The CARIBOU

Integrated Care Pathway

for Adolescents with Depression
Pathway Manual
The CARIBOU Integrated Care Pathway for Adolescents with Depression: Pathway Manual

Version 1.1, May 2020

Darren Courtney, MD, FRCPC

Peter Szatmari, MD, FRCPS

Printed in Canada

Copyright © 2020 Centre for Addiction and Mental Health

All rights reserved. No part of this work may be reproduced or transmitted in any form or by any
means electronic or mechanical, including photocopying and recording, or by any information
storage and retrieval system without written permission from the publisher—except for a brief
quotation (not to exceed 200 words) in a review or professional work. Please address permission
requests to publications@camh.ca

For more information: Cundill.Centre@camh.ca

Suggested citation: Courtney, D. & Szatmari, P. (2020). The CARIBOU Integrated Care Pathway
for Adolescents with Depression: Pathway Manual. Version 1.1. Toronto, ON: Centre for
Addiction and Mental Health.

This publication may be available in other formats. For information about alternative
formats or other CAMH publications, or to place an order, please contact CAMH
Publications:
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6079b - single page layout / 05-2020

i
Acknowledgements

ICP LEAD
Dr. Darren Courtney*

SENIOR ADVISOR
Dr. Peter Szatmari*

PARTICIPATING CLINICIANS
Dr. Oshrit Wanono Dr. Marcia Zemans
Dr. Priya Watson Patricia Merka, RN
Dr. Marco Battaglia* Ameeta Sagar, MSW
Dr. John Strauss* Dr. Madison Aitken
Dr. Marissa Leong Dr. Stephanie Ameis
PARTICIPATING MEMBERS OF THE YOUTH ENGAGEMENT INITIATIVE
AT THE MARGARET AND WALLACE MCCAIN CENTRE FOR CHILD,
YOUTH & FAMILY MENTAL HEALTH
Karleigh Darnay
Jacqueline Relihan
Emma McCann

RESEARCH CO-INVESTIGATORS (IN ADDITION TO THOSE * ABOVE)

Dr. Amy Cheung Dr. Joanna Henderson
Dr. Rachel Mitchell Dr. Kathryn Bennett
Dr. Karen Wang

RESEARCH CO-ORDINATORS
Kirsten Neprily Leanne Wilkens
Michelle Li Kamna Mehra
Alenka Bullen

KNOWLEDGE TRANSLATION CO-ORDINATOR

Renira Narrandes

CUNDILL INTERNATIONAL ADVISORY BOARD

Prof. Ian Goodyer Mr. David Feather
Dr. Jean Séguin Mr. Richard Parry
Prof. Ian Hickie Mr. John Rendel
Dr. Kathleen Merikangas Dr. Bonnie T. Zima

We are grateful to the Peter Cundill Foundation for supporting the Cundill Centre
and making this work possible.

ii
Contents

Introduction
About this manual............................................................................................................................................................................. 1
How should this manual be used?.......................................................................................................................................... 1
Who is this manual for?.................................................................................................................................................................. 2
What will you learn in this manual?...................................................................................................................................... 2
Why implement an integrated care pathway for adolescents with depression?..................................... 2
Development of the CARIBOU Integrated Care Pathway.......................................................................................... 2

Instructions
Step 1: Assessment.............................................................................................................................................................................. 4
Step 2: Mood Foundations............................................................................................................................................................. 6
Step 3a: Cognitive-Behavioural Therapy Group.............................................................................................................. 7
Step 3b: Individual Cognitive-Behavioural Therapy................................................................................................... 8
Step 4: Caregivers of Depressed Youth (CODY) Group ................................................................................................. 9
Step 5: Medication stream...........................................................................................................................................................10
Step 6: Team reviews.......................................................................................................................................................................11
Step 7: Completion of the pathway.......................................................................................................................................12

Other helpful information

Deviations from the pathway...................................................................................................................................................13
Quality improvement plan........................................................................................................................................................13
Updates to the pathway and its materials.......................................................................................................................13

References
References..............................................................................................................................................................................................14

Appendices
A: CARIBOU Pathway Flow Diagram......................................................................................................................................16
B: CARIBOU Initial Assessment Form ..................................................................................................................................19
C: Derivation of “moderate to severe depression” classification ......................................................................20
D: CARIBOU Team Review Feedback Form.........................................................................................................................22
E: Team Review Explanation for Clinicians with MFQ-C Clinical Distribution ......................................25
F: CARIBOU Team Review Checklist.......................................................................................................................................27
G: Abbreviations.................................................................................................................................................................................30
H: List of Pathway Materials.......................................................................................................................................................31

iii
Introduction

ABOUT THIS MANUAL

This pathway manual was developed to outline the steps of an evidence-based integrated care
pathway (ICP) for adolescents with depression. ICPs are structured, multidisciplinary care plans that
map a treatment process from start to finish.

The Care for Adolescents who Receive Information ‘Bout OUtcomes (CARIBOU) ICP for adolescents
with depression has seven steps and two treatment streams:

1. Assessment
2. Mood Foundations
3. a) Group cognitive-behavioural therapy
b) Individual cognitive-behavioural therapy PSYCHOTHERAPY STREAM
4. Caregivers of Depressed Youth (CODY) group
5. Medication stream MEDICATION STREAM
6. Team reviews
7. Completion of the pathway

This manual will explain what happens at each step, including the materials and people needed
to implement the pathway. The manual is meant to be used alongside the CARIBOU Pathway Flow
Diagram (see Appendix A on page 16).

HOW SHOULD THIS MANUAL BE USED?

This manual should be used together with the CARIBOU Pathway Flow Diagram in Appendix A (and
pictured below). The diagram has three pages:
∙ The first page is an overview of the entire treatment pathway.
∙ The second page focuses on the psychotherapy stream (Steps 3 and 4).
∙ The third page focuses on the medication stream (Step 5).
The steps are indicated in dark purple boxes on the diagram; corresponding manual pages are also
indicated for quick reference.

1
WHO IS THIS MANUAL FOR?
This manual is intended for clinicians, administrators and researchers who are interested in the
evidence-based treatment of adolescents with depression.

WHAT WILL YOU LEARN IN THIS MANUAL?

This manual, along with the CARIBOU Pathway Flow Diagram and other supporting materials, will:
∙outline the seven steps of the CARIBOU integrated care pathway for adolescents with depression
∙help you understand the activities required to complete each step.

Clinicians may decide to include components of the pathway in their practice. Administrators may
wish to implement the complete pathway in their organizations. Researchers may be interested in
the implementation process.

“The practice of evidence-based

medicine means integrating individual
clinical expertise with the best
available external clinical evidence
from systematic research…” and
the “use of individual patients’
predicaments, rights, and
preferences in making decisions
about their care.”

—Sackett et al.

WHY IMPLEMENT AN INTEGRATED CARE PATHWAY FOR ADOLESCENTS

WITH DEPRESSION?
ICPs are structured, multidisciplinary plans of care that are based on scientific evidence. The CARIBOU
ICP was synthesized from the recommendations made in high-quality clinical practice guidelines
(CPGs). Evidence-informed and based on rigorous systematic reviews, meta-analyses and input from
experts and consumers, CPGs aim to promote optimal patient outcomes by influencing critical steps
in the clinical decision-making process. The integration of research evidence, professional expertise
and patient preferences has been defined by Sackett et al. (1996) as the practice of evidence-based
medicine.1 CPGs, then, are the pinnacle of evidence-based care.

2
THE CARIBOU INTEGRATED CARE PATHWAY
The CARIBOU ICP is intended to apply to ≥80 per cent of adolescents presenting for outpatient
psychiatric care with a primary diagnosis of a depressive disorder, recognizing that some youth with
depression may require specific alternate care to address life circumstances or comorbidities. The
pathway spans 20 weeks of care after the initial assessment, with enough time to provide the main
treatment components. The main outcomes of interest for these youth are:
1. Decrease in depressive symptoms.
2. Improvement in functioning.

DEVELOPMENT OF THE CARIBOU INTEGRATED CARE PATHWAY

The CARIBOU ICP was created through the synthesis of:
1. Evidence-based treatment recommendations from the National Institute for Health and Care
Excellence (NICE) CPG: Depression in Children and Young People (2005) and any updates that
arise from that date (there was an update in June 2019); 2 these guidelines were determined to
be of the highest quality based on a systematic review and appraisal of CPGs.3
2. Clinician input at the Centre for Addiction and Mental Health (CAMH).
3. Input from the Youth Engagement Initiative at the Margaret and Wallace McCain Centre for
Child, Youth and Family Mental Health at CAMH. 4,5

This pathway can be contextualized for different settings. Please contact Cundill.Centre@camh.ca
to learn more.

For more information on the development of this pathway, see Courtney et al. (2019).6

The ICP was guided by key elements of ICPs outlined in Croucher, 2005; 7 these include:
∙front page
∙instructions
∙abbreviations
∙reference section
∙version control
∙clearly defined patient group and scope
∙a plan of expected/anticipated care along some form of timeline
∙sequential order
∙documentation from all the disciplines involved
∙evidence-based practice and guidelines
∙processes and outcomes
∙variance-recording framework (variance, cause of variance and action taken)
∙risk management tools
∙placement of the patient at the centre of the care cycle
∙facilitation and promotion of continuous quality improvement.

A plan for updating the pathway is included, in addition to the previously identified quality
indicators.

3
Instructions

Step 1: Assessment
PEOPLE
Youth, caregiver(s) (if youth agrees) and trained clinician.

MATERIALS
∙ CARIBOU Initial Assessment Form (version 1.0) (includes
assessment of risk) (Appendix B, p. 19)

∙ Mood and Feelings Questionnaire – Childhood Long Version

(MFQ-C) 8

∙ Columbia Impairment Scale – Youth Version (YCIS) 9

∙ Columbia Impairment Scale – Parent Version (PCIS) 8

Adolescents, ages 14 to 18 (inclusive), presenting to clinical care undergo a standard mental health
assessment by a psychiatrist. The CARIBOU Initial Assessment Form (see Appendix B, page 19) is used
to help support the assessment. As part of this assessment, the clinician will ask about acute safety
issues and manage these as a priority; this may include evaluation of self-injurious thoughts and
behaviours, aggression, concerns about driving, pregnancy, child abuse, neglect, high-risk substance
use and other high-risk activities. The clinician will also particularly note if bullying, parental
mental illness, or stressors related to sexual orientation/gender identity are involved, since these may
influence treatment recommendations. The clinician will also present a biopsychosocial formulation
and discuss this with the youth (and caregiver, if appropriate), adjusting the formulation according
to feedback from the youth (and caregiver) to see that it fits their perspective.

Measures of depressive symptoms (MFQ-C) and function (YCIS) are completed by the youth. Available
caregivers complete the PCIS. This can be done before or after the psychiatric assessment. The
psychiatrist presents the results of these measures to the youth (and caregiver), being sensitive
to the possibility that youth can interpret the scores in different ways (as validating, neutral or
pathologizing)—and supportively responding to their reaction.

Youth are offered the CARIBOU pathway if the following criteria are met:
∙ major depressive disorder or persistent depressive disorder (dysthymia) is diagnosed, as per the
DSM-5, 10 and thought to be a primary target of treatment
∙ the MFQ-C score ≥22. 11

Exclusion criteria are as follows:

∙ acute florid psychosis (delusions with no insight, persistent and impairing hallucinations, severely
disorganized thinking)
∙ bipolar I or II
∙ moderate-to-severe eating disorders
∙ moderate-to-severe substance use disorders
∙ autism spectrum disorder or intellectual disability
∙ inability to speak, read or write English
∙ imminent risk (e.g., active suicidal ideation) requiring hospitalization.

4
When offering candidates the CARIBOU pathway, the psychiatrist will describe the further
components of the pathway in youth-friendly language. Clarification questions are invited. All youth
and caregivers are offered the Mood Foundations Group (Step 2); all youth are offered the 16-session
Cognitive-Behavioural Therapy Group (CBT group; Step 3a) by the psychiatrist. If the youth refuses to
attend the CBT group, they are offered four sessions of individual CBT, with the intention of preparing
them for group (Step 3b). All caregivers are offered the eight-session Caregivers of Depressed Youth
(CODY) Group (Step 4). The psychiatrist adds youth and caregivers to the corresponding waitlists.

If the youth and caregiver are agreeable and the MFQ-C and CIS scores indicate moderate-to-severe
depression, youth may be offered medication options (see Step 5); this may start immediately after
the assessment if the youth, caregiver and psychiatrist see fit.

5
Step 2: Mood Foundations
PEOPLE
Psychiatric nurse facilitator, youth and caregiver(s),
option: youth who has been through the pathway.

MATERIALS
∙ Mood Foundations Youth Handouts (version 1.0)
∙ Mood Foundations Facilitator Guide, including Mood Foundations Survey (version 1.0)
These materials are available (or will be available soon) on the Cundill Centre website.

All youth and caregivers are offered a one-time, 90-minute, multi-family education session called
Mood Foundations. In a structured and interactive seminar format, attendees are provided
information about the nature of depression, as well as the benefits of healthy sleep, exercise and
eating habits.

Youth are provided with handouts summarizing this information (see Mood Foundations Youth
Handouts on the Cundill Centre website).

The nurse is responsible for calling youth and caregivers on the waitlist to give a brief overview of
the rationale of the group and invite them to attend at the appropriate location and time. The Mood
Foundations Facilitator Guide provides instruction on how to run the session.

The session starts with a discussion of how to use the information. Participants learn that it is
difficult to make all of these changes at once and are encouraged to choose which changes are going
to be easiest and most effective for youth to work on first. Caregivers are asked to take a supportive
(rather than punitive) stance as the material is covered; that is, they are advised to resist the urge to
reprimand youth when behaviour changes are suggested.

If the group is large enough, a second staff member (psychiatrist or social worker) may take the youth
to a separate room from the caregivers to go over the same material, but in a space that may be more
comfortable for youth to interact with the material. Healthy snacks are provided to model the diet
encouraged in the session.

There is the option of having a selected youth who has been through the pathway attend and discuss
their experience as well. This may help engage youth (and caregivers) with the material.

There is also a satisfaction survey for the Mood Foundations Group to promote quality improvement.
This can be found at the end of the Facilitator Guide.

6
 PSYCHOTHERAPY STREAM

Step 3a: Cognitive-Behavioural

Therapy Group
PEOPLE
Group of youth, two clinician facilitators (any two
of psychiatrist, psychologist, nurse, social worker,
child and youth worker).

MATERIALS
∙ CARIBOU Group CBT – Facilitator’s Manual
(version 1.0) including description of
development
∙ CARIBOU Group CBT – Youth Handouts (version 1.0)
∙ Problem-Solving Worksheets (version 1.0)
∙ Cognitive Restructuring Worksheets (version 1.0)

These items are available (or will be available soon) on the Cundill Centre website.

All youth are offered 16-sessions of a structured CBT group therapy. If the youth agrees, they are
invited to a one-on-one “engagement” session with one of the group facilitators prior to starting
group, where the basic theory of CBT, structure of the group and group norms are discussed. This
may take place at one of the team reviews (Step 6, see below).

The group is presented in four four-week modules:

a. Power Up: Behavioural activation
b. Multiplayer: Communication and relationships
c. Level Up: Problem solving
d. Reboot: Cognitive restructuring

The CARIBOU Group CBT Facilitator’s Manual outlines the modules in detail and provides instructions
for facilitators. Youth are provided with handouts that correspond to each module (CARIBOU
Group CBT Youth Handouts), as well as a Problem-Solving Worksheet and a Cognitive Restructuring
Worksheet.

The CARIBOU Group CBT content is based on the Adolescent Coping with Depression Course by Dr.
Gregory Clarke12; however, the content has been reorganized to be deliverable in a modular format.
The language has been updated, and new examples thought to fit better with today’s youth have been
added (e.g., examples including social media, texting, LGBTQ-related issues). The modular format
allows for rolling entry; each youth can start the group at the beginning of any of the modules, and
the group can run continuously. This has many advantages, including being able to offer timely
access to the group and opportunities for youth to engage with multiple other youth who may have
similar experiences. One downside is that it may interfere with coherence of the group; however, our
experience is that this is not the case.

7
 PSYCHOTHERAPY STREAM

Step 3b: Individual Cognitive-Behavioural Therapy

PEOPLE
Youth, therapist (one of psychiatrist, psychologist, nurse, social worker).

MATERIALS
∙ CARIBOU Individual CBT – Youth Handouts (version 1.0) (in development)
∙ CARIBOU Individual CBT – Therapist Manual (version 1.0) (in development).
These materials are in development and will be posed on the Cundill Centre website when they
are ready.

Youth are only offered individual CBT if they refuse group. It is only four sessions. Each session
corresponds to each of the group CBT modules, with a focus on using some basic skills to be able
to get to group eventually.

8
 PSYCHOTHERAPY STREAM

Step 4: Caregivers of Depressed Youth (CODY) Group

PEOPLE
Caregivers (may include mothers, fathers, step-parents, other guardians; may involve couples or single
parents), two clinician facilitators (e.g., psychologist, social worker, nurse, psychiatrist).

MATERIALS
∙ CODY Group – Caregiver Handouts (version 1.0)
∙ CODY Group – Caregiver Manual (version 1.0)
These materials, which are in development, are based on the Adolescent Coping with Depression
Course by Dr. Gregory Clarke. The original leader’s manual13 and parent workbook14 are available
online.

Caregivers of youth with depression are invited to participate in a weekly eight-session group
program based on the Adolescent Coping with Depression Course parent group.

The group uses cognitive-behavioural principles and addresses three main areas:
1. psychoeducation about youth depression and the cognitive-behavioural model
2. caregiver-youth communication
3. problem solving.

Session structure follows a CBT framework, consisting of a check-in, review and discussion of home
practice, introduction of skills and strategies, and home practice assignment. Sessions also include
opportunities to role-play and practise the communication strategies, and for discussion among
caregivers.

9
 MEDICATION STREAM

Step 5: Medication stream

PEOPLE
Youth, caregiver(s) (if youth agrees), psychiatrist, pediatrician or family doctor.

MATERIALS
∙ SSRI Information Handout for Youth (version 1.0) (in development)
∙ Derivation of “Moderate to Severe Depression” Classification (version 1.0) (Appendix C, p. 20)
Youth may be offered medication treatment in the following situations:
1. the youth has been assessed as having moderate-to-severe depression (please see Derivation
of “Moderate to Severe Depression” Classification in Appendix C)
2. the youth’s symptoms have not been responding to eight weeks of psychosocial interventions.

Please see the third page of the treatment pathway (Appendix A, p. 16) for the medication stream.

Caregivers should be involved in discussions about antidepressant medications. Potential benefits

and risks of the medications should be discussed with youth and caregivers—including the potential
for increased self-injurious thoughts and behaviours, and agitation with these medications. The
psychiatrist needs to monitor for these side effects particularly within the first seven to 10 days of
being on the medication and have a safety plan should these side effects occur.

The titration schedule is suggested and not rigid. Ultimately, the physician should ensure that an
adequate dose has been tried for an adequate duration (for fluoxetine: total of ≥8 weeks, with at least
2 weeks at ≥40mg/d or maximum tolerated dose; and for sertraline: total of ≥8 weeks, with at least
2 weeks at ≥100mg/d or maximum tolerated dose; no more than 12 weeks if there is no response).
Intolerable side effects are also a potential reason to switch medication.

If the youth has had an adequate trial of fluoxetine prior to the pathway, sertraline would be tried
first. If the youth has already had adequate trials of fluoxetine and sertraline, the psychiatrist may
offer further options according to their expertise and patient preferences.

10
Step 6: Team reviews
PEOPLE
Youth, caregiver(s) (if youth agrees), psychiatrist (MRP: most responsible physician); any allied health
professionals currently involved (e.g., CBT group facilitator, CODY group facilitator, therapist).

MATERIALS
∙ CARIBOU Team Review Feedback Form (version 3.0) (Appendix D, p. 22)
∙ Team Review Explanation for Clinicians with MFQ-C Clinical Distribution (Appendix E, p. 25)
∙ CARIBOU Team Review Checklist (includes documentation from multiple disciplines) (version 2.0)
(Appendix F, p. 27)

Measurement-based care (MBC) “entails the systematic administration of symptom rating scales
and uses the results to drive clinical decision making at the level of the individual patient.”15 To
incorporate MBC, team reviews are held every four weeks over a span of 20 weeks. Youth complete
the MFQ-C and YCIS just prior to the team review; caregivers complete the PCIS just prior to the team
review. All members of the team review and discuss changes in scores of the measures and decide
to continue or change the current treatment plan at the indicated decision points according to the
treatment algorithm. The scores and changes over time are presented on the CARIBOU Team Review
Feedback Form (see Appendix D).

In brief, a response is considered a 20% decrease in MFQ-C score at four weeks since the last major
change in treatment, or a 40% decrease in MFQ-C score at eight weeks since the last major change
in treatment, coinciding with decision points used by Gunlicks-Stoessel et al.16 Remission is defined
as an MFQ-C score <2210 and CIS scores <16.17 Typically, if a response or remission has occurred,
treatment is continued as is. If there is no response, options for changing treatment are discussed;
this may include:
∙ increasing the dose or switching medications
∙ changing the type/modality of psychotherapy
∙ providing further caregiver support
∙ addressing comorbid conditions
∙ targeting specific stressors (e.g. bullying, LGBTQ related-stressors) more directly.

Changes in functioning and family functioning are also considered in the discussion. Remission
may also be an indicator of appropriateness to discharge the youth to primary care.

A bell curve showing the distribution of a large clinical sample of depressed adolescents is provided
as a reference to assist clinicians in gauging severity of depressive symptoms as well. Please see the
Team Review Explanation for Clinicians with MFQ-C Clinical Distribution in Appendix E and the
CARIBOU Team Review Checklist in Appendix F for more information on team reviews.

11
Step 7: Completion of the pathway
If the youth has achieved remission at the end of the pathway, discharge back to primary care is
indicated. If the youth has not responded or remitted at the end of the pathway, the psychiatrist
and multidisciplinary team may offer alternative treatments or referrals elsewhere. Enrolment in
randomized controlled trials is ideal, if the youth is eligible, given that the evidence does not guide
further care beyond this pathway to a rigorous degree.

12
Other helpful information

DEVIATIONS FROM THE PATHWAY

Deviations from the pathway are to be expected from time to time. These are permitted; however,
clinicians are responsible for documenting such deviations using a Variance Recording Framework,
as outlined below. Clinicians should:
a. use the term “pathway deviation” in the chart when it arises for clear identification in chart
review processes
b. describe the nature of the deviation
c. describe the cause or rationale of the deviation
d. describe anticipated outcomes of the deviation and follow-up plan to check that the deviation
has been effective once implemented.

QUALITY IMPROVEMENT PLAN

This version of the ICP is currently undergoing a pilot study (manuscript submitted). Results from
this study will include the measurement-based care measures previously listed, research-specific
measures (e.g., the Childhood Depression Rating Scale – Revised18), a measure of clinician adherence
and qualitative feedback from focus groups held with youth, caregivers and clinicians. Further
quality improvement initiatives will continue to be created with further iterations of the pathway.

UPDATES TO THE PATHWAY AND ITS MATERIALS

Every six months, delegated personnel will meet to review the posted material on the website to
ensure that it is the most up-to-date version. We will also check with the NICE website to ensure that
the ICP is still in keeping with the NICE CPG recommendations. The next update will be reviewed by
Dr. Darren Courtney, Madison Aitken and Renira Narrandes in fall 2020.

13
References

1. Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B. & Richardson, W.S. (1996). Evidence
based medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72. doi: 10.1136/
bmj.312.7023.71

2. National Institute for Health and Care Excellence. (2005). Depression in children and young
people: Identification and management. (NICE Clinical Guideline No. 28). https://www.nice.org.uk/
guidance/cg28

3. Bennett, K., Courtney, D., Duda, S., Henderson, J. & Szatmari, P. (2018). An appraisal of the
trustworthiness of practice guidelines for depression and anxiety in children and youth.
Depression & Anxiety, 35 (6), 530–540. doi: 10.1002/da.22752

4. Heffernan, O.S., Herzog, T.M., Schiralli, J.E., Hawke, L.D., Chaim, G. & Henderson, J.L. (2017).
Implementation of a youth-adult partnership model in youth mental health systems research:
Challenges and successes. Health Expectations, 20 (6), 1183–1188. doi: 10.1111/hex.12554

5. Youth Engagement Initiative, CAMH.

6 Courtney, D., Bennett, K., Henderson, J., Darnay, K., Battaglia, M., Strauss, J....Szatmari, P. (2019).
A way through the woods: Development of an integrated care pathway for adolescents with
depression. Early Intervention in Psychiatry. doi.org/10.1111/eip.12918

7. Croucher, M. (2005). An evaluation of the quality of integrated care pathway development

in the UK National Health Service. International Journal of Care Coordination, 9 (1), 6–12.
doi:10.1177/147322970500900102

8. Angold, A., Costello, E.J., Messer, S.C. & Pickles, A. (1995). The development of a questionnaire for
use in epidemiological studies of depression in children and adolescents. International Journal
of Methods in Psychiatric Research, 5 (4), 237–249.

9. Bird, H.R., Shaffer, D., Fisher, P. & Gould, M.S. (1993). The Columbia Impairment Scale (CIS): Pilot
findings on a measure of global impairment for children and adolescents. International Journal
of Methods in Psychiatric Research, 3 (3), 167–176.

10. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders
(5th ed.). Arlington, V.A.: Author.

11. Neufeld, S.A.S., Dunn, V.J., Jones, P.B., Croudace, T.J. & Goodyer, I.M. (2017). Reduction in adolescent
depression after contact with mental health services: A longitudinal cohort study in the UK. The
Lancet Psychiatry, 4 (2), 120–127. doi:10.1016/S2215-0366(17)30002-0

12. Clarke, G.N., Rohde, P., Lewinsohn, P.M., Hops, H. & Seeley, J.R. (1999). Cognitive-behavioral
treatment of adolescent depression: efficacy of acute group treatment and booster
sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (3), 272–279.
doi:10.1097/00004583-199903000-00014

13. Lewinsohn, P., Rohde, P., Hops, H., & Clarke, G. (1991). Leader’s Manual for Parent
Groups. Adolescent Coping with Depression Course. Retrieved June 2019 from https://
research.kpchr.org/Portals/0/Docs/project%20websites/ACWD/CWDA_parent_manual.
pdf?ver=2016-04-07-083508-963

14
14. Lewinsohn, P., Rohde, P., Hops, H., & Clarke, G. (1991). Parent Workbook. Adolescent Coping
with Depression Course. Retrieved June 2019 from https://research.kpchr.org/Portals/0/Docs/
project%20websites/ACWD/CWDA_parent_wkbook.pdf?ver=2016-04-07-083507-300

15. Fortney, J.C., Unützer, J., Wrenn, G., Pyne, J.M., Smith, J.R., Schoenbaum, M. & Harbin, H.T. (2017).
A tipping point for measurement-based care. Psychiatric Services (Washington, D.C.), 68 (2).
doi:10.1176/appi.ps.201500439

16. Gunlicks-Stoessel, M., Mufson, L., Bernstein, G., Westervelt, A., Reigstad, K., Klimes-Dougan, B. …
Vock, D. (2019). Critical decision points for augmenting interpersonal psychotherapy for
depressed adolescents: A pilot sequential multiple assignment randomized trial. Journal of the
American Academy Of Child and Adolescent Psychiatry, 58 (1), 80–91. doi:10.1016/j.jaac.2018.06.032

17. Bird, H.R., Andrews, H., Schwab-Stone, M., Goodman, S., Dulcan, M., Richters, J. . . .Gould, M.S.
(1996). Global measures of impairment for epidemiologic and clinical use with children
and adolescents. International Journal of Methods in Psychiatric Research, 6 (4), 295–307. doi.
org/10.1002/(SICI)1234-988X(199612)6:4<295::AID-MPR173>3.3.CO;2-5. https://psycnet.apa.org/
record/1997-07417-010

18. Poznanski, E.O. & Mokros, H.B. (1996) Children’s Depression Rating Scale, Revised (CDRS-R). Los
Angeles: Western Psychological Services.

15
Appendix A: CARIBOU Pathway Flow Diagram

16
17
18
 MRN #: Study #: Date: Time:

DISCUSSION AREA DETAILS NOTES

Standard assessment Diagnoses:

Scales Mood and Feelings Questionnaire

· Score:
· Symptoms:
· Severity rating:
Youth Columbia Impairment Scale:
· Score:
· Severity rating: Severe
· Impairment? Y/N (i.e. ≥16)
Acute risk assessed · Self-harm/ suicide attempts/ suicidal ideation
· Abuse
· Other? Possibility of pregnancy, driving concerns

Parental mental illness Known or suspected active parental mental illness? No

· Plan?:

Bullying Active bullying known? No

· Plan? :
Appendix B: CARIBOU Initial Assessment Form

Sexual/gender identity Identified by youth as an active stressor? No

· Plan?:

Formulation Formulation charted? Yes

Described to patient? Yes

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Appendix C: Derivation of “Moderate to Severe Depression” Classification
DERIVATION OF “MODERATE TO SEVERE DEPRESSION” CLASSIFICATION

There are no established cut-offs on the MFQ-C to determine “moderate to severe depression.” As such,
we are aiming to follow the DSM-5 definition of moderate severity:

Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree
of functional disability.*

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity
of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social
or occupational functioning.

Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between
those specified for “mild” and “severe.”

Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the
intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly
interfere with social and occupational functioning.

With this interpretation, there need to be at least six symptoms present and significant functional
impairment to be considered moderate. With regard to the above definitions, note that academic
functioning should be considered in place of occupational functioning, given the developmental
stage. The chart below shows how MFQ items were mapped on to DSM-5 criteria.

MFQ items that would count toward

DSM-5 “A” criteria for Major Depressive Disorder the DSM-5 symptoms
(if any of the corresponding items scored at “2”)

1. Depressed mood or irritable: Depressed mood most 1. I felt miserable or unhappy

of the day, nearly every day, as indicated by either
11. I felt grumpy and cross with my parents
subjective report (e.g., feels sad, empty, hopeless) or
observation made by others (e.g., appears tearful). 14. I cried a lot
(Note: In children and adolescents, can be irritable 15. I thought there was nothing good for me in the future
mood.)
2. Decreased interest or pleasure: Markedly diminished 2. I didn’t enjoy anything at all
interest or pleasure in all, or almost all, activities most
20. I didn’t want to see my friends
of the day, nearly every day (as indicated by either
subjective account or observation). 29. I didn’t have any fun in school

3. Significant weight change (5%) or change in appetite: 3. I was less hungry than usual
significant weight loss when not dieting or weight gain
4. I ate more than usual
(e.g., a change of more than 5% of body weight in a
month), or decrease or increase in appetite nearly every
day. (Note: In children, consider failure to make expected
weight gain.)
4. Change in sleep: Insomnia or hypersomnia nearly every 32. I didn’t sleep as well as I usually sleep
day.
33. I slept more than usual

5. Change in activity: Psychomotor agitation or 6. I was moving and walking more slowly than usual
retardation nearly every day (observable by others,
7. I was very restless
not merely subjective feelings of restlessness or being
slowed down). 13. I was talking slower than usual

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 MFQ items that would count toward
DSM-5 “A” criteria for Major Depressive Disorder the DSM-5 symptoms
(if any of the corresponding items scored at “2”)

6. Fatigue: Fatigue or loss of energy nearly every day. 5. I felt so tired I just sat around and did nothing

7. Guilt/worthlessness: Feelings of worthlessness 8. I felt I was no good anymore

or excessive or inappropriate guilt (which may be
9. I blamed myself for things that weren’t my fault
delusional) nearly every day (not merely self-reproach or
guilt about being sick). 23 I hated myself
24. I felt I was a bad person
28. I thought no one really loved me
30. I thought I could never be as good as other kids
31. I did everything wrong
8. Concentration: Diminished ability to think or 10. It was hard for me to make up my mind
concentrate, or indecisiveness, nearly every day (either
21. I found it hard to think properly or concentrate
by subjective account or as observed by others).

9. Suicidality: Recurrent thoughts of death (not just fear 16. I thought that life wasn’t worth living
of dying), recurrent suicidal ideation without a specific
17. I thought about death or dying
plan, or a suicide attempt or a specific plan
for committing suicide. 18. I thought my family would be better off without me
19. I thought about killing myself

In order to approximate functional impairment, we will use the cut-off of age 16 on the Youth
Columbia Impairment Scale (either parent or child version).

If ≥6 symptoms are present and the CIS ≥16, this would represent “moderate to severe depression”
for the purposes of the pathway.

* American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.
(5th ed.). Arlington, VA: Author.

21
 CARIBOU Integrated Care Pathway
MBC FORM

DEPRESSION BASICS

SLEEP HYGIENE

HEALTHY EATING
MOOD FOUNDATIONS
PHYSICAL ACTIVITY

CODY FAMILY GROUP

CBT MODULES

BEHAVIOURAL COMMUNICATION & PROBLEM-SOLVING COGNITIVE

ACTIVATION RELATIONSHIPS SKILLS RESTRUCTURING
Appendix D: CARIBOU Team Review Feedback Form

MEDICATION STREAM FLUOXETINE SERTRALINE

6079f / 05-2020 ©CAMH

For more information about this project, or to receive an electronic copy of this product, email cundill.centre@camh.ca

22
 CARIBOU Integrated Care Pathway
MOOD AND FEELINGS QUESTIONNAIRE 6079f / 05-2020 ©CAMH

For more information about this project, or to receive an electronic copy of this product, email cundill.centre@camh.ca

23
 CARIBOU Integrated Care Pathway
COLUMBIA IMPAIRMENT SCALE 6079f / 05-2020 ©CAMH

For more information about this project, or to receive an electronic copy of this product, email cundill.centre@camh.ca

24
Appendix E: Team Review Explanation for Clinicians
with MFQ-C Clinical Distribution
TEAM REVIEWS: OVERVIEW AND RATIONALE
Thank you for participating in the CARIBOU project. Your involvement is much appreciated and your
feedback is needed for success.

The overall aim of CARIBOU is to examine if a structured treatment approach following principles
of evidence-based care, a collaborative framework and measurement-based care (MBC) improves
outcomes over treatment as usual. The idea is that this treatment approach would be sustainable
over time—if it is not sustainable, we need your feedback on this.

Multidisciplinary team reviews and measurement-based care are a direct result of NICE guideline
recommendations—particularly if there has been non-response to treatment.

In their ideal form, the following parties are present: the youth, caregiver(s), the most responsible
physician and other allied health professionals involved with care. At this review, changes in
measurement scores are reviewed and the treatment plan is adjusted (or not adjusted) accordingly.

Potential downsides of this model:

∙ requires a lot of administrative co-ordination
∙ risks using more time.

Potential benefits of this model:

∙ care is co-ordinated between disciplines; everyone can be updated on the youth’s progress through
the pathway (or updated on waitlist time)
∙ opportunity to promote engagement with treatment, including increasing engagement of
caregiver(s)
∙ opportunity to prime youth and caregiver(s) on upcoming material to be learned in groups
∙ opportunity for youth to take material learned in group and apply it to life
∙ opportunity to review missed material (including Mood Foundations, CBT or CODY group)
∙ opportunity to see if severity of symptoms or risk of self-harm has changed
∙ active monitoring shown to improve outcomes outside of more formal treatments
∙ opportunity to make decisions around medication
∙ may end up being more efficient use of time.

25
That being said, “clinical judgment” is a component of Sackett’s model of evidence-based care, and if
your clinical judgment is that the next team review is not indicated, you can cancel it. Please consider
pros and cons prior to doing this.

Evidence for optimizing measurement-based care:

∙ Higher frequency of measurement and review (even up to once every two weeks) corresponds to
better outcomes in adults.
∙ Focusing on percentage change since baseline, rather than absolute number leads to better results.
∙ Having clinical appointment soon after measurement is done leads to better results.
∙ MBC in adult mental health issues (including depression) leads to better outcomes.
∙ MBC in adolescents has only been studied in one RCT with a small effect size.

Considerations for being efficient with timing:

∙If youth needs to be seen more frequently than once every four weeks, keep team reviews in mind
so that you don’t schedule them too closely together.
∙Use team reviews to incorporate group orientation, half-way sessions and post-group sessions.
∙Consider having one clinician assigned for 50 minutes (if in active treatment) and the others for
just 20 minutes (rather than everyone for 50 minutes).

MFQ-C CLINICAL DISTRIBUTION

15 25 35 45 55 65 75
SPECIFY PARAMETERS:
MEAN 45
SD 10

Normal distribution representation of the baseline mean and standard deviation of the MFQ within
the IMPACT trial (reference: Goodyer, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J. . . . Fonagy,
P. (2017). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief
psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT):
A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. The Lancet
Psychiatry, 4 (2), 109–19. doi:10.1016/S2215-0366(16)30378-9

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 RN #: Study #: Date: Time:

DISCUSSION MINIMUM REQUIREMENTS OPTIONAL DETAILS NOTES

AREA FOR THE ICP

Introductions · Who is present?

· What are their roles?
- An involved allied health professional (i.e., group leader)?
· Any recent stressors?
· Any acute safety concerns that need to be addressed immediately
(including self-harm, suicide attempts, suicidal ideation or aggression)?
· Any topics you want to make sure we cover?

Review steps in · Which components of the pathway have been completed so far? Complete:
treatment - Multi-family education group (Mood Foundations)
so far - Any individual CBT (4 sessions of individual to prep for group)?
- CBT Activation skillset
- CBT Communication skillset
- CBT Problem-solving skillset
- CBT Cognitive strategies skillset In progress:
- Caregiver intervention group (CODY)
- Medication management

Multi-family Offered “Mood Foundations” · Which parts of the education session has the youth been working on? Has N/A
psycho-ed group it been helpful?
group - Sleep hygiene
- Exercise
- Diet

If individual CBT · How has individual CBT been going? N/A

· Is the youth ready to try entering the group? If not, review downsides of
group and review pros of group?
(includes documentation from multiple disciplines) (version 2.0)

· (Note: if youth refuses group, can still be in the pathway—just would have
to go to the community for individual therapy)
Appendix F: CARIBOU Team Review Checklist

If in group CBT Offered “group CBT” or · How have you found the group?
“4-session individual CBT” · What do you like about it? What should we keep doing?
· What do you not like about it? What should we stop doing?
· What skills have you found most helpful/least helpful?
· Have you been using the skills? Which ones?
· Does anything get in the way of using the skills?

If caregiver in Offered caregiver group · How have you found the group?
CODY · What do you like about it? What should we keep doing?
· What do you not like about it? What should we stop doing?
· What skills have you found most helpful/least helpful?
· Have you been using the skills? Which ones?
· Does anything get in the way of using the skills?

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 DISCUSSION MINIMUM REQUIREMENTS OPTIONAL DETAILS NOTES
AREA FOR THE ICP

Measures Physician and client discussed · Review baseline scores of MFQ and CIS (if caregiver present) See measurement-
MBC measure scores · Review scores at last major change in treatment (if applicable) based care (please
· Review percent change in score from last major change (or baseline if no provide handouts for
change) participant to take
· Does the change in score accurately represent youth’s and caregiver’s home)
perceptions?
· If there is a change, what does the youth and caregiver believe the change
is from? Do they agree with the change?
· Does the course of symptoms lead any member of the meeting to think
about changing treatment? What change?
· How can the youth use the tools for implementation?

Medication If no previous medication · Which medications is the youth taking?

review trial and moderate-to-severe - What dose?
depression, fluoxetine offered · Does the youth and caregiver believe it is helping?
as first-line - It is making things worse
If failed fluoxetine, sertraline - No change
offered as second-line - Slightly better
If tolerated, medication - Moderately better
allowed to continue until - A lot better
“team review corresponding · Are there any side effects with the medication?
to 8 weeks since medication · Which side effects?
initiation” even if no response - How severe?
If no response at “team - Is it tolerable?
review corresponding to - Is there anything that can be done to limit side effects?
12 weeks since medication - Does it lead to the youth stopping the medication?
initiation,” discussion around · Does anything get in the way of taking it regularly?
switching medication · Do you have thoughts about stopping the medication?
Not offered any other · Has the youth had any change in symptoms over 4 weeks?
antidepressant as 1st or · Has the youth tried the medication for 8 weeks without any change?
2nd line medication for
depression · Medication decision:
- Stop medication
- Reduce dose
- Remain at same dose
- Increase dose to
- Start new medication
- If not following algorithm, reason for
deviation?

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 DISCUSSION MINIMUM REQUIREMENTS OPTIONAL DETAILS NOTES
AREA FOR THE ICP

“Flags” to address · Parental mental illness?

from initial · Bullying?
assessment · Gender/sexual identity issues identified by youth as a stressor?
· Bereavement?

Suicide risk · Complete clinical assessment and document in PowerChart (if severe, call
MD or go to the ER).
If MD present – no need for PowerChart

Safety and · Complete, discuss and document in PowerChart (if severe, call MD or go to
comfort plan the ER)
(optional as - Provide paper copy to client
per MD) · Stress to youth: “If you are ever in emotional distress while attending group
session, please tell one of your facilitators; they will do what they can to
support you in this regard.”

Any outstanding
items?

Next team Date and time?

meeting?

Readiness for · Is the patient ready for discharge back to the GP? (Particularly after 20 N/A
discharge back weeks of treatment?)
to GP? · If not, what are barriers to discharge?
· If so, what is the follow-up plan?

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Appendix G

ABBREVIATIONS

CARIBOU: Care for Adolescents who Receive Information ‘Bout Outcomes

CODY: Caregivers of Depressed Youth

CPG: Clinical practice guideline

DSM-5: Diagnostic and Statistical Manual of Mental Disorders (5th ed.)

ICP: Integrated care pathway

MFQ-C: Mood and Feelings Questionnaire – Childhood Long Version

PCIS: Columbia Impairment Scale – Parent Version

YCIS: Columbia Impairment Scale – Youth Version

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Appendix H

LIST OF PATHWAY MATERIALS

∙ CARIBOU Pathway Flow Diagram
Step 1: Assessment (see page 4)
∙ CARIBOU Initial Assessment Form (version 1.0) (includes assessment of risk)
∙ Mood and Feelings Questionnaire – Childhood Long Version (MFQ-C)7
∙ Columbia Impairment Scale – Youth Version (YCIS)8
∙ Columbia Impairment Scale – Parent Version (PCIS)8

Step 2: Mood Foundations (see page 6)

∙ Mood Foundations – Youth Handouts (version 1.0)
∙ Mood Foundations – Facilitator Guide (version 1.0)
∙ Mood Foundations – Survey (version 1.0)

Step 3a: Group cognitive-behavioural therapy (see page 7)

∙ CARIBOU Group CBT – Facilitator’s Manual (version 1.0)
∙ CARIBOU Group CBT – Youth Handouts (version 1.0)
∙ Problem-Solving Worksheets (version 1.0)
∙ Cognitive Restructuring Worksheets (version 1.0)

Step 3b: Individual cognitive-behavioural therapy (see page 8)

∙ CARIBOU Individual CBT – Youth Handouts (version 1.0)
∙ CARIBOU Individual CBT – Therapist Manual (version 1.0)

Step 4: Caregivers of Depressed Youth Group (CODY) (see page 9)

∙ CODY Group – Caregiver Handouts (version 1.0)
∙ CODY Group – Caregiver Manual (version 1.0)

Step 5: Medication stream (see page 10)

∙ SSRI Information Handout for Youth (version 1.0)
∙ Derivation of “Moderate to Severe Depression” Classification (version 1.0)

Step 6: Team reviews (see page 11)

∙ Team Review Explanation for Clinicians with MFQ-C Clinical Distribution
∙ CARIBOU Team Review Checklist (includes documentation from multiple disciplines) (version 2.0)
∙ CARIBOU Team Review Feedback Form (version 3.0)

31