Usual Care for Adolescent Depression From Symptom Identification Through Treatment Initiation
Usual Care for Adolescent Depression From Symptom Identification Through Treatment Initiation
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DOI：
10.1001/jamapediatrics.2015.4158
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发表时间：
2016-04-01
期刊：
影响因子：
26.1
通讯作者：
Scholle, Sarah Hudson
中科院分区：
文献类型：
--
作者：
O'Connor, Briannon C.;Lewandowski, R. Eric;Scholle, Sarah Hudson
重要性出版的指南描述了初级保健环境中有效的青少年抑郁症护理，包括筛查、评估、治疗启动和症状监测。目前尚不清楚这些步骤在患者健康记录中的记录程度。目的确定在3个大型医疗系统中对新发现的抑郁症状的青少年进行适当的后续护理的比率。设计、设置和参与者在2014年3月至9月进行的这项分析中，回顾从电子健康记录中提取的结构化数据在最初的症状识别后进行了3个月的分析，以确定是否对患者进行了随访，如果是，是否开始治疗和/或监测症状。记录是从美国西部的两个大型健康维护组织和东北部的一个社区卫生中心网络收集的。研究组包括新发现的抑郁症状的青少年(N=4612)，在患者健康问卷上被定义为分数升高(>；=10)和/或被诊断为抑郁。MAIN结果和测量在最初症状识别的3个月内记录的治疗启动、症状监测和随访护理的比率。结果在4612名参与者中，指数事件发生时的平均年龄(SD)为16.0岁(2.3岁)，其中女性3060岁(66%)。近三分之二的青少年(79%的被诊断为严重抑郁症的人；n=1023)开始接受治疗；大多数人单独或与药物联合接受心理治疗。然而，在确诊后的3个月内，36%的青少年没有接受治疗(n=1678)，68%的青少年没有接受后续症状评估(n=3136)，19%的青少年没有接受任何后续护理(n=854)。此外，40%服用抗抑郁药物的青少年在3个月内没有任何随访护理的文件(n=356)。年龄较小(15-17岁：优势比[OR]，0.78；95%CI，0.67-0.92，18-20岁：OR，0.83；95%CI，0.70-0.99；P=.008)，首发症状较重(中度：OR，0.99；95%CI，0.82-1.21；中至重度：OR：1.46；95%CI，1.19-1.80；重度：OR，2.14；95%CI，1.65-2.79；接受诊断(重度抑郁/心境恶劣：OR，2.65；95%CI，2.20-3.20；以及未指明的抑郁/适应障碍：OR，1.75；95%CI，1.43-2.14；P<；.001)与开始治疗显著相关。不同地点(地点2：OR，1.77；95%CI，1.45-2.16和地点3：OR，2.10；95%CI，1.72-2.57)的随访率差异明显，这表明卫生系统内的差异也可能影响接受的护理。结论和相关性大多数新发现的抑郁症状的青少年在确诊后的前3个月内接受了一些治疗，通常包括心理治疗。然而，随访护理很低，而且不同地点之间存在很大差异。这些结果引发了人们对青少年抑郁症护理质量的担忧。
IMPORTANCE Published guidelines describing effective adolescent depression care in primary care settings include screening, assessment, treatment initiation, and symptom monitoring. It is unclear the extent to which these steps are documented in patient health records.OBJECTIVE To determine rates of appropriate follow-up care for adolescents with newly identified depression symptoms in 3 large health systems.DESIGN, SETTING, AND PARTICIPANTS In this analysis conducted from March to September 2014, structured data retrospectively extracted from electronic health records were analyzed for 3 months following initial symptom identification to determine whether the patient was followed up and, if so, whether treatment was initiated and/or symptoms were monitored. Records were collected from 2 large health maintenance organizations in the western United States and a network of community health centers in the Northeast. The study group included adolescents (N = 4612) with newly identified depression symptoms, defined as an elevated score on the Patient Health Questionnaire (>= 10) and/or a diagnosis of depression.MAIN OUTCOMES AND MEASURES Rates of treatment initiation, symptom monitoring, and follow-up care documented within 3 months of initial symptom identification. RESULTS Among the 4612 participants, the mean (SD) age at index event was 16.0 (2.3) years, and 3060 were female (66%). Treatment was initiated for nearly two-thirds of adolescents (79% of those with a diagnosis of major depression; n = 1023); most received psychotherapy alone or in combination with medications. However, in the 3 months following identification, 36% of adolescents received no treatment (n = 1678), 68% did not have a follow-up symptom assessment (n = 3136), and 19% did not receive any follow-up care (n = 854). Further, 40% of adolescents prescribed antidepressant medication did not have any documentation of follow-up care for 3 months (n = 356). Younger age (ages 15-17 years: odds ratio [OR], 0.78; 95% CI, 0.67-0.92 and ages 18-20 years: OR, 0.83; 95% CI, 0.70-0.99; P = .008), more severe initial symptoms (moderate: OR, 0.99; 95% CI, 0.82-1.21; moderate to severe: OR, 1.46; 95% CI, 1.19-1.80; and severe: OR, 2.14; 95% CI, 1.65-2.79; P < .001), and receiving a diagnosis (major depression/dysthymia: OR, 2.65; 95% CI, 2.20-3.20 and unspecified depression/adjustment disorder: OR, 1.75; 95% CI, 1.43-2.14; P < .001) were significantly associated with treatment initiation. Differences in rates of follow-up care were evident between sites (site 2: OR, 1.77; 95% CI, 1.45-2.16 and site 3: OR, 2.10; 95% CI, 1.72-2.57), suggesting that differences within health systems may also affect care received.CONCLUSIONS AND RELEVANCE Most adolescents with newly identified depression symptoms received some treatment, usually including psychotherapy, within the first 3 months after identification. However, follow-up care was low and substantial variation existed between sites. These results raise concerns about the quality of care for adolescent depression.