Primary care providers' initial treatment decisions and antidepressant prescribing for adolescent depression

Adolescent depression is a serious public health problem which is under-recognized as well as undertreated.1 The primary care setting may be a key place where adolescent mental health concerns can be addressed. Most adolescents have a usual place of health care,2 and up to one-third of adolescents presenting to primary care have an emotional problem, with 14% screening positive for depression.3, 4 Furthermore adolescents with mental health problems more frequently visit their primary care provider (PCP) than do adolescents without mental health problems.5 Understanding how PCPs make treatment decisions for depressed adolescents and identifying the factors that influence these decisions may help increase the initiation of depression treatment in the primary care setting. Current PCP guidelines for adolescent depression recommend active support and monitoring (or watchful waiting) for mild depression, and cognitive behavioral therapy (CBT) and/or selective serotonin reuptake inhibitors (SSRIs) for moderate or severe depression.6-8 CBT is recommended for first-line treatment in the primary care setting,9 especially for moderate depression which may respond to CBT alone.7, 8 SSRIs, which show a greater benefit for lowering depressive symptoms for severely depressed teens compared with moderate or mildly depressed teens, are the first-line treatment for patients with a severe major depressive disorder diagnosis with or without psychotherapy.7, 10 A mental health consultation is also strongly encouraged for severely depressed teens.7 Of note, a recent systematic review and meta-analysis found limited evidence for the effectiveness of antidepressants in children and adolescents, especially at follow-up,11 and there are a small number of trials with positive findings.12 However, many factors beyond treatment guidelines influence PCPs’ treatment decisions for adolescent depression, such as structural barriers to care including poor access to mental health specialists, insurance barriers, and insufficient training in depression management.13 For families in many parts of the United States, access to specialty pediatric mental health care is characterized by long waits for appointments associated with an insufficient and poorly distributed mental health workforce, particularly child psychiatrists.14-16 Many pediatric PCPs lack training in the treatment of depression, and therefore, may lack confidence to prescribe antidepressants independently.17-19 Indeed, studies suggest that only one quarter of pediatric PCPs had recently independently prescribed an SSRI for an adolescent.17, 19 PCPs are particularly likely to refer patients to mental health specialists when symptoms are severe,20, 21 and due to discomfort with prescribing antidepressants,17, 18, 22 may prefer to refer a more severely depressed adolescent to child psychiatry for medication management as opposed to initiating medication themselves. While prior studies have examined PCP treatment decisions for adolescent depression, in many cases structural barriers may have dominated PCP decision-making, reducing the ability to study other PCP-level factors that influence treatment decisions for depressed adolescents. For this reason, we sought to examine this issue in a practice environment with fewer structural barriers due to frequent access to on-site mental health therapists, PCP training in depression diagnosis and management, and communication between PCPs and mental health providers through an integrated electronic health record. The current work addresses this gap by examining PCP beliefs about adolescent depression treatment in a setting with few structural barriers, allowing a clearer perspective on the impact of PCP characteristics and beliefs on their intentions. We examined PCPs’ initial treatment decisions using adolescent depression scenarios, assessing the impact of depression severity and other related factors on these treatment decisions. These other factors were exploratory due to limited research in this area. We hypothesized that PCPs would be sensitive to the severity of adolescent depression, and would alter treatment decisions based on the clinical information available in structured vignettes. We also hypothesized that PCPs with better knowledge of depression and more positive attitudes toward managing psychosocial problems would be more likely to prescribe antidepressants.