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How one primary care network used SSRIs for child anxiety, depression

April 18, 2023

Primary care pediatricians (PCPs) in one large network who prescribed selective serotonin reuptake inhibitors (SSRIs) for anxiety and/or depression generally followed clinical practice guidelines but could make improvements, according to a new study.

Many PCPs are uncomfortable managing mental health conditions, but guidelines recommend they initiate treatment for children and adolescents with these conditions and partner with subspecialists in severe or complex cases.

The study, “Anxiety and Depression Treatment in Primary Care Pediatrics,” (Lester TR, et al. Pediatrics. April 17, 2023) found pediatricians documented appropriate indications for starting the medication and prescribed it independently. However, 47% of the patients taking SSRIs did not have documented subspecialist involvement, nor were they referred to a mental health subspecialist.


Researchers identified 1,685 patients ages 6 to 18 years who had been diagnosed with anxiety and/or depression; were seen in at least one visit between 2015 and 2021; and were prescribed an SSRI. Of these, 110 patient charts were randomly reviewed.

All of the patients were from a network of 25 primary care offices in the San Francisco Bay area. Of the children and teens, 58% were female, 60% had private insurance, 55% were White and 64% were non-Hispanic.

Researchers analyzed the visit when the SSRI first was prescribed (“medication visit”), and the visits immediately before and after it. They evaluated documentation about the reason for the prescription, the medications used, involvement of subspecialists, referral for psychotherapy and follow-up monitoring for potential adverse side effects.

Study results

The pediatricians documented why they started medication for 82% of the patients, with “clinical change” the most commonly cited (57%) reason. This was due to failure to improve, worsening symptoms, high severity or, in the majority of cases, functional impairment (issues like missing school, community functioning issues such as not participating in previously enjoyed sports, and concerns about eating or sleeping). In 20% of patients, PCPs prescribed the medication as a continuation after a subspecialist initiated it.

PCPs documented the involvement of subspecialists or referrals to a mental health specialist in 53% of patients. Thirty percent of the patients had involvement of developmental-behavioral pediatrics or psychiatry subspecialists at one of the three visits; 33% were referred to unspecified psychotherapy; and 4% for cognitive behavioral therapy (CBT).

Pediatricians counseled patients about other factors, including nutrition, sleep hygiene and exercise but did not consistently document those discussions.

The study also found that PCPs used a screening tool in 26% of patients, which is in line with other survey findings.

At the medication visit, behavioral or mental health conditions were found to coexist in nearly half of cases, with attention deficit/hyperactivity disorder (28%) most common. The most prescribed medications were sertraline (37%), fluoxetine (30%), and escitalopram (26%).

However, of 69 patients with a subsequent visit, less than half (48%) were monitored for side effects, as evidenced in the health record.

Areas for improvement

Researchers identified three areas for improvement:

  • Embed a summary of evidence-based treatment into order sets for therapy. The study found PCPs often referred patients for unspecified therapy but rarely prescribed evidence-based therapies such as CBT.
  • Monitor for medication side effects in a systematic manner.
  • Make screening tools accessible through the electronic health record to help increase their use.

Pediatricians “must be the frontline providers for common disorders such as anxiety and depression,” wrote an author of a related commentary. “The findings by Lester et al. highlight that pediatricians can appropriately provide evidence-based care for these conditions.”

Additional suggestions in the commentary include increasing referral rates for accessing support from schools; employing more therapeutic communication tools such as motivational interviewing; and accessing innovations such as health coaches and care navigators, integrated behavioral health services within practices, and telemedicine and other apps for interventions.

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