Received: 31 January 2022

DOI: 10.1002/jcv2.12083

ORIGINAL ARTICLE
- Accepted: 4 May 2022

CARIBOU‐1: A pilot controlled trial of an Integrated Care

Pathway for the treatment of depression in adolescents

Darren B. Courtney1 | Amy Cheung1 | Joanna Henderson1 | Kathryn Bennett2 |

Wei Wang3 | Sheng Chen3 | Marco Battaglia1 | John Strauss4 | Rachel Mitchell1 |
Karen Wang1 | Jacqueline Relihan5 | Matthew Prebeg5 | Karleigh Darnay3 |
Peter Szatmari1

1
Department of Psychiatry, University of
Toronto, Toronto, Ontario, Canada
2
Department of Clinical Epidemology &
Biostatistics, McMaster University, Hamilton,
Ontario, Canada
3
Centre for Addiction and Mental Health,
Toronto, Ontario, Canada
4
Island Health, Nanaimo, Ontario, Canada
5
Margaret and Wallace McCain Centre for
Child, Youth and Family Mental Health,
Toronto, Ontario, Canada
Correspondence
Darren B. Courtney, Department of
Psychiatry, University of Toronto, Toronto,
Ontario, Canada.
Email: dr.courtney.research@gmail.com
Funding information
Cundill Centre for Child and Youth Depression
Abstract
Background: To co‐ordinate a multidisciplinary team in the delivery of guideline
recommendations using a measurement‐based care framework, our group previ-
ously developed a care pathway for the treatment of depression in adolescents.
Core components of the pathway were: assessment, education, cognitive‐behav-
ioural therapy, a caregiver intervention group, a medication algorithm, and monthly
measurement‐based care “team reviews” with the adolescent present. The aim of
this study was to test the feasibility of conducting a controlled clinical trial of the
pathway.
Method: We conducted a 20‐week pilot controlled clinical trial of the care pathway
relative to treatment as usual. Participants were adolescents (age 14–18) with a
primary diagnosis of Major Depressive Disorder recruited from one of two outpa-
tient psychiatric clinics at academic hospitals. Site of presentation was the method
of allocation. Thirty‐five youth were allocated to the pathway and 31 were allocated
to treatment as usual. As this is a pilot study, trial feasibility outcomes were of
primary interest, including clinician fidelity to the care pathway.
Results: Our target sample size was recruited over a 15‐month time interval.
Clinician fidelity and adolescent engagement in the care pathway components on a
priori checklists were high (95% and 80%, respectively). We collected baseline and
20‐week endpoint data for our primary outcome of the Children's Depression
Rating Scale – Revised (CDRS‐R) for 83% of the sample. On linear mixed effects
modelling, we observed a linear decrease in CDRS‐R across 4‐week intervals up to
the 20‐week endpoint in both groups (β = −2.07; 95% CI −3.14 to −1.01).
Conclusion: A controlled clinical trial of a complex, multi‐component intervention
for the treatment of depression in adolescents is feasible. Given the need to find
optimal strategies to deliver effective care for adolescents with depression, a
definitive randomized controlled trial of the pathway is warranted.
Trial is registered at Clinicaltrials.gov: NCT03428555

KEYWORDS

-
adolescent, care pathway, depression, pilot controlled trial

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, pro-
vided the original work is properly cited.
© 2022 The Authors. JCPP Advances published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

JCPP Advances. 2022;2:e12083. wileyonlinelibrary.com/journal/jcv2 1 of 8

https://doi.org/10.1002/jcv2.12083

2 of 8
- COURTNEY
Major Depressive Disorder in adolescents (MDD‐A) is common
(Avenevoli et al., 2015; Cheung & Dewa, 2006; Polanczyk
et al., 2015), debilitating (Clayborne et al., 2019; Fergusson &
Woodward, 2002; Gore et al., 2011) and a risk factor for suicide
(Renaud et al., 2008). Treatment approaches used in real‐world
clinical practice are heterogeneous, and often insufficiently sup-
ported by evidence (Watson et al., 2019). Greater adherence to care
standards in the treatment of depressive disorders in adolescents
treated in primary care has been associated with improved outcomes
(Wells et al., 2012). Circumscribed evidence‐based treatment ap-
proaches like antidepressant medication and/or cognitive behav-
ioural therapy (CBT) have had limited benefits, with up to 40% of
adolescents unremitted at follow‐up (March et al., 2009; Vitiello
et al., 2011; Cuijpers et al., 2021). High‐quality clinical practice
guidelines, like the NICE guideline for depression in children and
young people (Bennett et al., 2018; NICE, 2019), call for more
comprehensive care in addition to medications and therapy,
including: structured assessment; education about sleep, exercise and
diet; family involvement and; measurement‐based care (MBC). While
other research groups have explored service delivery models (Asar-
now et al., 2005; Martinez et al., 2018) and MBC strategies (Abright
& Grudnikoff, 2020; Bickman et al., 2011; Chorpita et al., 2017;
Emslie et al., 2004; Gunlicks‐Stoessel et al., 2019), the effectiveness
of Integrated Care Pathways (ICPs) to guide comprehensive delivery
of care for MDD‐A has not been studied. ICPs are pre‐defined
treatment flow processes intended to co‐ordinate the use of clinical
practice guideline recommendations for a given condition (Campbell
et al., 1998). They have the potential to help both the standardization
and personalization of management of a given condition by facili-
tating the delivery of comprehensive and multidisciplinary care
through a series of decision points and treatment steps. The ultimate
aim of ICPs is to optimize the provision of evidence‐based care
through finding the intersection between research evidence, clinical
judgement of the expert provider and patient/family values in the
context of finite resources (Courtney, Bernett, & Szatmari, 2019;
Sackett et al., 1996; Allen et al., 2009).
Our group collaboratively and systematically developed an ICP
for the treatment of adolescent depression (Courtney, Bennett,
Henderson, et al., 2019) based on a contextualization of the NICE
guideline recommendations (NICE, 2019). The resulting ICP has been
called the CARIBOU‐1 pathway, representing “Care for Adolescents
who Receive Information ‘Bout OUtcomes” (first iteration). The
components of the CARIBOU‐1 pathway offered to youth include: (1)
a structured assessment, with particular attention to assessment of
risk for self‐harm, exposure to bullying and caregiver mental illness,
(2) a group education session (called Mood Foundations) where the
nature of depression and the role of sleep hygiene, exercise and diet
are discussed with youth and caregivers, (3) 16 sessions of group CBT
(group therapy was offered rather than individual therapy, reflecting
the available resources at our centre and some evidence of similar
efficacy between the two CBT formats (Rosselló et al., 2008)), (4) an
8‐session caregiver group focussing on validating communication and
collaborative problem‐solving, (5) a medication algorithm with
fluoxetine as the first‐line treatment and sertraline as second‐line, (6)
all in the framework of MBC. MBC took place through monthly
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ET AL.
Key points
� The NICE guideline for have been appraised as a high
quality guideline for the treatment of depression in
adolescents
� Many adolescents with depression do not receive
guideline‐adherent care
� It is feasible to implement and test a collaboratively
developed Integrated Care Pathway for the treatment of
adolescent depression relative to treatment as usual to
facilitate the delivery of guideline‐adherent care
“Team Reviews” whereby youth meet with their main clinician (most
often a psychiatrist), any other clinicians involved (often a social
worker co‐facilitating the CBT group) and, at the youth's discretion,
the youth's caregiver (e.g. parent). At these Team Reviews, partici-
pants reviewed changes in scale scores on measures of depressive
symptoms (youth reported Mood and Feelings Questionnaire (Angold
& Costello, 1987; MFQ), general functioning (Columbia Impairment
Scale – youth and caregiver versions; YCIS & PCIS; completed by the
relevant informant (Bird et al., 1993)) and family functioning
(McMaster Family Assessment Device general functioning subscale –
MFAD‐GF (Epstein et al., 1983) completed separately by youth and
caregivers). Results from these measures were used to collabora-
tively decide on starting, continuing, intensifying, switching, tapering
or stopping various treatment components. This approach makes the
pathway both standardized and personalized. More details of the
pathway are well documented elsewhere (Courtney, Bennett, Hen-
derson, et al., 2019; Courtney, Cheung, et al., 2019; Courtney &
Szatmari, 2020).
The literature supports the concept of patient engagement in
research to improve outcomes (Domecq et al., 2014; O’Mara‐Eves
et al., 2015). The Youth Engagement Initiative (YEI) (Heffernan
et al., 2017) at our centre is a team of youth engagement facilitators
on staff who are young people with lived/living experience of mental
health and substance use challenges and work with a broader
network of paid youth advisors (e.g. National Youth Action Council
(Mood Disorders Society of Canada, n.d.) for purposes of making
research innovations relevant to the people they are intended to
serve. Investigators worked closely with the YEI to develop materials
related to recruitment, orientation, and treatment components as
they pertained to the CARIBOU‐1 intervention and pilot study
(Cundill Centre for Child and Youth Depression, n.d.).
The current study's aim is to examine the feasibility of a
controlled clinical trial testing the effectiveness of the CARIBOU‐1
pathway on reducing depression symptom severity over 20 weeks
relative to treatment as usual (TAU) for adolescents with MDD‐A.
Our main hypotheses and benchmarks for a successful pilot study
were that:
(1) At least 30 participants at each of two sites over a span of 21‐
month would be recruited.
(2) 95 percent of youth participants would be able to complete the
baseline assessment within a span of 2 hours.

CARE PATHWAY FOR ADOLESCENTS WITH DEPRESSION
(3) Within the ICP arm, clinicians would be able to achieve 90%
adherence to the ICP model as per a prespecified checklist.
(4) As a benchmark of retention, 80% of the ideal scheduled data
points on the primary clinical outcome (Children's Depression
Rating Scale‐ Revised), would be obtained.
METHODS
Our methods are detailed in our published protocol, with few de-
viations (each are mentioned below) (Courtney, Cheung, et al., 2019).
In brief, this was a pilot parallel non‐randomized controlled clinical
trial. Psychiatrists assessed adolescents aged 14–18 presenting to
the outpatient psychiatry clinics at one of two academic hospitals in
Toronto, Ontario, Canada: the Centre for Addiction and Mental
Health (CAMH) and Sunnybrook Health Sciences Centre (SHSC).
SHSC also ran a satellite clinic in the community where youth are
assessed by a psychiatrist and treated. If depression was identified as
a primary presenting concern for consenting youth, a research ana-
lyst conducted an assessment for inclusion/exclusion criteria.
Ethical considerations
The study was approved by the CAMH and SHSC research ethics
boards.
Inclusion and exclusion criteria
Youth were included into the trial if they met criteria for MDD based
on DSM‐5 criteria as assessed by a semi‐structured diagnostic
interview (the Diagnostic Interview for Affective Symptoms for
Children – DIAS‐C (Merikangas et al., 2014)). Youth were excluded if
they presented with active and impairing psychotic symptoms, bi-
polar disorder, moderate to severe substance use disorder, moderate
to severe eating disorder, autism spectrum disorder, intellectual
disability, or imminent risk of suicide requiring hospitalization.
Caregivers were included if the enrolled youth agreed to caregiver
involvement in the trial. Youth and caregivers also needed to be able
to read and write in English and provide informed consent.
Treatment allocation
Youth were allocated to one of two treatment models based on site
of presentation. The intervention is applied at the clinic level, so
randomizing participants to the treatment within site was not
possible without the risk of contamination effects. Enrolled youth
presenting to CAMH were assigned the CARIBOU‐1 pathway, while
those presenting to SHSC were assigned to TAU.
Clinical research outcome measures
These were collected at baseline and every 4 weeks for 20 weeks
including the evaluator‐rated Children's Depression Rating Scale –
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- 3 of 8
Revised (CDRS‐R; Poznanski et al., 1985), self‐rated WHO Disability
Assessment Scale – Child/Youth version 2.0 (WHODAS CY 2.0;
Scorza et al., 2013) and caregiver‐rated Child Behaviour Checklist
internalizing subscale (CBCL‐int; Achenbach & Edelbrock, 1991). The
Childhood Interview for Borderline Personality Disorder (CI‐BPD;
Sharp et al., 2012) and Beck Hopelessness Scale (BHS: Beck &
Steer, 1988) were collected at baseline to further describe the
sample. The psychometric properties of these measures are detailed
in our protocol (Courtney, Cheung, et al., 2019). These research
outcomes were not provided to clinicians and youth participants to
maintain some independence from the MBC‐framework of the
intervention.
Clinician adherence and youth engagement in the
pathway
Clinician adherence was obtained using the a priori determined
checklist (see Appendix of the protocol (Courtney, Cheung,
et al., 2019)) with one deviation from the original protocol; that is, the
component criteria “team review offered every 4 weeks” was omitted
from the checklist scores as the concept was found to be too broad to
operationalize and was better captured in subsequent more detailed
criteria around receipt of MBC. For each youth study participant,
clinician adherence was calculated as the number of components the
clinician offered divided by the number of components that were
applicable for that youth x 100%. During the data collection phase,
we also created a form matching the clinician adherence checklist to
extract and code youth engagement in each of the components.
Inter‐rater reliability
The inter‐rater reliability for semi‐structured interviews pertaining
to evaluator‐rated measures was calculated by having the principal
investigator (DBC) and the research assistant independently rate
audio recordings; 6 for the DIAS‐C, 10 for the CDRS‐R and 6 for the
CI‐BPD. All six participants with audio‐recorded DIAS‐C diagnostic
assessments were coded as meeting criteria for MDD‐A, and perfect
agreement was achieved with regards to this classification. With
respect to the CDRS‐R, weighted kappas ranged from 0.77 to 0.93.
With respect to the CI‐BPD, weighted kappas ranged from 0.63 to
0.83 on five ratings, with one early participant's recording removed
as it was an outlier (weight kappa = −0.42). Weighted kappas are the
reported statistic here as item‐level scores are ordinal in nature;
greater between‐rater score differences on an item are given more
weight than smaller differences.
Statistical analysis
Baseline differences between groups were calculated using chi‐
square or Fisher's exact tests for binary data, Mann–Whitney U tests
for non‐parametric continuous data and Student's t‐test for para-
metric data. Feasibility outcomes were assessed as count and pro-
portion data. Clinician adherence and participant engagement
percentage scores were summed and divided by the number of youth

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- COURTNEY
to provide the mean score. Differences in exposure to various
treatment components were calculated using chi‐square analysis, or
Fisher exact tests if one cell had a value of ≤5. None of these com-
parisons were testing a priori hypotheses (i.e. exploratory); therefore,
significance threshold was set at p ≤ .05 (two‐tailed). The above
analyses were conducted using Stata software version 17 (2021).
Linear mixed effects modelling was used to describe changes in
clinical research outcome measure scores (i.e. CDRS‐R, WHODAS CY
2.0 and CBCL‐int) over time within groups. Baseline score for the
variable of interest, time, and treatment arm were included as
the fixed effects. The random participant effect was also included in
the model to account for intra‐participant correlation over time. In a
sensitivity analysis, a time � time interaction term was added to the
model to investigate the possibility of a quadratic pattern to the data,
as decelerating patterns of change had been found in other studies
(Varigonda et al., 2016). In a further analysis, we also added the
treatment � time term the initial model. In a large trial, this treat-
ment � time interaction term from the models would be the term of
interest. We calculated the treatment � time interaction here for
description purposes with two notable caveats; (1) Pilot studies are
not intended to be hypothesis‐testing with respect to clinical out-
comes (Thabane et al., 2010), particularly as the sample size would
not have sufficient power; (2) The intra‐class correlation with respect
to the CDRS‐R over time was relatively high, at 0.119, indicating that
site‐level effects are too strong to make appropriate comparisons
between sites. An intent‐to‐treat approach was used. Multiple
imputation, with 20 imputed sets, was used to address missing data.
Regression analyses were conducted using SAS software version
7.1 (2014).
Within the ICP arm, mixed effects modelling was also used to
describe the within group changes in the measurement‐based care
measure scores over time, as a reference for other groups consid-
ering implementing service delivery models for the treatment of
adolescent depression. Baseline score for the variable of interest and
time terms were included as the fixed effects for this model, with
random participant effect included here again.
RESULTS
Recruitment and sample characteristics
One hundred and seven youth diagnosed with major depressive
disorder were approached by the research analyst. Of these, 66
participants were enrolled in the study: 35 in the CARIBOU‐1
intervention group over a 13‐month time span (March 2018 to April
2019) and 31 in the TAU group over a 15‐month time span
(December 2018 to March 2020). Sample ascertainment is described
in the CONSORT Flow Diagram in Supplementary Figure S1. 10
youth recruited from the SHSC sample were recruited from the
community satellite clinic. Baseline characteristics are described in
Supplementary Table S1. The median age of the sample was 16 years
old. The sample was predominantly white (53%; 35 of 66) and pre-
dominantly cis‐gender girls (68%; 45 of 66). The household income
was significantly higher in the TAU group. The median age of onset
for MDD was numerically lower in the CARIBOU‐1 intervention
group (p = .06). Most of the overall sample (80%; 53 of 66) met
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ET AL.
criteria for comorbid generalized anxiety disorder. One participant
met criteria for oppositional defiant disorder, and none met criteria
for conduct disorder. The participants in the CARIBOU‐1 interven-
tion group had significantly higher scores on the CDRS‐R and CBCL
“withdrawn/depressed” subscale at baseline relative to TAU, repre-
senting greater severity of depressive symptoms. Sixty‐three percent
(42 of 66, with no significant difference between groups) were taking
an antidepressant at baseline.
Reach and examination of ascertainment bias of
sample
Supplementary Figure S1 outlines the ascertainment of the sample at
CAMH during recruitment period (March 2018 to April 2019). Of
youth who were approached to engage in the study at the CARIBOU‐
1 intervention site (CAMH, N = 63), we compared those who enrolled
in the study (n = 35) and those who declined (N = 28) with respect to
four variables of interest at intake. We did not observe significant
differences between those who enrolled and those who declined the
research study with respect to age (Mann–Whitney U, z = 0.55,
p = .58), proportion identifying as girls (χ2 = 0.01, p = .94), socio-
economic status (Mann–Whitney U, z = 0.51, p = .61) and Patient
Health Questionnaire‐9‐Adolescent scores at intake (Mann Whitney
U, z = −1.31, p = .19).
Clinician adherence and youth participant
engagement for the CARIBOU‐1 intervention
Within the CARIBOU‐1 intervention arm, mean clinician adherence
to the pathway was 95% (SD 9%). Mean participant engagement was
80% (SD 18%). Supplementary Table S2 outlines clinician adherence
and participant engagement in pathway‐specific components (i.e.
Mood Foundations, the Caregiver Group and Measurement‐Based
Care). Supplementary Tables S3 and S4 outline adherence/engage-
ment outcomes for psychotherapy components and medication
components, respectively.
Differential exposure between CARIBOU‐1 relative to
treatment‐as‐usual
In the CARIBOU‐1 group, 26 youth had documentation of MBC,
whereas 3 had documentation of receiving MBC in the TAU group (of
29 where charts were available for review). This difference was sig-
nificant (p < .001). In the CARIBOU‐1 group, 20 youth were docu-
mented to have received at least one session of group CBT, relative
to none in the TAU group (p < .001). Twenty‐five and 24 youth in the
CARIBOU‐1 and TAU group, respectively, received at least one
session of any psychotherapy during the trial (p = .95). In the TAU
group, 3 were documented to have received individual CBT, 1
interpersonal therapy, 1 dialectical behaviour therapy skills group, 1
family therapy, 1 had therapy in the context of day hospital and 16
were documented to have received an individual therapy, but the
type of therapy was not specified. Differential exposure to medica-
tions is outlined in Supplementary Table S4.

CARE PATHWAY FOR ADOLESCENTS WITH DEPRESSION
Data collection efficiency and participant retention
The median time to complete the baseline assessment was 54 min
(IQR: 45–72 min, Range: 31–158 min). Most participants (95.5%)
completed the baseline assessment in under 2 hours. With 66 par-
ticipants, each with 6 potential longitudinal data points on the pri-
mary outcome (CDRS‐R), there were 396 ideal data points collected
for this measure. We collected 308 data points on the CDRS‐R,
indicating a data collection‐efficiency rate of 78%. Fifty‐five of the 66
participants (83%) who provided a baseline primary outcome mea-
sure (CDRS‐R) also provided a 20‐week primary outcome measure.
Description of course of clinical research outcome
measures (n = 66)
The linear mixed effects model of CDRS‐R scores found a main effect
of time of β = −2.07 (95% CI −3.14 to −1.01); that is, a decrease of
2.07 points on the CDRS‐R every 4 weeks was estimated. When the
treatment x time term was added to the model, the regression co‐
efficient for this interaction was β = −.008 (95% CI −2.01 to 1.99).
With respect to the WHODAS CY 2.0, the main time effect was
represented as β = −1.43 (95% CI −2.3 to −0.55). When added, the
treatment � time interaction term was β = 1.34 (95% CI −0.42 to
3.10). The model of CBCL‐int scores found a main time effect of
β = −1.41, 95% CI −1.94 to −0.86). When added, the treat-
ment � time interaction term had a regression co‐efficient of
β = −.38, 95% CI −1.47 to 0.72).
These models did not demonstrate significant time � time
interaction term on the CDRS‐R, WHODAS or CBCL internalizing
subscale scores; that is, we did not find evidence of a quadratic
pattern to the data over time.
Description of course of MBC measures in the
CARIBOU‐1 intervention arm (n = 35)
Through an exploratory linear mixed effects modelling analysis on
available MBC measurement data (non‐imputed), we found that the
MFQ scores decreased by 1.05 points (95% CI of −2.05 to −0.04),
YCIS scores decreased by 0.93 points (95%CI of −1.40 to −0.46),
PCIS scores decreased by 1.31 points (95%CI of −2.05 to −0.56) for
every 4 weeks in the pathway. We did not find evidence that MFAD
scores changed over time (β = .005, 95% CI of −0.038 to 0.029).
DISCUSSION
This pilot study of the CARIBOU‐1 pathway for the treatment of
adolescent depression is, to our knowledge, the first to explore a
complex care model, collaboratively developed with youth with lived
experience and aligned with appraised high quality clinical practice
guidelines and using measurement‐based care. Our primary objective
of this pilot was met; that is, to assess feasibility outcomes with
respect to conducting a properly powered controlled clinical trial.
More specifically, we recruited our target sample size of over 60
participants in a reasonable interval of 15 months. Furthermore, the
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- 5 of 8
comprehensive baseline assessment was completed within an
acceptable time span of 2 hours. We also collected primary clinical
outcome data at nearly 80% of our ideal time points, with over 80%
completing the 20‐week endpoint primary outcome measure (i.e. the
CDRS‐R). Clinician fidelity to the CARIBOU‐1 pathway model was
also high at 95% on an a priori locally developed checklist.
We suspect that the success of these feasibility outcomes are, in
part, due to the input of the Youth Engagement Initiative at CAMH
(Heffernan et al., 2017). Youth partners were involved in creating
materials used to describe the pathway, reviewing accessible lan-
guage in consent forms, and provided consultation with respect to
how to approach youth for the study. They also provided substantial
input into the content and design of the materials used for the
intervention itself (Courtney, Bennett, Henderson, et al., 2019).
Multi‐disciplinary clinicians were involved in the creation of the
pathway (Courtney, Bennett, Henderson, et al., 2019), which we
believe contributed to good fidelity. Youth engagement with pathway
components was good at 80%. Indicated caregiver engagement in the
caregiver‐specific group was low at 42%. Qualitative analysis of in-
terviews and focus groups is planned to learn about ways to further
improve clinician fidelity and youth participant engagement in
treatment for next iterations of the pathway.
At CAMH, the reach of the pathway was limited by geographical
barriers as frequent in‐person group sessions and team reviews
required proximity to the hospital site. Strategies to overcome these
barriers, such as internet‐based services, are worth exploration.
The participant samples obtained by our recruitment procedures
were characterized as being predominantly cis‐girls, consistent with
the gender distribution of depression of adolescents in community
samples (Cheung & Dewa, 2006; Mojtabai et al., 2016). About half of
the sample identified as white, with the other half from various racial
backgrounds, representative of Toronto's diversity (City of Tor-
onto, 2021). The majority of participants in our sample endorsed
threshold criteria for generalized anxiety disorder (80%), which is a
higher rate than in the IMPACT trial (21%; Goodyer et al., 2017) and
all anxiety disorders in samples of depressed adolescent studied in
large controlled trials (e.g. any anxiety disorder in TADS; 27% (March
et al., 2004) and in TORDIA; 36% (Brent et al., 2008)). Conversely,
our sample also had very few participants who endorsed criteria for
oppositional defiant disorder or conduct disorder (1.5%), which is
much lower that other samples (e.g. TADS 23% (March et al., 2004),
TORDIA 10% (Brent et al., 2008), IMPACT 12% (Goodyer
et al., 2017)). These differences may be related to specific referral
processes. Alternatively, these large RCTs used the Schedule for
Affective Disorders and Schizophrenia for School‐Age Children‐
Present and Life‐time Version (Kaufman et al., 2000) for their diag-
nostic assessments, whereas this current study used the DIAS‐C
(Merikangas et al., 2014). Questions, prompts and branching logic are
different between these two diagnostic assessments, which may
affect categorization of diagnoses. Participants receiving CARIBOU‐
1, on average, were from significantly lower income levels compared
to the TAU arm, which was anticipated given the geographical loca-
tions of each site in the city. What was not anticipated was that the
CARIBOU‐1 sample would have greater depression symptom
severity scores on both the CDRS‐R and the CBCL; this may have
been due to chance, to associations with income level or differences
in referral patterns at the two sites.

6 of 8
- COURTNEY
Overall, the sample showed evidence of improvement in both
groups in mood symptoms on the CDRS‐R. In contrast, we did not
observe improvements in functioning on the WHODAS CY 2.0. With
few options of validated measures of function in youth, the WHO-
DAS CY 2.0 was chosen as a measure to have a measure of func-
tioning independent from the measurement‐based care component
of the intervention; however, studies examining its validity, reliability
and responsiveness are limited. The lack of change observed could be
related to lack of responsiveness in the measure or a true lack of
change in functioning. In the CARIBOU‐1 intervention arm, we did
find significant reductions in both the youth reported and caregiver‐
reported versions of the CIS, suggesting the former explanation is
more likely. The relatively high ICC and linear modelling of the lon-
gitudinal CDRS‐R data (vs. a quadratic model) may inform future trial
designs and power calculations.
A future iteration of the pathway is already being planned with
two key additions. (1) Given the expected limited engagement and
retention in CBT, we will plan to have a second line therapy that is
also evidence‐based and feasible in the context of limited resources;
namely, “Brief Psychosocial Intervention” (Goodyer et al., 2017). (2)
We also want to more formally ensure that principles of shared de-
cision‐making (Charles et al., 1997) are being applied at team re-
views. These principles include giving emphasis to the patient's
perspective, the clinician offering of at least two treatment options
(e.g. starting or not starting medication), and accepting that the pa-
tient's decision may differ from clinical recommendations (Zisman‐
Ilani et al., 2021). The concept of shared decision‐making has become
a formal field of study, though with notable gaps in the field of child
and adolescent psychiatry (Hayes et al., 2021). It nicely fits in with
the aims of ICPs and MBC by optimizing the chances that patient/
caregiver values are being accounted for at the key decision‐points,
consistent with our ideal view of evidence‐based care.
A larger RCT of the pathway is underway testing both effective-
ness and implementation outcomes (Courtney, Barwick, et al., 2022).
In the context of this trial, we will also be able to conduct a detailed
examination of the role of baseline variables associated with outcome.
Among an extensive list of candidate variables (Courtney, Watson,
et al., 2022) are measures relating to sleep (Wang et al., 2016) and
exercise (Brand et al., 2017). As the role of technology in the man-
agement of depression is increasing in prominence (Marciano
et al., 2022; Sequeira et al., 2019, 2020), we are also piloting a remote
electronically delivered version of the pathway (Courtney et al., 2021).
Limitations
Allocation to treatment was not randomized and fidelity to the model
was assessed using a chart review checklist as opposed to video re-
cordings of sessions. This study was conducted at academic centres
and the results may not apply to community settings.
CONCLUSION
Our feasibility outcomes are favourable with proceeding with a full‐
scale cluster randomized controlled trial. The design and planning
phase of a definitive trial is already underway, with materials and pilot
26929384, 2022, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1002/jcv2.12083, Wiley Online Library on [24/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ET AL.
data being used to facilitate its execution. Should the results of our
definitive trial show that the CARIBOU pathway leads to better clin-
ical outcomes, can be delivered with fidelity, and be cost‐effective,
investing in wide‐spread use of the model would be warranted. The
broad‐scale delivery of comprehensive, guideline‐adherent, stan-
dardized and personalized treatment through an ICP for adolescents
with depression has the potential to unlock all the knowledge we have
accrued so far in the field, tipping the balance towards better out-
comes relative to current practice and previous clinical trials.
A U T H O R C O N T R I B U T I O NS
Darren B. Courtney was the principal investigator. Darren B.
Courtney, Amy Cheung, Joanna Henderson, Kathryn Bennett, Marco
Battaglia, John Strauss, Karen Wang, Jacqueline Relihan, Matthew
Prebeg, Karleigh Darnay and Peter Szatmari provided input on trial
design, recruitment strategies, outcome measurement, and inter-
pretation of the findings. Wei Wang and Sheng Chen provided sta-
tistical support. Darren B. Courtney, Matthew Prebeg, Jacqueline
Relihan, Karleigh Darnay and Peter Szatmari co‐developed the
intervention materials.
A CK NO W L E D GM E N T S
Thank you to Kirsten Neprily and Michelle Li for their work as
research analysts on the project. Thank you also to Lisa Hawke and
Susan Dickens for research infrastructure support.
Funding for this pilot study was provided by the Cundill Centre
for Child and Youth Depression. The funders had no role in collecting
or interpreting the information synthesized in this review.
CONFLICT OF INTEREST
The authors have declared that they have no competing or potential
conflicts of interest.
D A T A A V A I LA B I L I T Y S T A T E M E N T
Data available on request due to privacy/ethical restrictions.
E T HI C S S T A T E M E N T
The study was approved by the CAMH and SHSC research ethics
boards.
O R CI D
Darren B. Courtney https://orcid.org/0000-0003-1491-0972
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S U P P O R T I N G I N F O RM A T I O N
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How to cite this article: Courtney, D. B., Cheung, A.,
Henderson, J., Bennett, K., Wang, W., Chen, S., Battaglia, M.,
Strauss, J., Mitchell, R., Wang, K., Relihan, J., Prebeg, M.,
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controlled trial of an Integrated Care Pathway for the
treatment of depression in adolescents. JCPP Advances, 2(2),
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