Children with anxiety and depression may be at greater risk due to gaps in care
Louise Ellis, Louise Wiles, Raghu Lingam, Gaston Arnolda, Peter Hibbert, and Jeffrey Braithwaite, Australia, June, 2020
This article has been adapted from a paper recently published in the Australian & New Zealand Journal of Psychiatry titled: Assessing the quality of care for paediatric depression and anxiety in Australia: A population-based sample survey.
How prevalent are depression and anxiety in Australian children?
Depression and anxiety are two of the most common mental health disorders (Gore et al., 2011) which, together, affect around one in five children and adolescents (Lawrence et al., 2015). These conditions can have serious negative impacts on children, including:
- physical health problems
- difficulties with social inclusion; and
- poorer academic achievement (Jaycox et al., 2009; Lawrence et al., 2015).
If left untreated, childhood depression or anxiety can continue into adulthood – and over time can become increasingly difficult to manage (Birmaher, Arbelaez, & Brent, 2002). Despite this, there is a lack of research on services for depression and anxiety in children (Knapp et al., 2016).
Why is adherence to clinical practice guidelines important?
Clinical practice guidelines (CPGs) are generally accepted as effective mechanisms for the delivery of high quality and safe care to patients. They assist practitioners in making decisions about the appropriate care of patients with specific conditions (Lohr & Field, 1990). While primary care providers are trained to make informed decisions for children and their families, adhering to good quality CPGs that are designed by themselves, and other medical and systems experts, offers many benefits.
It is generally accepted that adherence to CPGs has the potential to:
- enhance patient outcomes,
- ease the journey of patients through the health system; and
- improve the overall quality and safety of care (Amer et al., 2019; Bukstein, 2010).
Over the last decade or so, CPGs for the appropriate management of depression and anxiety in children have been developed in several countries, including Australia. Until now, little was known about the level of adherence to these guidelines in paediatric settings.
Understanding how care is delivered is important, as despite increasing acceptance of an evidence-based approach to clinical decision-making, much clinical practice is not based on the best available evidence. For example, it has been reported that less than one adult in two receives minimally adequate treatment for depression or anxiety, based on CPG recommendations (Roberge et al., 2016).
What did the study do?
The Care Track Kids project, led by the Australian Institute of Health Innovation (Braithwaite et al., 2018), has for the first time provided a detailed picture of how Australian children with anxiety or depression are treated, and how much of this treatment is in accordance with CPGs.
The study looked at how often children in Australia receive care that is in line with CPGs for depression and anxiety.
The study investigated the medical records of more than 500 children (aged under 16 years) that had been assessed for depression or anxiety in 2011 and 2012.
What were the key findings?
Overall, the research showed that there is room for critical improvement in the diagnosis and management of anxiety and depression in children and adolescents, including in adherence to key evidence-based recommendations for high quality care.
- Across both depression and anxiety, lower levels of compliance with CPGs were reported for GPs than in hospital paediatrics or paediatric clinics in the community.
- A third of children diagnosed with depression received appropriate assessment and just over a third received appropriate depression management.
- For children with depression, less than half of those considered at risk had an emergency safety plan completed as part of their care.
- For children with anxiety, only half received appropriate assessment.
- For children with anxiety, only half of parents were informed about the risks and benefits of prescribed anxiety medication.
What are the implications of these findings?
With demand for mental health services for children and young people growing and limited specialist care available, primary care providers such as GPs are filling the gaps but need additional support.
This study highlights the need to support primary care providers to better meet clinical practice guidelines for the treatment of anxiety and depression in childhood. It also demonstrates that:
- GPs need support to adhere more closely to clinical practice guidelines.
- Improvements are needed in the assessment and management of children with depression.
- Emergency safety plans should be provided more often for children with depression.
- Improvements are needed in adherence to guidelines for the assessment of childhood anxiety.
- Primary care providers need to give children and families better information about the child’s mental health condition.
One strategy for achieving these recommended improvements is to provide support to GPs in the following areas:
- Making it easier for a thorough mental health assessment to be documented. This will help ensure that a child has a complete medical record.
- Clarifying what key information should be provided to children, adolescents and families about the care of a person with childhood anxiety or depression.
- Advising how and when to develop an emergency safety plan with a child or adolescent.
The ongoing roll out of electronic health records also offers the opportunity to implement a monitoring and feedback system in conjunction with clinicians to streamline work practices and assist in the decision-making process. Primary care practitioners could then map how care and practice are improving over time, and provide feedback to patients, families and clinicians.
Amer, Y. S., Al-Joudi, H. F., Varnham, J. L., Bashiri, F. A., Hamad, M. H., Al Salehi, S. M., . . . Saudi, A. S. (2019). Appraisal of clinical practice guidelines for the management of attention deficit hyperactivity disorder (ADHD) using the AGREE II Instrument: A systematic review. PloS One, 14(7), e0219239-e0219239.
Birmaher, B., Arbelaez, C., & Brent, D. (2002). Course and outcome of child and adolescent major depressive disorder. Child and adolescent psychiatric clinics of North America, 11(3), 619-637.
Braithwaite, J., Hibbert. P. D., Jaffe, A., et al. Quality of Health Care for Children in Australia, 2012-2013. JAMA. 2018, 319(11):1113–1124.
Bukstein, O. G. (2010). Clinical practice guidelines for Attention-Deficit/Hyperactivity Disorder: A review. Postgraduate Medicine, 122(5), 69-77.
Gore, F. M., Bloem, P. J., Patton, G. C., Ferguson, J., Joseph, V., Coffey, C., . . . Mathers, C. D. (2011). Global burden of disease in young people aged 10–24 years: a systematic analysis. The Lancet, 377(9783), 2093-2102.
Jaycox, L. H., Stein, B. D., Paddock, S., Miles, J. N., Chandra, A., Meredith, L. S., . . . Burnam, M. A. (2009). Impact of teen depression on academic, social, and physical functioning. Pediatrics, 124(4), e596-e605.
Knapp, M., Ardino, V., Brimblecombe, N., Evans-Lacko, S., Lemmi, V., King, D., . . . Crane, S. (2016). Youth mental health: New economic evidence. London: Personal Social Services Research Unit.
Lawrence, D., Johnson, S., Hafekost, J., Boterhoven de Haan, K., Sawyer, M., Ainley, J., & Zubrick, S. R. (2015). The mental health of children and adolescents: Report on the second Australian child and adolescent survey of mental health and wellbeing. Canberra: Department of Health.
Lohr, K. N., & Field, M. J. (1990). Clinical practice guidelines: Directions for a new program (Vol. 90). Washington: National Academies Press.
Roberge, P., Hudon, C., Pavilanis, A., Beaulieu, M.-C., Benoit, A., Brouillet, H., . . . Gaboury, I. (2016). A qualitative study of perceived needs and factors associated with the quality of care for common mental disorders in patients with chronic diseases: the perspective of primary care clinicians and patients. BMC Family Practice, 17(1), 134.