It is estimated that 1.9% of primary school children and 4.7% of adolescents are affected by depression; the consequences of depression in this age group can include social dysfunction, academic underachievement and suicidal behavior. Within the last three decades, the recognition of a behavioral component of the primary care of children, coupled with the introduction of managed care and new psychopharmaceuticals, has changed the role of the primary care clinician. Also, while reports of the efficacy and safety of antidepressants in children and adolescents are mixed, their use has dramatically increased in the last decade. It is still unclear, however, how childhood depression and psychiatric disorders fall within the scope of primary care.
To assess the current management of childhood depression in primary care, researchers Jerry L. Rushton, M.D., and colleagues at the University of Michigan conducted a survey of general pediatricians and family physicians in North Carolina. Both groups were surveyed using identical four-page questionnaires designed to assess the patterns of use of four management strategies for childhood depression: medication, referral, counseling and watchful waiting. Adolescent medicine specialists, behavioral pediatricians and medicine-pediatrics physicians were excluded from the study. The mailed survey also gathered information on physician demographics, practice characteristics, general management approaches to depression in children, volume of pediatric patients with depressive symptoms, prescription of selective serotonin reuptake inhibitors for depression, and opinions on the management of depression.
Completed surveys were received from 349 pediatricians and 242 family practitioners. Although the study only collected data from one state, the demographics of respondents were found to be similar to nonrespondents and to other national samples of primary care physicians.
Investigators found that family physicians and pediatricians were similar in their use of both watchful waiting and counseling, while family physicians were more likely to report prescription of medications more often (18% versus 9%;p=0.001) and pediatricians were more likely to report referral more often (77% versus 48%; p0.001). There was no significant difference in the use of referrals between those who did or did not prescribe medications often; in fact, the most common timing for prescription was after referral to a specialist (38%). Selective serotonin reuptake inhibitors (SSRIs) were the antidepressant of choice, comprising 53% of antidepressant prescriptions written by pediatricians and 75% of those written by family physicians (p<0.001).
Researchers also studied the nature of counseling practiced by physicians and how it was integrated into primary care. Very few physicians reported that they conducted dedicated counseling sessions within the medical visit, and the majority referred to a counselor or specialist for this intervention. However, family physicians were more likely to provide counseling in their office (44% versus 27%; p0.001), and pediatricians were more likely to refer patients for counseling (86% versus 63%; p0.001). Physicians used many referral options, including psychologists (90% pediatricians versus 82% family physicians; p=0.005), child psychiatrists (96% pediatricians versus 79% family physicians; p0.001), school counselors (29% both pediatricians and family physicians; p=0.990) and general psychiatrists (22% pediatricians versus 37% family physicians; p<0.001).
When asked about opinions regarding depression, antidepressants and counseling, most physicians reported inadequate training and comfort in these factors influencing the management of childhood depression. Few respondents appeared convinced of the benefits of antidepressants over counseling or of the use of SSRIs in this age group. Family physicians were more likely than pediatricians, however, to report comfort with treatment of childhood depression, belief in the safety of selective serotonin reuptake inhibitors, and lack of referral availability. Pediatricians were more likely to report that depression treatment was too time-consuming for their office schedules.
Family physicians were also more likely to prescribe medications after adjusting for differences in physician demographics, practice setting, physician opinions and other influences. Physician age, year completed residency, practice setting, managed care and Medicaid population, and perceived quality of residency training in childhood depression were not found by investigators to be significantly associated with differences in management. In addition, other factors such as perceived parental pressures for medications and managed care pressures were not associated with differences in management choices.
In discussing the differences in management strategies apparent in the study, investigators explained that, among other factors, family physicians were more confident in the safety and effectiveness of selective serotonin reuptake inhibitors. Pediatricians, on the other hand, reported they had less office visit time available to manage depression in primary care as well as better availability and access to referral specialists.