Pediatric primary care providers and adolescent depression: a qualitative study of barriers to treatment and the effect of the black box warning.
OBJECTIVE
The recent black box warning on antidepressants has drawn attention to controversies regarding the treatment of adolescent depression in primary care settings, but little is known about how providers decide to treat depressed youth and what resources are employed.


METHODS
We conducted focus groups with 35 providers and staff in nine community-based pediatric practices in rural and urban settings of western Washington State. Discussion topics included perceived barriers to the treatment of depression in youth, how providers addressed these barriers, and the impact of the recent Federal Drug Administration (FDA) black-box warning. Focus groups were audiotaped and professionally transcribed. Qualitative content analysis was conducted using Atlas ti software and differences in coding were resolved via discussion by three independent reviewers.


RESULTS
Based on analysis of interviews, a conceptual model was developed detailing factors influencing primary care providers' (PCP) decisions about depression treatment. The three key themes that influenced doctors' decisions about treating depression were lack of availability of mental health resources in the community, feeling responsible for helping based on long-standing relationships with patients and families, and patient and family beliefs and preferences regarding treatment. Most of the approaches to address barriers were not systemized and were physician dependent. Most providers expressed concern about recent antidepressant warnings, but many continued to treat and none had developed new strategies for closer monitoring of youth initiating treatment with antidepressants.


CONCLUSIONS
The decision of when and how PCPs decide to treat adolescent depression is strongly influenced by PCP perceptions of their role in treatment, availability of other treatment resources, and family and patient preferences and resources. Few practices have developed changes in the approach to practice needed to meet FDA black-box recommendations regarding close monitoring of response to medications.
Richardson
Laura P
LP
Department of Pediatrics, Child Health Institute, University of Washington School of Medicine, Seattle, Washington 98115, USA. lpr@u.washington.edu
Lewis
Charlotte W
CW
Casey-Goldstein
Mary
M
McCauley
Elizabeth
E
Katon
Wayne
W
D000293:Adolescent; D000928:Antidepressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D002648:Child; D003866:Depressive Disorder / Q000175:diagnosis / Q000188:drug therapy*; D004363:Drug Utilization / Q000592:standards*; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000592:standards; D020380:Needs Assessment; D017063:Outcome Assessment, Health Care; D010372:Pediatrics / Q000379:methods / Q000592:standards*; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000379:methods / Q000592:standards*; D036301:Qualitative Research; D018570:Risk Assessment; D014481:United States; D014486:United States Food and Drug Administration
D000928:Antidepressive Agents