Watkins Katherine E, Paddock Susan M, Zhang Lily, Wells Kenneth B
RAND Corporation, Santa Monica, CA 90407-2138, USA.
Am J Psychiatry. 2006 Jan;163(1):125-32. doi: 10.1176/appi.ajp.163.1.125.
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.
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.
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.
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.
作者研究了针对抑郁症的质量改进项目在药物滥用者中是否有效，以及是否存在项目与共病之间的差异效应。
一项群组水平的随机对照试验（关爱伙伴项目）将两种针对抑郁症的质量改进项目与常规护理进行了比较。对来自五个州六个管理式医疗组织的连续患者（N = 27332）进行了筛查，1356人被纳入研究：443人接受常规护理，其余患者进入质量改进项目，其中一部分接受药物治疗（N = 424），另一部分接受心理治疗（N = 489）。使用多重逻辑回归来检验假设，并计算抑郁症调整率、心理治疗和抗抑郁药物使用情况的标准化预测值。
在常规护理条件下，尽管总体适当治疗率较高，但患有药物滥用的抑郁症患者持续抑郁的可能性增加。在患有共病药物滥用的患者中，质量改进项目与12个月时抑郁症结局改善以及6个月时抗抑郁药物使用增加相关。在没有药物滥用的患者中，质量改进项目在6个月时改善了抑郁症结局，并与治疗利用率增加相关。
共病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效果较差的风险增加。质量改进项目可以显著降低患有和未患有共病药物滥用的抑郁症患者发生可能的抑郁障碍的可能性。除了提示没有药物滥用的个体心理治疗增加幅度更大外，未发现质量改进项目与共病之间存在一致的差异效应证据。
