Respondent and agency characteristics
Of the 869 participants, most were program managers (64.2%); other respondents included directors (9.4%); clinicians (13.6%), and respondents in other positions (2.6%); 10.1% did not describe their role at their agency. Most respondents had graduate degrees (40.5%), followed by undergraduate degrees (29.2%), college diplomas (16.5%), or other (3.2%); 10.6% did not report their education level. The median number of years respondents reported working with youth was 16 (Interquartile range [IQR] = 10 - 25 years). In order to gain nuance and context for their role descriptions, respondents were also asked to describe the extent to which they believed they had influence on decisions in their agencies on a visual analogue scale from 0 to 100. The perceived degree of influence was related to position, with directors (M = 78.3, SD = 15.9) reporting higher perceived influence than program managers (M = 63.1, SD = 18.9), who reported higher perceived influence than clinicians (M = 45.1, SD = 24.7; all p values < .001).
Respondent agencies were located primarily in urban or suburban communities (68.8%), with 22.3% in rural or remote communities, and 9.0% reporting other. Almost half of reporting agencies had fewer than 30 employees (45.3%). While most respondents (63.1%) reported completing the survey based solely on their own knowledge, 19.3% consulted with other staff, 12.0% consulted administrative data, and 10.2% did not report on their sources of information. The majority of respondents came from programs within the mental health sector, with smaller percentages based in addictions, health, or multiservice respondent programs (Figure 1).
In terms of populations served, a minority of respondents (31.0%) reported offering services to children under 12, while 70.0% serve adolescents between 13-17 years of age, and 80.9% provide services to TAY from 18-25 years (Figure 2). Complexity and comorbidities were reported to be common among the depressed children and youth being served by these agencies (Figure 3). Respondents indicated that in over 70% of agencies, more than 25% of the depressed children and youth they served also had challenges with anxiety; approximately 50% of respondents reported comorbid ADHD in at least 25% of their depressed children or youth. Both anxiety and ADHD comorbidity rates showed little variation by client age. Conversely, Post-Traumatic Stress Disorder (PTSD) and problematic substance use were reported at higher rates among agencies serving TAY, which is consistent with the known age distributions of these issues. Developmental trauma rates were reported at high rates across all age ranges (Figure 3).
Service characteristics
The types of services reported to be offered varied by client age (Figure 4). Psychotherapy (61.3-71.7% of agencies) and assessment (63.0-68.4%) were the most commonly reported types of services available, followed by psychoeducation. Medication treatment was much less commonly offered (23.7-28.2%) possibly reflecting low availability of physicians to prescribe. Inpatient and residential settings were also much less commonly available at participating agencies. Psychotherapy and psychoeducation were more likely to be offered for younger age groups, while case management was more likely to be offered as a service for older youth. With the exception of medication, large agencies were significantly more likely to offer all services than smaller agencies (Table 1).
Table 1 Proportion of agencies offering specific services, by size of the agency*
Services
|
Small/Medium
N=187
|
Large
N=190
|
χ2
|
p
|
Psychotherapy
|
75.4%
|
89.5%
|
12.9
|
<0.001
|
Assessment
|
65.8%
|
84.2%
|
17.1
|
<0. 001
|
Case management
|
58.8%
|
87.9%
|
40.9
|
<0. 001
|
Medication
|
33.7%
|
42.6%
|
3.2
|
0.074
|
Psychoeducation
|
62.0%
|
80.0%
|
14.8
|
<0. 001
|
Day treatment/Inpatient/Residential
|
26.7%
|
48.4%
|
18.9
|
<0. 001
|
Note: *Small/medium agency ≤ 30 full time staff; large agency > 30 full time staff. Contradictory responses between respondents from the same agency (N=36) were not included.
Availability of specific psychotherapeutic approaches
A range of psychotherapies for children, adolescents and TAY were reported to be offered by respondents among participating agencies (Figure 5). Among agencies offering services to children, “social skills training”, CBT, and family/parent therapies were most commonly reported. Among agencies offering services to adolescents and TAY, CBT, “social skills training”, and “solution-focused therapies” were most frequently reported. Reported availability of some therapies varied significantly by age group: CBT and DBT Skills were more frequently reported as available for adolescents and youth, and family/parent therapies were more frequently offered for children. Interpersonal therapy (IPT) was not among the most commonly reported therapies; among agencies offering psychotherapy to children, 10.9% reported offering IPT to children and among agencies offering psychotherapy to adolescents and TAY, 17.6-19.6% reported offering them IPT.
Psychotherapy services: format, frequency, duration and total sessions
As can be seen in Table 2, agencies were as likely to offer individual therapy less than weekly as weekly or more frequently (Table 2). In addition, individual therapy for depression and related concerns across age groups was more likely to involve 4 or more sessions and span 3 months or more than shorter durations or fewer sessions. However, a considerable proportion of agencies (37.2%-50.4%) reported offering less than 12 weeks of individual therapy, while a similar proportion reported offering a total of only 3 sessions or less (33.1%-44.8%). Among agencies offering group therapy, therapy was more likely to involve 4 or more sessions and extending over 3 months, although therapy was more likely to be offered weekly or more frequently. These patterns were consistent across age groups (Table 2). Over 60% of agencies offer family therapy to children, adolescents or TAY, typically less than weekly (Table 2).
Table 2 Among agencies offering individual, group, and family therapy: frequency, duration, and total number of sessions
|
Children (%)
|
Adolescents (%)
|
TAY (%)
|
Individual therapy
Frequency
- Less than weekly
- Weekly or more
Duration
- Less than 3 months
- 3 months or more
Number of total sessions
- 1-3 sessions
- 4 or more sessions
|
60.1
61.1
37.2
63.5
33.1
66.9
|
75.2
76.8
50.4
79.9
44.8
85.1
|
75.7
76.2
48.8
82.7
43.4
88.4
|
Group therapy
Frequency
- Less than weekly
- Weekly or more
Duration
- Less than 3 months
- 3 months or more
Number of total sessions
- 1-3 sessions
- 4 or more sessions
|
8.1
40.4
33.0
38.0
6.9
52.0
|
23.1
66.7
44.9
62.8
14.8
81.9
|
29.4
64.4
45.9
66.7
17.6
81.8
|
Family therapy
Frequency
- Less than weekly
- Weekly or more
Duration
- Less than 3 months
- 3 months or more
Number of total sessions
- 1-3 sessions
- 4 or more sessions
|
63.0
46.5
44.8
59.2
42.5
59.8
|
74.2
47.8
53.6
67.6
56.0
65.4
|
69.4
35.0
49.4
53.9
55.4
50.3
|
Note: TAY = Transition Aged Youth
Service engagement
For each age group and psychotherapy type, respondents indicated their agencies’ experiences with discontinuation rates of more than 25% at each stage of service (i.e., before intake, before first session, after first session, after 2-6 sessions). Results show that no-show and discontinuation rates climb with age, with TAY generally demonstrating the highest rates (Table 3).
Table 3 Percentage of agencies with more than 25% no show or discontinuation rates at various stages of treatment.
Age group
|
Individual therapy
|
Group therapy
|
Family therapy
|
Children
|
(N=122)
|
(N=60)
|
(N=100)
|
No show for intake
|
4.9%
|
3.3%
|
2.0%
|
No show for first session
|
9.8%
|
6.7%
|
6.0%
|
Discontinue after first session
|
6.6%
|
10.0%
|
12.0%
|
Discontinue after 2-6 sessions
|
24.6%
|
11.7%
|
21.0%
|
Adolescents
|
(N=240)
|
(N=141)
|
(N=168)
|
No show for intake
|
23.8%
|
16.3%
|
7.7%
|
No show for first session
|
25.8%
|
19.9%
|
8.3%
|
Discontinue after first session
|
22.5%
|
18.4%
|
14.9%
|
Discontinue after 2-6 sessions
|
37.9%
|
24.1%
|
23.8%
|
TAY
|
(N=238)
|
(N=138)
|
(N=130)
|
No show for intake
|
32.8%
|
26.8%
|
10.8%
|
No show for first session
|
29.4%
|
20.3%
|
10.0%
|
Discontinue after first session
|
26.9%
|
18.8%
|
19.2%
|
Discontinue after 2-6 sessions
|
37.0%
|
23.9%
|
22.3%
|
|
|
|
|
|
TAY = Transition aged youth.
Agency activities
Respondents reported high rates of agency referrals to other mental health services and physicians, across small/medium and large agencies. The only significant differences between small/medium and large agencies were in rates of medical doctor (MD) referrals and child welfare referrals, which were both higher in large agencies (Table 4). Outcome evaluations and quality improvement measures also varied significantly by agency size (Table 5). Respondents from larger agencies were more likely to report using client satisfaction surveys, assessing clients at the end of treatment, following-up after treatment, monitoring treatment fidelity, participating in team case conferences and engagement in outcomes research. Finally, survey respondents indicated their perceived needs around future research priorities related to services for children and youth with depression. The top three research priorities identified by respondents were effective treatment for depression (41.5%), gaps in service provision (33.8%), and improving access to therapy (31.3%).
Table 4 Proportion of agencies referring to further services, by size of agency*
Further Services
|
Small/Medium
N=179
|
Large
N=184
|
χ2
|
p
|
MD
|
79.3%
|
90.2%
|
8.4
|
0.004
|
Mental health services
|
83.2%
|
87.0%
|
1.0
|
0.320
|
Substance use/addictions
|
84.4%
|
89.1%
|
1.8
|
0.180
|
Psychotherapy (Individual/Parent)
|
81.6%
|
78.8%
|
0.4
|
0.510
|
Education
|
65.4%
|
74.5%
|
3.6
|
0.059
|
Child Welfare
|
62.0%
|
78.8%
|
12.3
|
<0. 001
|
Note: *Small/medium agency ≤ 30 full time staff; large agency > 30 full time staff.
Table 5 Proportion of agencies using evaluation approaches, by size of agency*
Evaluation
|
Small/Medium
N=179
|
Large
N=184
|
χ2
|
p
|
Client Satisfaction Survey (Children/parents)
|
74.3%
|
91.3%
|
18.5
|
<0. 001
|
Assessment at the end of treatment
|
50.3%
|
69.0%
|
13.3
|
<0. 001
|
Follow-up after treatment
|
31.3%
|
47.8%
|
10.4
|
0.001
|
Monitor treatment fidelity
|
15.6%
|
32.1%
|
13.4
|
<0. 001
|
Team case conference
|
59.2%
|
86.4%
|
34.0
|
<0. 001
|
Participation in outcomes research
|
21.8%
|
35.3%
|
8.1
|
0.004
|
Note: *Small/medium agency ≤ 30 full time staff; large agency > 30 full time staff.