Half of all lifetime mental illnesses start by 14 years of age,1 emphasizing the critical role that primary care pediatricians have in identifying and treating mental and behavioral health disorders. The role of pediatricians is further amplified by the limited workforce of psychologists, psychiatrics, and other mental health care providers. Pediatricians must be the frontline providers for common disorders such as anxiety and depression.
In this issue of Pediatrics, Lester et al2 describe the work that pediatricians are doing for children and adolescents with anxiety or depression. Their conclusions are compelling. Reviewing electronic health records from a large practice network in northern California, the authors found that pediatricians generally followed clinical practice guidelines for prescribing selective serotonin reuptake inhibitor medication to children with anxiety and/or depression. The findings by Lester et al. highlight that pediatricians can appropriately provide evidence-based care for these conditions.
Several observations offer an optimistic perspective. The pediatricians documented that approximately 1 in 10 patients had challenges in accessing mental health care services and other recommended treatment. Given the national mental health crisis and challenges with access to care,3 this study suggests that these pediatricians are aware that they must fill the access gap in mental health services. Second, pediatricians are making medication decisions consistent with subspecialty practice. Of the cases who had documentation of a subspecialist involvement after medications were started by the pediatrician, only a small number (n = 2) had documentation of the subspecialist adjusting medications. The low rate of medication changes by the subspecialist is encouraging because it validates the pediatricians’ decisions. Third, standardized screening tools were used to assess and manage the care for 26% of the patients followed and symptom severity was documented in some way for nearly half of the patients. Finally, 82% of patients had a documented reason for starting medication, with the most common reason (57%) being clinical change including the failure for symptoms to improve, worsening symptoms, high symptom severity, or functional impairment. Pediatricians are especially well-positioned, knowing their patients over time, to make decisions about therapeutic changes and to identify the emergence of functional impairment.
Despite these encouraging findings, there were also deviations in management from best practice care. Notably, pediatricians did not consistently document issues related to nutrition, sleep hygiene, and exercise, and rarely counseled patients on the potential pitfalls and limitations of complementary and alternative medicine approaches to treating anxiety or depression. Pediatricians can help guide patients and their caregivers on important dimensions of physical health in the context of mental health care. Not addressing these factors within the context of primary care pediatrics is a lost opportunity and should be viewed as a chance for quality improvement.
Other important concerns included pediatricians’ inconsistent practices in follow-up and monitoring of medication side effects, limited care coordination and collaborative care with subspecialists as well as psychosocial providers, and the lack of recommending evidence-based treatments when referring for psychological therapy.
The most concerning limitations of the pediatricians’ healthcare delivery was their lack of referral for evidence-based psychological treatments and the related low referral rates for accessing support from schools through the special education 504 Plan and Individualized Education Plan processes. Lester et al highlight that one possible strategy to address these gaps is to provide a summary of evidence-based recommendations embedded into the electronic medical record order sets.4
Can we ask more of our primary care pediatricians than simply forwarding a comment in the electronic medical record to a collaborating mental health subspecialist? The more pediatricians know about effective psychosocial treatment of anxiety and depression, the more they can educate patients and caregivers on the type of treatment they need to pursue. For example, cognitive behavioral therapy can improve symptoms of depression and break the cycle of avoidance that worsens symptoms of anxiety.5 Interpersonal Psychotherapy for Adolescents is a 12-session treatment that can also address depression by improving patients’ personal relationships.6 Understanding these treatments and educating patients and caregivers about them can facilitate linkage of patients to treatments that work in combination with the medications being prescribed.
No primary care pediatrician will have the training or time to implement the many treatments that are available. However, pediatricians can work to understand the key features of the evidence-based treatments referenced by Lester et al. Pediatricians can also use basic therapeutic communication tools, such as motivational interviewing7 for aspects of anxiety and depression care that pediatricians are uniquely qualified to address such as sleep hygiene, exercise, and nutrition.
This study notes that there are systematic care model innovations that can be helpful. The growth of behavioral health services integrated within primary care pediatric practices is transforming how anxiety and depression can be treated.6 Additionally, the availability of telemedicine and other apps for interventions such as cognitive behavioral therapy offer new ways to supplement treatment provided in primary care. The use of health coaches or care navigators to help monitor treatment response, increased continuing medical education for primary care pediatricians on mental health topics, and the proliferation of additional patient-centered resources about anxiety and depression can be helpful. The children’s mental health crisis requires all child-serving health care providers to do more. Improved care for anxiety and depression in pediatric primary care is needed and does not have to be overly burdensome to pediatricians.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-058846.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The author has indicated he has no conflicts of interest to disclose.