Pediatrician and Family Physician Prescription of Selective Serotonin Reuptake Inhibitors
Authors: Rushton Jerry L. , Clark Sarah J. , Freed Gary L. 
Published: August 2004

Objectives.
Selective serotonin reuptake inhibitor (SSRI) prescriptions for children and adolescents have increased greatly in recent years despite a paucity of demonstrated safety and efficacy data and a lack of clear guidelines for use. Our study sought to describe family physician and pediatrician SSRI prescribing patterns for children and adolescents, identify influences on SSRI prescription variations, and describe the use of SSRI within the overall management of depression and other mental disorders in primary care.

Design.
A survey was mailed to all 596 active North Carolina general pediatricians and a random sample of 557 family physicians in primary care practice. Family physicians who did not see children in their practice were excluded. The survey instrument consisted of a 4-page questionnaire. Survey items included physician demographics, practice characteristics, general management, volume of pediatric patients with depressive symptoms, prescription of SSRIs for depression and other diagnoses, and potential influences on SSRI prescribing practices. The main outcomes were self-reported physician prescription of SSRIs for children and adolescents. Results were analyzed using χ2 comparisons and logistic regression.

Results.
The overall response rate was 66% (55% family physicians and 76% pediatricians). Of the physicians, 72% had prescribed an SSRI for a child or adolescent. Depression was the most common reason for prescribing an SSRI; over two thirds of respondents had prescribed an SSRI for depression in a child 18 years of age or younger. Over half of the physicians reported they had prescribed an SSRI for a diagnosis other than depression in a child 18 years of age or younger. Attention-deficit/hyperactivity disorder was the most frequent use cited other than depression, followed by obsessive–compulsive disorder, aggression, eating disorders, and enuresis.
Primary care physicians prescribed SSRIs for adolescents more commonly than for younger children. Only 6% of the respondents had ever prescribed an SSRI for a child younger than 6 years of age. In terms of SSRI prescriptions written for depression in the last 6 months, 32% of the physicians had recently prescribed SSRIs for adolescent patients and 6% for patients younger than 12 years of age. Family physicians were more likely than pediatricians to have recently prescribed SSRIs for adolescent patients (41% vs 26%), but there was no difference in recent SSRI prescriptions for children &lt;12 years of age by physician specialty (4% vs 6%).
Prescription of SSRIs was not associated with decreased use of counseling for treatment of depression, but prescription of SSRIs was associated with decreased use of referrals (63% vs 74%). There was no difference in the use of counseling between family physicians and pediatricians (61% vs 59%). However, pediatricians were more likely to use referrals in their usual approach to depression (77% vs 48%) compared with family physicians.
More family physicians had prescribed SSRIs for pediatric patients compared with pediatricians (91% vs 58%), and more family physicians had prescribed SSRIs in combination with other psychotropic medications (54% vs 31%). For the majority of respondents, SSRI prescriptions constituted most of the medications used to treat childhood depression (75% of family physicians vs 61% of pediatricians). Family physicians were more likely to report a belief in the safety (63% vs 48%) and effectiveness (40% vs 32%) of SSRIs. Only 8% of physicians reported adequate training in the treatment of childhood depression and just 16% were comfortable with the treatment of depression. There were no specialty differences in training for the treatment of childhood depression; however, more family physicians than pediatricians agreed that they were comfortable with the management of childhood depression (22% vs 11%).
In logistic regression analysis of SSRI prescriptions controlling for physician demographics and practice settings, physicians who were more likely to have prescribed an SSRI for a pediatric patient included: family physicians (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 3.7–11.4), physicians who had limited referral availability (OR: 5.9; 95% CI: 2.2–15.7), physicians comfortable with management of depression (OR: 5.4; 95% CI: 1.8–15.8), and physicians who believed in SSRI safety (OR: 2.4; 95% CI: 1.4–3.9) and effectiveness (OR: 2.9; 95% CI: 1.6–5.3). Factors that were not associated with SSRI prescription rates included parental pressures or fears, constraints of managed care, training experience, year of residency, gender, age, practice type, percentage of Medicaid patients, and percentage of managed care patients.

Conclusions.
Many primary care physicians, especially family physicians, prescribe SSRIs for children and adolescents. SSRIs have become the primary care physician's medication of choice for depressed children and adolescents, and SSRIs are also used for other pediatric diagnoses. Despite concerns of inappropriate uses, a number of primary care practices seem to be reasonable: depression is the most common diagnosis cited, adolescents receive SSRIs more often than younger children, and SSRI use does not seem to be a substitute for counseling. However, it is not clear whether adult treatment practices and preliminary pediatric clinical trials generalize to children and adolescents in primary care. Future pediatric studies need to examine the use of SSRIs to treat attention-deficit/hyperactivity disorder and other diagnoses, safety of combination pharmacotherapy, and outcomes for children treated in primary care. In addition to considerations of potential overuse or inappropriate use of SSRIs, we must conversely evaluate issues of underdiagnosis and undertreatment of mental disorders. The lack of training and comfort of care of pediatric depression and mental illnesses cannot be overlooked. Training and continuing education must improve and change as new pharmacotherapies emerge. Finally, physician specialty differences must be explored further to determine whether differences in physician SSRI prescription practices translate into different health outcomes for children and adolescents with mental illnesses.