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While primary care pediatricians (PCPs) who prescribe selective serotonin reuptake inhibitors (SSRIs) for the management of anxiety and depression in children and adolescents largely follow clinical practice guidelines, they often do not consult with mental health subspecialists, a study showed.

Looking at 110 patients in a large primary care network, PCPs explicitly stated a reason for starting an SSRI medication in 82% of these patients, with clinical change listed as the reason in 57% of cases, including failure to improve, worsening symptoms, high severity, or functional impairment, reported Lynne C. Huffman, MD, of Stanford University School of Medicine, in Palo Alto, California, and colleagues.

Of note, PCPs documented either subspecialist (developmental behavioral pediatrics or psychiatry) involvement or referral to a mental health subspecialist in 53% of patients, while 33% of patients had documented subspecialist involvement in at least one of three visits, they noted in .

"Anxiety and depression are common in pediatric patients," co-author Talia Lester, MD, also of Stanford University, told MedPage Today in an email. "We know that there is a shortage of mental health specialists. Concerns about difficulty accessing mental healthcare for children have intensified over the past several years. It is important to understand how pediatricians are managing patients with anxiety and depression."

"We were surprised at the high rate of patients that did not have documented involvement of a mental health subspecialist," she added. "This is not necessarily concerning. In fact, we believe it indicates that pediatricians are rising to the challenge of caring for children with anxiety and depression."

Functional impairment, including problems with academics (e.g., missing school), community functioning (e.g., not participating in previously enjoyed sports activities), eating, and sleep, was the most commonly documented factor for initiation of an SSRI (72%).

At the medication visit -- when the SSRI was first prescribed -- PCPs referred the patient for unspecified therapy in 33% of cases, and for cognitive behavioral therapy (CBT) in 4% of cases.

Furthermore, 62% of patients had a subsequent visit. Of these patients, PCPs documented monitoring for medication side effects in 48% and for suicidality in 34%.

"There were a few areas for improvement where we may be able to better support pediatricians in providing care to children with anxiety and depression," Lester noted. "The rates of medication follow-up visits and documented monitoring for side effects was lower than expected. It is very important for clinicians to monitor patients closely when prescribing SSRI medications."

"When they refer patients for therapy, we recommend for clinicians to specify evidence-based treatments," she said, adding that CBT "is the specific type of therapy that has the most evidence for use in children."

"There was also a lower rate of use of standardized anxiety and depression assessment tools than expected," Lester said. "Future study is needed to see how we can make the use of standardized tools more accessible to clinicians."

In a , Eric Butter, PhD, of Nationwide Children's Hospital in Columbus, Ohio, wrote that "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" mentioned by Huffman and colleagues.

He said that pediatricians can also use therapeutic communication tools, and that the study pointed out that there are systemic care model innovations that can help.

"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," Butter wrote. "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 healthcare providers to do more," Butter concluded. "Improved care for anxiety and depression in pediatric primary care is needed and does not have to be overly burdensome to pediatricians."

For this study, Lester and colleagues identified 1,685 patients who had at least one visit with a diagnosis of anxiety and/or depression and were prescribed an SSRI by a PCP. They randomly selected 110 patients for chart review and looked at the visit when the SSRI was first prescribed, as well as the immediate previous visit and the immediate subsequent visit.

Of the 110 patients, 68% were 12 to 18 years old at first visit for anxiety or depression, 58% were girls, 55% were white, 12% were Hispanic, 4% were Black, and 6% were Asian.

Of this group, 28% had attention-deficit or hyperactivity disorder, 7% had autism spectrum disorder, 4% had eating disorders, 3% had sleep disorders, and 2% had gender dysphoria.

The mean interval between previous visit and medication visit was 148 days, while the mean interval between medication visit and subsequent visit was 79 days.

Huffman and colleagues noted several limitations to their study. First, they focused solely on cases in which the PCP wrote a prescription for an SSRI, and not on those who did not receive medication or whose medication was prescribed only by a subspecialist. Additionally, they relied on electronic health record review, and aspects of decision making, recommendations, and counseling during the visit that were not included in patient notes were not captured.

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