Can Primary Care Pediatricians Properly Manage Patients With Depression and Anxiety?

While PCPs tend to follow guidelines when prescribing SSRIs, they rarely use screening tools, involve subspecialists in their prescribing decisions, or monitor medication side effects.

Study findings published in Pediatrics suggest that primary care pediatricians (PCPs) who prescribed selective serotonin reuptake inhibitors (SSRIs) for children with anxiety or depression tended to follow guideline recommendations; however, a large percentage of PCPs did not use screening tools, involve a mental health subspecialist in medication decisions, or follow-up on patient progression or medication side effects.

While a PCP is often the first point of contact for many children and adolescents with unmet mental health needs, a survey of PCPs has shown that many are uncomfortable with managing mental health conditions. In addition, comprehensive data regarding how PCPs manage anxiety and depression in their patients are lacking.

The current study was a medical record review of data from the Packard Children’s Healthcare Alliance (PCHA), a community-based network of 25 primary care offices in Northern California. Included in this analysis were patients (N=1685) who had at least 1 contact with their PCP between 2015 and 2021, had a diagnosis of anxiety and/or depression, and had been prescribed SSRIs by a network PCP. Of those who met inclusion criteria, 110 were randomly selected for chart review. The patients were aged 6 to 12 years and had anxiety or depression (n=35), or were aged 12.1-18.9 years and had anxiety (n=25), depression (n=25), or both anxiety and depression (n=25). The outcomes of interest were SSRI indications, referral to a subspecialist, and medication monitoring.

The study cohort comprised 58% girls, 55% were White, 28% had attention-deficit/hyperactivity disorder, 7% autism spectrum disorder, and 5% obsessive-compulsive and related disorders.

These findings encourage subspecialists collaborating with PCPs to make specific therapy recommendations and to ensure that children and adolescents with anxiety and depression on SSRIs receive timely and comprehensive follow-up care.

The average interval between the premedication and medication visits was 148 days and between the medication and postmedication visits was 79 days.

The patients were prescribed sertraline (37%), fluoxetine (30%), escitalopram (26%), or citalopram (7%).

Most cases (82%) had an explicit documentation for SSRI initiation, including clinical change (57%), continuation of an SSRI prescribed by a subspecialist (20%), family preference (5%), therapist suggestion (5%), or inability to access other treatments (1%). The most common reason for SSRI initiation was functional impairment (72%), such as missing school, not participating in sporting activities they previously enjoyed, or impaired eating or sleeping.

Nearly half (46%) of the PCPs documented the severity of the child’s symptoms, but only a quarter (26%) endorsed using a screening tool, such as the Spence Child Anxiety Scale or Patient Health Questionnaire, at the medication visit.

Only about half (53%) of PCPs involved or referred patients to a mental health subspecialist. Among the patients who had subspecialist involvement, 2 had their medication changed by the subspecialist. Only a small percentage of PCPs also referred the patients for unspecified therapy (33%), cognitive behavioral therapy (4%), or other types of therapy (4%).

Overall, only 62% of patients had a follow-up visit. Of the patients who did complete a follow-up visit, there was a large range in time between medication and subsequent visits (1 week to 1 year). This suggests inconsistent approaches to follow-up scheduling. Furthermore, only 48% of patients with a follow-up visit were monitored by PCPs for medication side effects and 34% for suicidality. Finally, only 18% of PCPs endorsed using a screening tool at follow-up.

In the regression analysis, no significant predictors for receiving a follow-up visit or mental health subspecialist referral were identified.

The study authors recommended 3 primary areas of improvement:

  1. PCPs should consider evidence-based therapies, such as cognitive behavioral therapy. A summary of evidence-based treatment should be embedded into order sets for therapy.
  2. Screening tools should be made accessible through electronic health records, as it may help increase the rate of use.
  3. Prepopulating documentation templates with important patient or caregiver interview questions related to the patients’ medication side effects is recommended, as it may increase consistency of gathering related information at follow-up visits.

Researchers noted several study limitations: exclusion of patients with documented anxiety or depression who were not prescribed an SSRI by their PCP; exclusion of patients who only received a prescribed anti-anxiety medication or antidepressant through a subspecialist, not a PCP; reliance on electronic health record review, which may not encompass all counseling or recommendations patients received; and the use of only 1 primary care network for data extraction, which limits the generalizability of the findings.

According to the investigators, “These findings encourage subspecialists collaborating with PCPs to make specific therapy recommendations and to ensure that children and adolescents with anxiety and depression on SSRIs receive timely and comprehensive follow-up care.”

This article originally appeared on Psychiatry Advisor

References:

Lester TR, Herrmann JE, Bannett Y, Gardner RM, Heldman HM, Huffman LC. Anxiety and depression treatment in primary care pediatrics. Pediatrics. Published online April 17, 2023. doi:10.1542/peds.2022-058846