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Research Letters
July 2012

Providing Depression Care in the Medical Home: What Can We Learn From Attention-Deficit/ Hyperactivity Disorder?

Author Affiliations

Author Affiliations: Departments of Pediatrics (Drs Garbutt, Sterkel, and Strunk and Mss Leege and Gentry) and Medicine (Dr Garbutt), Washington University, and St Louis Children's Hospital (Dr Sterkel), St Louis, Missouri.

Arch Pediatr Adolesc Med. 2012;166(7):672-673. doi:10.1001/archpediatrics.2011.1565

Although many primary care providers (PCPs) are reluctant to manage adolescent depression,1 they commonly provide care for children with attention-deficit/hyperactivity disorder (ADHD).1,2 We sought to describe differences in care for these common diseases to identify opportunities to improve depression care.

Methods

Primary care providers from the St Louis, Missouri, area completed a 29-item, self-administered, mailed questionnaire (eAppendix). Questions assessed attitudes toward and behaviors regarding screening, diagnosis, and management of depressed adolescent patients. Four-point categorical scales were used to indicate agreement with attitudinal statements and confidence in delivery of depression care. Respondents also agreed or disagreed with statements about care for depression and ADHD. The Washington University Human Research Protection Office approved the study.

Results

Of the respondents (100 pediatricians, 4 pediatric nurse practitioners, 45% response), 96% wanted to improve the care they provided and 47% agreed (strongly agree or agree) that adolescent depression should be cared for in the medical home. The PCPs cared for few of their depressed patients (median, 5%; interquartile range [IQR], 0%-25%), although many reported frequent problems accessing high-quality psychiatric care (83%) and psychotherapy (46%). Patients were identified by parental (median, 50%; IQR, 10%-88%) or patient (median, 30%; IQR, 0%-70%) concern; only 4% of PCPs used a validated screening tool at annual visits. The PCPs lacked confidence (not very or not confident) in interpreting screening tools (43%), assessing suicide risk (37%), providing supportive counseling (60%), and monitoring treatment response (39%), and 74% suggested additional training was needed.

In contrast, PCPs cared for almost all their patients with ADHD (80%; IQR, 70%-90%) and felt adequately trained and confident to do so (Table). The difference in agreement that easy-to-use guidelines are available for these 2 disorders is notable.

Table. PCP Beliefs About Providing Mental Health Care for Depression and ADHD
Table. PCP Beliefs About Providing Mental Health Care for Depression and ADHD
Table. PCP Beliefs About Providing Mental Health Care for Depression and ADHD

The majority felt effective safe treatments were available for ADHD and depression. Although 67% prescribed selective serotonin reuptake inhibitors, 65% were reluctant because of concern about the black box warning (40%), unfamiliarity with use (29%), and fear of litigation (24%).

Comment

Although the PCPs in this survey overwhelmingly wanted to improve the care they provided for their depressed adolescents, the extent of care they provided currently was quite limited. They preferred to refer their depressed patients to mental heath specialists rather than provide care themselves (although access is clearly limited) and were reluctant to prescribe selective serotonin reuptake inhibitors (although they believe them to be safe and effective). Lack of confidence to recognize and manage depression and inadequate training were previously reported1,3 and likely reduce PCPs willingness to follow recent recommendations to screen all adolescents for depression.4

In contrast, most PCPs in this and other studies were confident in their ability to identify and manage children with ADHD without the help of mental health professionals.3 Acceptance of the responsibility to provide ADHD care seems to have been accomplished by increasing awareness of the national guidelines published and promulgated by the American Academy of Pediatrics that encouraged PCPs they can and should provide this care, and availability of easy-to-use tools to aid diagnosis and treatment monitoring, and effective treatments.3,5 Thus, it appears that a similar transition for depression care will require active promotion of national treatment guidelines by the American Academy of Pediatrics together with encouragement for PCPs to provide care for depression, education about how to use tools designed to aid diagnosis and treatment monitoring in the primary care setting (such as the Patient Health Questionnaire 9),6 and system changes to support timely access to mental health professionals when needed as well as improved reimbursement for time spent.

Although these data may not be generalizable because the study sample was small and from one geographical location, study findings and experience with ADHD suggest that such efforts would be welcomed by many PCPs and effective.

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Article Information

Correspondence: Dr Garbutt, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8116, St Louis, MO 63110 (jgarbutt@dom.wustl.edu).

Author Contributions: Dr Garbutt had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Garbutt, Leege, Sterkel, Gentry, and Strunk. Acquisition of data: Garbutt, Leege, Gentry, and Strunk. Analysis and interpretation of data: Garbutt, Leege, Sterkel, and Strunk. Drafting of the manuscript: Garbutt and Leege. Critical revision of the manuscript for important intellectual content: Garbutt, Leege, Sterkel, Gentry, and Strunk. Statistical analysis: Garbutt and Leege. Administrative, technical, and material support: Leege and Gentry. Study supervision: Garbutt, Gentry, and Strunk.

Financial Disclosure: None reported.

Funding/Support: This publication was made possible by grant UL1 RR024992 from the National Center for Research Resources, a component of the National Institutes of Health and National Institutes of Health Roadmap for Medical Research.

Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or National Institutes of Health Roadmap for Medical Research.

References
1.
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2.
Leslie LK, Wolraich ML. ADHD service use patterns in youth.  J Pediatr Psychol. 2007;32(6):695-710PubMedArticle
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Stein RE, Horwitz SM, Storfer-Isser A, Heneghan A, Olson L, Hoagwood KE. Do pediatricians think they are responsible for identification and management of child mental health problems? results of the AAP periodic survey.  Ambul Pediatr. 2008;8(1):11-17PubMedArticle
4.
US Preventive Services Task Force.  Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement.  Pediatrics. 2009;123(4):1223-1228PubMedArticle
5.
American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement.  Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder.  Pediatrics. 2001;108(4):1033-1044PubMedArticle
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Richardson LP, McCauley E, Grossman DC,  et al.  Evaluation of the Patient Health Questionnaire–9 Item for detecting major depression among adolescents.  Pediatrics. 2010;126(6):1117-1123PubMedArticle
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