What is Role of primary care paediatricians in appropriate treatment of anxiety/depression in youth?

In a recent study published in the journal Pediatrics, the researchers have described paediatricians' work for children and adolescents with depression or anxiety. Reviewing electronic health records from an extensive practice network in northern California, they found that when prescribing selective serotonin reuptake inhibitors (SSRI) in this pediatric population, PCPs generally follow clinical practice guidelines. They often prescribe medication without subspecialist involvement. 

"Continuing medical education for paediatricians who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects," the researchers wrote in their study. The findings highlight that paediatricians can appropriately provide evidence-based care for these conditions.

Paediatricians must be the frontline providers for common disorders such as depression and anxiety. Primary care paediatricians are critical in managing child and adolescent anxiety and depression. Their role is further amplified by the limited workforce of psychiatric, psychologists, and other mental health care providers.

Against the above background, Talia R. Lester, Division of Developmental Behavioural Pediatrics, Department of Pediatrics, and colleagues aimed to describe PCP care practices around prescribing SSRI for depression and anxiety using medical record review.

The team identified 1685 patients having at least one visit diagnosed with anxiety/depression in an extensive primary care network and were prescribed an SSRI by a network PCP. One hundred ten were randomly selected for chart review. The visit was reviewed when the SSRI was first prescribed (medication visit), subsequent visit, and immediately previous visit. The rationale was abstracted for subspecialist involvement, prescribing medication, monitoring practices, and referral for psychotherapy.

The study revealed the following findings:

• At the medication visit, in 82% of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%).
• Thirty percent of patients had documented involvement of developmental-behavioural paediatrics or psychiatry subspecialists at 1 of the three visits reviewed.
• Thirty-three percent were referred to unspecified psychotherapy; 4% were explicitly referred for cognitive behavioural therapy.
• Of 69 patients with a subsequent visit, 48% had documentation of monitoring for side effects.

"When first prescribing SSRIs for children with anxiety/depression, paediatricians documented rationales for medication and often prescribed independently, without subspecialist involvement, but did not monitor medication side effects systematically," the researchers wrote. "A minority recommended psychotherapy and rarely specified evidence-based psychotherapy."

"These findings encourage subspecialists collaborating with PCPs to make specific therapy recommendations and to ensure that pediatric patients with depression and anxiety on SSRIs receive timely and comprehensive follow-up care," they conclude.

Reference:

Talia R. Lester, Jessica E. Herrmann, Yair Bannett, Rebecca M. Gardner, Heidi M. Feldman, Lynne C. Huffman; Anxiety and Depression Treatment in Primary Care Pediatrics. Pediatrics 2023; e2022058846. 10.1542/peds.2022-058846