Improving care for depression in patients with comorbid substance misuse
Improving care for depression in patients with comorbid substance misuse
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DOI：
10.1176/appi.ajp.163.1.125
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发表时间：
2006-01-01
影响因子：
17.7
通讯作者：
Wells, KB
中科院分区：
文献类型：
--
作者：
Watkins, KE;Paddock, SM;Wells, KB
目的：作者调查了针对抑郁症的质量改进计划在药物滥用者中是否有效，以及是否会因合并症而产生不同的计划效果。方法：一项团体水平随机对照试验（护理合作伙伴）比较了两种针对抑郁症的质量改进计划与常规护理。对来自 5 个州的 6 个管理式医疗组织的连续患者 (N = 27,332) 进行了筛查，并招募了 1,356 名患者：443 名患者接受常规护理，其余患者进入涉及药物 (N = 424) 或治疗 (N = 489) 的质量改进计划。使用多元逻辑回归来检验假设并计算抑郁症调整率以及心理治疗和抗抑郁药使用的标准化预测。结果：在常规护理条件下，尽管整体适当治疗率较高，但药物滥用的抑郁症患者持续抑郁的可能性增加。在患有药物滥用的客户中，质量改进计划与 12 个月时抑郁结果的改善以及 6 个月时抗抑郁药物的使用增加有关。在没有药物滥用的客户中，质量改进计划在 6 个月时改善了抑郁症的结局，并且与治疗利用率的提高相关。结论：同时发生的药物滥用与抑郁症相关，并且在常规护理条件下，抑郁症治疗结果较差的风险增加。质量改进计划可以显着降低患有或不患有药物滥用共病的抑郁症患者可能患抑郁症的可能性。除了有建议在没有药物滥用的个体中增加更多的心理治疗外，没有发现一致的证据表明不同的计划对合并症的影响存在差异。
Objective: The authors investigated whether quality improvement programs for depression would be effective among substance misusers and whether there would be a differential program-by-comorbidity effect.Method: A group-level randomized controlled trial (Partners in Care) compared two quality improvement programs for depression with usual care. Consecutive patients (N = 27,332) from six managed care organizations in five states were screened, and 1,356 were enrolled: 443 received usual care while the rest entered a quality improvement program involving either medication (N = 424) or therapy (N = 489). Multiple logistic regression was used to test hypotheses and compute standardized predictions of the adjusted rates of depression and use of psychotherapy and antidepressants.Results: Under usual care conditions, depressed patients with substance misuse had an increased probability of ongoing depression despite higher rates of overall appropriate treatment. Among clients with comorbid substance misuse, the quality improvement programs were associated with improved depression outcomes at 12 months and increased antidepressant use at 6 months. Among clients with no substance misuse, the quality improvement programs improved depression outcomes at 6 months and were associated with increased treatment utilization.Conclusions: Co-occurring substance misuse is associated with depression and with increased risk for poorer depression treatment outcomes under usual care conditions. Quality improvement programs can significantly reduce the likelihood of probable depressive disorders in depressed patients with and without comorbid substance misuse. No consistent evidence was found for a differential program-by- comorbidity effect except for a suggestion of greater increase in psychotherapy among individuals with no substance misuse.