ANN ARBOR, Mich. - Despite concerns about doctors' potential reliance on medications to treat childhood depression, a new study by University of Michigan researchers finds that most primary care physicians still rely mostly on referral and counseling for their young patients.
However, the study also found that some physicians are indeed using new antidepressants like Prozac for children and adolescents. Primary care physicians varied in their management: Depressed teenagers are more likely to receive Prozac or similar medications if they're being seen by a family physician, rather than a pediatrician.
In general, the study finds that neither kind of primary care doctor hands out anti-depressants like candy; less than 20 percent reported using them often. In fact, a quarter of pediatricians surveyed said they had never prescribed drugs like Prozac, Paxil and Zoloft, known as selective serotonin reuptake inhibitors or SSRIs. The drugs have not been specifically approved for use in depressed children and teens, but their use for this and other disorders is rising amid concerns.
The results, from of a survey of nearly 600 doctors, add new data to the debate over kids and behavior-modifying drugs. The report is published in the new Journal of the Ambulatory Pediatric Association within the April issue of the journal Pediatrics.
"Both types of doctors are on the front lines for spotting depression and steering treatment," says lead author Jerry Rushton, M.D., MPH, a U-M pediatrician and assistant professor. "While there seem to be striking differences between practices by family physicians and pediatricians, we also found an overall lack of self-confidence in handling childhood depression."
In addition, he adds, the reliance on referral to specialists may be cause for concern because many patients don't or can't easily follow their doctors' recommendation to see mental health specialists because of stigma, cost, insurance or availability issues. Pediatricians especially, he says, may need extra training in diagnosing and treating depressed children. And there may be a need for a system to make sure that referred patients actually get the help they need.
Approximately 5 percent of children and adolescents may suffer from depression, which if left untreated can lead to suicide or more severe depression in adulthood. The symptoms, including a persistent sad or irritable mood, loss of interest in previously enjoyed activities, and difficulty sleeping or oversleeping, are often mistaken as part of the normal course of growing up. But if the disorder is spotted early, treatments like psychotherapy, medications and changes in the home or school environment are believed to help a large percentage of patients.
Rushton's study, performed while he was at the University of North Carolina, used a survey questionnaire sent to more than 1,000 pediatricians and family physicians practicing in that state. The work was supported by the Robert Wood Johnson Clinical Scholars Program. It is the first study to look at the use of SSRIs from the primary care physician point of view, rather than reviewing SSRI prescriptions by all types of doctors.
The survey form asked physicians about how many depressed young patients they had seen in the past six months, how they had typically managed most cases, and why they had chosen those options or combinations of options. It also asked about their other uses of SSRIs, including for eating disorders and attention deficit hyperactivity disorder. And, it requested that doctors report their general attitudes toward treating depression, including their own training and comfort level, the impact of managed care insurance on their management of depression and their overall feelings about the effectiveness of SSRIs.
A total of 591 eligible surveys were returned and analyzed. Though the respondents were self-selected and from one state, Rushton feels that the results indicate at least general trends.
"These physicians represent a typical cross-section of American family physicians and pediatricians, who are increasingly being asked to deal with mental health issues in their own practice due to managed care, lack of access to pediatric mental health specialists, or other factors," Rushton says. "We wanted to describe the current state of SSRI use and depression management, without making value judgements about the different options. The results signal the need for more research, and for more discussion of how primary care doctors are being equipped to recognize and treat childhood depression."
In all, more than 85 percent of pediatricians said they often refer patients for specialty care when they exhibit depressive symptoms, compared with 63 percent of family physicians. Specialists included psychologists, general and child psychiatrists, and school counselors. A small percentage of both types said they also often counsel patients themselves or engage in "watchful waiting", though time limits on office visits were seen as a limit on these practices.
But when it came to prescribing SSRIs or their older cousins, tricyclics, family physicians diverged from pediatricians. Twenty-eight percent of family physicians said they sometimes recommended SSRIs before sending their patients to a specialist, while only 6 percent of pediatricians reported this practice. Both types were more likely to prescribe the drugs after referral, yielding a total percentage of 38 percent.
There were also differences in factors that influence management of depressed patients. Pediatricians were two times less likely to say they are comfortable with treating childhood depression, and twice as likely to say that managing it is too time-consuming for them.
Doctors' own confidence in their ability to treat depression seems to make a difference in the use of SSRIs: those who reported they were comfortable with managing childhood depression were three times more likely to prescribe the drugs before referral.