Interventions for pediatricians only partially successful

Continuing medical education, newsletters and resource guides were only partially successful in changing the way that pediatricians handled behavioral health problems, according to a follow-up study at Wake Forest University School of Medicine.

But external factors, especially “black box warnings” from the U.S. Food and Drug Administration “exerted a powerful effect on prescribing practices,” said Jane Williams, Ph.D., and colleagues, writing in the June issue of Clinical Pediatrics . So did the changes in the public mental health system brought about by North Carolina's mental health reform.

In 2004, the same group reported in Pediatrics that pediatricians were diagnosing and treating growing numbers of children with behavioral health problems – about 15 percent of the children they see – but did not always feel sufficiently trained to fill this new role.

This year, Williams and her colleagues went back to 42 primary care pediatricians they had originally interviewed in 2002-03 to find out which of a series of what they called “structured interventions” worked.

The structured interventions “focused on recognition, treatment and referral of children with behavioral health problems,” Williams said. They included a quarterly newsletter, Pediatric Mental Health Connections, a Mental Health Resource Guide consisting of information about community mental health providers, quarterly collaborative behavioral health “rounds,” and three continuing education workshops covering screening children for developmental and behavioral problems and diagnosing and treating depression.

Williams noted that the structured interventions “focused on increased education in areas requested by the pediatricians, especially recognition of anxiety and depression, increased awareness of community mental health providers, increased communication between pediatricians and mental health providers, and use of a community protocol for attention deficit hyperactivity disorder (ADHD).”

She said the interventions were associated with:

• A significant increase in the use of community social workers for mental health referrals.
• Collaboration with mental health providers concerning patient care.
• Use of a common measure for the diagnosis of ADHD.

ADHD remained the behavioral problem most often diagnosed by the pediatricians, who continued to have a high degree of confidence in treating ADHD with stimulants.

The level of pediatricians who said they used a class of drugs called SSRIs (selective serotonin reuptake inhibitors) “frequently or occasionally” plummeted from 52 percent to 26 percent after the FDA warning that use of the drugs might increase suicidal behavior.

In the interviews, 88 percent of the pediatricians said they read the Pediatric Mental Health Connections, 79 percent used the resource guide, 31 percent participated in the interdisciplinary sessions, 21 percent attended a workshop, and 60 percent said they pursued increased mental health training.

Most important, “Eighty-three percent indicated they consulted with a mental health colleague concerning pediatric patients with mental health problems,” Williams said.

Williams and her colleagues noted that identification and treatment of mental health disorders in primary care is evolving. She said systemic changes including use of financial incentives to motivate primary care pediatricians to identify, treat and refer behavioral patients, increased access to mental health providers for consultations, practice guidelines and use of technology for continuing education may change practice patterns.

The Wake Forest research team included Kurt Klinepeter, M.D., Guy Palmes, M.D., Anita Pulley, M.S.N., R.N., and Jane Meschan Foy, M.D.

Wake Forest University Baptist Medical Center is an academic health system comprised of North Carolina Baptist Hospital and Wake Forest University Health Sciences, which operates the university's School of Medicine. U.S. News & World Report ranks Wake Forest University School of Medicine 18th in primary care and 44th in research among the nation's medical schools. It ranks 35th in research funding by the National Institutes of Health. Almost 150 members of the medical school faculty are listed in Best Doctors in America.