With the epidemic of anxiety and depression, primary care pediatricians are often the only ones available to establish the diagnosis and begin treatment. How well do pediatricians do with following clinical practice guidelines for medication use? Do they refer or consult mental health specialists for help in designing an appropriate pharmacologic and/or nonpharmacologic treatment plan?
Lester et al (10.1542/peds.2022-058846) from Stanford University share with us an analysis of 110 chart reviews of patients with anxiety and depression randomly selected from a cohort of 1,685 patients in a northern California primary care network who were started on a serotonin reuptake inhibitor medication (SSRI) by their pediatrician. The authors looked at the immediate past visit prior to starting an SSRI, the visit where the medication was prescribed and the following visit to determine whether the chart indicated a rationale for starting the medication, whether consultation or referral to a mental health specialist occurred, and if there were monitoring of the medication for side-effects—all suggested as important steps in clinical practice guidelines for primary care pediatricians who wish to treat anxiety or depression in their patients.
Most pediatricians in this study (82%) documented why they initiated an SSRI. Only 30% noted involvement of a subspecialist in making the decision to initiate treatment, 33% referred to a subspecialist for additional nonpharmacologic therapy (type unspecified except for 4% specifically referring for cognitive behavioral therapy). About half (48%) documented that side effects were monitored.
What are the implications of these findings? To answer that we invited psychologist Dr. Eric Butter from Nationwide Children’s Hospital (10.1542/peds.2022-060877) to share his thoughts in an accompanying commentary. While Dr. Butter notes that it is great to see the majority of pediatricians in this study following clinical practice guidelines, he highlights the circumstances pediatricians in which the guidelines are not followed and opportunities for clinician education. He also reminds us to monitor side effects of these medications and supports the recommendation of Lester et al to consider embedding practice guideline recommendations into electronic health record order sets.
While more practices are integrating mental and behavioral health care specialists directly into their practices rather than refer patients onto long waiting lists, this study and commentary are a terrific way to understand the important role primary care pediatricians can play in treating depression and anxiety when the mental health system is not available. Link to the study and commentary and learn more.
