associated with adherence to guideline concordant care will enhance our ability to develop models of
interventions to modify those factors and processes to increase adherence.