Anxiety and Depression Treatment in Primary Care Pediatrics

BACKGROUND AND OBJECTIVES

Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review.

METHODS

We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices.

RESULTS

At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects.

CONCLUSIONS

When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.

Medication Management of Anxiety and Depression by Primary Care Pediatrics Providers: A Retrospective Electronic Health Record Study

OBJECTIVES

To describe medication management of children diagnosed with anxiety and/or depression by primary care providers within a primary care network.

STUDY DESIGN/METHODS

We performed a retrospective cross-sectional analysis of electronic health record (EHR) structured data from all children seen at least twice in a 4-year observation period within a network of primary care clinics in Northern California. For children who had visit diagnoses of anxiety, depression, anxiety+depression or symptoms characteristic of these conditions, we analyzed the rates and types of medications prescribed. A logistic regression model considered patient variables for the combined sample.

RESULTS

Of all patients 6-18 years old (N = 59,484), 4.4% (n = 2,635) had a diagnosis of anxiety only, 2.4% (n = 1,433) depression only, and 1.2% (n = 737) both anxiety and depression (anxiety + depression); 18% of children with anxiety and/or depression had comorbid ADHD. A total of 15.0% with anxiety only (n = 357), 20.5% with depression only (n = 285), and 47.4% with anxiety+depression (n=343) were prescribed a psychoactive non-stimulant medication. For anxiety and depression only, the top three medications prescribed were sertraline, fluoxetine, and citalopram. For anxiety + depression, the top three medications prescribed were citalopram, sertraline, and escitalopram. Frequently prescribed medications also included benzodiazepines. Logistic regression modeling showed that the depression only and anxety + depression categories had increased likelihood of medication prescription. Older age and mental health comorbidities were independently associated with increased likelihood of medication prescription.

CONCLUSIONS

In this network, ~8% of children carried a diagnosis of anxiety and/or depression. Medication choices generally aligned with current recommendations with the exception of use of benzodiazepines.

What Are the Unique Mentorship Needs of Fourth-Year Medical Students Applying to Pediatrics Residency?

OBJECTIVE

The qualities of good medical school mentors have been well described. However, there is little written about the mentoring needs of medical students applying to pediatrics residency.

METHODS

In order to characterize pediatrics interns' perspectives on the mentorship needs of fourth-year medical students applying to residency, the authors conducted an IRB-approved, qualitative-modified grounded-theory study using a brief survey and semistructured focus groups of pediatric interns in January and February 2018. Two investigators independently coded the focus group transcripts and reconciled codes to develop categories and themes using constant comparison, which were then reviewed by the third author for validation. To further ensure trustworthiness of analysis, participants were asked to comment on the themes' accuracy.

RESULTS

Eighteen pediatrics interns participated, representing 15 medical schools. Four major themes emerged: 1) effective mentors guide medical students to self-reflect and find their own answers about what is important to them in a residency program; 2) multiple mentors are helpful during the residency application process; 3) several key components of advising are often missing during the residency application process; 4) students find it difficult to be honest with their mentors if there is a perceived conflict of interest.

CONCLUSIONS

Medical students applying for pediatrics residency have specific mentorship needs and cite opportunities to improve this area of mentorship. Several key recommendations include utilizing multiple mentors and providing emotional support during the residency application process. In addition, near-peer mentorship is important for medical students applying to residency and should be facilitated by medical schools.