Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents: A Randomized Clinical Trial

Abstract

Importance: Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated.

Objective: To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care.

Design, setting, and participants: The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020.

Interventions: The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics.

Main outcomes and measures: Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms.

Results: Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, -6.6 to -0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, -7.7 to -0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes.

Conclusions and relevance: Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment.

Trial registration: ClinicalTrials.gov Identifier: NCT03034720.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.. Flow of Participants Through the Randomized Clinical Trial

Figure 2.. Postconcussive Symptoms and Suicidal Ideation in the Collaborative Care and Usual Care Groups by Adolescent Report

Postconcussive symptoms (A) were assessed with the Health Behavior Inventory, a 20-item questionnaire that assesses postconcussive symptoms on a 4-point scale, ranging from never to often, and yields total scores in cognitive and somatic domains (score range, 0-60 points, with higher scores indicating more symptoms). Suicidal ideation (B) was assessed according to participants’ response to the final item on the Patient Health Questionnaire–9. Responses to this item were dichotomized as any suicidal ideation vs none.

Figure 3.. Health-Related Quality of Life Scores in the Collaborative Care and Usual Care Groups by Adolescent Report

Health-related quality of life was assessed with the Pediatric Quality of Life Inventory, a 23-item questionnaire that assesses physical, emotional, social, and school functioning (score range, 0-100, with higher scores indicating greater quality of life).