Editorial: Pragmatic Precision Child Psychiatry: An Opportunity to Advance Quality of Child Mental Health Care.

The quality of publicly funded child mental health care is chronically poor. In this edition of the Journal, the largest study to date examining antidepressant medication adherence among US Medicaid-enrolled youth both validates prior concerns and prompts a critical examination of how we assess the quality of child mental health care. The study by Fontanella et al. is a retrospective longitudinal cohort study of 196,364 youth aged 9 to 24 years with a new episode of major depression who were prescribed antidepressant medication.1 The analysis used Medicaid claims data from 46 states and the District of Columbia, spanning January 1, 2016, to February 28, 2019. The study design is rigorous, with clearly defined time intervals for pretreatment and treatment periods and a requirement for continuous enrollment. The authors applied a well-established method to identify new episodes of depression and used study variables that reflect real-world clinical workflows (eg, ≤60 days for the first antidepressant prescription after diagnosis), as well as reasonable thresholds for gaps between prescription fills (acute: ≤30 days; continuation: ≤51 days). Consistent with the Healthcare Effectiveness Data and Information Set (HEDIS) quality measure for antidepressant medication management, the main outcomes were as follows: (1) the total days' supply of filled antidepressant prescriptions during the acute (12 weeks) and continuation (6 months) phases; and (2) at least 3 outpatient visits during the acute phase. Independent variables included sociodemographic and clinical characteristics from the 180 days prior to study entry. Using the county of residence, data were also linked to the Social Vulnerability Index-a composite of 16 social determinants of health-and categorized into quartiles to rank probable youth social vulnerability. During the acute phase, approximately half (49.6%) of the youth met criteria for antidepressant medication adherence, and 55.2% had at least 3 outpatient mental health visits. By 6 months, only 26.5% had likely received continuous antidepressant treatment. Young adults (aged 18-24 years), youth from minoritized racial/ethnic groups, and individuals who had 1 inpatient or 2 outpatient substance use disorder claims had lower odds of adherence compared to younger youth (aged 9-13 years), those who were White and non-Hispanic, and those who had no psychiatric comorbidities. Together, these findings signal poor quality and persistent disparities in depression care among US Medicaid-enrolled youth.