title: Antidepressant Prescribing by Pediatricians: A Mixed-Methods Analysis.
abstract: Among pediatricians, perceived knowledge of efficacy, tolerability, dosing, and side effects of antidepressants represent significant sources of variability in the use of these medications in youth with depressive and anxiety disorders. Importantly, the qualitative factors that relate to varying levels of comfort with antidepressants and willingness to prescribe are poorly understood. Using a mixed-methods approach, in-depth interviews were conducted with community-based and academic medical center-based pediatricians (N = 14). Interviews were audio recorded and iteratively coded; themes were then generated using inductive thematic analysis. The relationship between demographic factors, knowledge of antidepressants, dosing, and side effects, as well as prescribing likelihood scores for depressive disorders, anxiety disorders or co-morbid anxiety and depressive disorders, were evaluated using mixed models. Pediatricians reported antidepressants to be effective and well-tolerated. However, the likelihood of individual physicians initiating an antidepressant was significantly lower for anxiety disorders relative to depressive disorders with similar functional impairment. Pediatricians considered symptom severity/functional impairment, age and the availability of psychotherapy as they considered prescribing antidepressants to individual patients. Antidepressant choice was related to the physician׳s perceived knowledge and comfort with a particular antidepressant, financial factors, and the disorder-specific evidence base for that particular medication and consultation with mental health practitioners. Pediatricians noted similar efficacy and tolerability profiles for antidepressants in youth with depressive disorders and anxiety disorders, but tended to utilize "therapy first" approaches for anxiety disorders relative to depressive disorders. Parental and family factors that influenced prescribing of antidepressants by pediatricians included parental ambivalence, family-related dysfunction and impairment secondary to the child׳s psychopathology as well as the child׳s psychosocial milieu. Pediatricians consider patient- and family-specific challenges when choosing prescribing antidepressant medications and are, in general, less likely to prescribe antidepressants for youth with anxiety disorders compared to youth with depressive disorders. The lower likelihood of prescribing antidepressants for anxious youth is not related to perception of the efficacy or tolerability, but rather to a perception that anxiety disorders are less impairing and more appropriately managed with psychotherapy.
authors.affiliation: Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH.
authors.forename: Anne K
authors.initials: AK
authors.lastname: Tulisiak
authors.affiliation: Department of Pediatrics Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Jillian A
authors.initials: JA
authors.lastname: Klein
authors.affiliation: Division of Child & Adolescent Psychiatry, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH.
authors.forename: Emily
authors.initials: E
authors.lastname: Harris
authors.affiliation: Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH.
authors.forename: Marissa J
authors.initials: MJ
authors.lastname: Luft
authors.affiliation: Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH.
authors.forename: Heidi K
authors.initials: HK
authors.lastname: Schroeder
authors.affiliation: Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Mossman
authors.affiliation: Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH.
authors.forename: Sara T
authors.initials: ST
authors.lastname: Varney
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, UT.
authors.forename: Brooks R
authors.initials: BR
authors.lastname: Keeshin
authors.affiliation: Department of Family and Community Medicine, University of Cincinnati, College of Medicine, Cincinnati, OH.
authors.forename: Sian
authors.initials: S
authors.lastname: Cotton
authors.affiliation: Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH; Division of Child & Adolescent Psychiatry, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Strawn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001008:Anxiety Disorders / Q000188:drug therapy*; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D003866:Depressive Disorder / Q000188:drug therapy*; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006302:Health Services Research / Q000379:methods; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D000072143:Pediatricians / Q000523:psychology; D010865:Pilot Projects; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D014481:United States
chemical_list: D000928:Antidepressive Agents