糖尿病与疾病控制不佳：共病的抑郁症是否与药物依从性差或缺乏治疗强化有关？
Diabetes and poor disease control: is comorbid depression associated with poor medication adherence or lack of treatment intensification?
作者信息
Katon Wayne, Russo Joan, Lin Elizabeth H B, Heckbert Susan R, Karter Andy J, Williams Lisa H, Ciechanowski Paul, Ludman Evette, Von Korff Michael
机构信息
Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington School of Medicine, Seattle, WA 98195-6560, USA.
出版信息
Psychosom Med. 2009 Nov;71(9):965-72. doi: 10.1097/PSY.0b013e3181bd8f55. Epub 2009 Oct 15.
OBJECTIVE
To hypothesize that patients with comorbid depression and diabetes and poor disease control will have poorer adherence to disease control medication and less likelihood of physician intensification of treatment. Many patients with diabetes fail to achieve American Diabetes Association Guidelines for glycemic, blood pressure and lipid control. Depression is a common comorbidity and may affect disease control through adverse effects on adherence and physician intensification of treatment.
METHODS
In a cohort of 4117 patients with diabetes, depression was measured at baseline with the Patient Health Questionnaire-9 (PHQ-9). Patient adherence and physician intensification of treatment were measured in those who had evidence of poor disease control (HbA(1c) >or=8.0%, LDL >or=130 mg/dL, systolic blood pressure >or=140 mm Hg) over this 5-year period. Poor adherence was defined as having medication refill gaps for >or=20% of days covered for medications prescribed for each of these conditions. Treatment intensification was defined as an increased medication dosage in a class, an increase in the number of medication classes, or a switch to a different class within 3-month periods before and after notation of above target levels.
RESULTS
Among patients with diabetes and poor disease control, depression was associated with an increased likelihood of poor adherence to diabetes control medications (odds ratio [OR] = 1.98; 95% Confidence Interval [CI] = 1.31, 2.98), antihypertensives (OR = 2.06; 95% CI = 1.47, 2.88), and LDL control medications (OR = 2.43; 95% CI = 1.19, 4.97). In patients with poor disease control who were adherent to medication or not yet started on a medication, depression was not associated with differences in likelihood of physician intensification of treatment.
CONCLUSIONS
In patients with diabetes and poor disease control, depression is an important risk factor for poor patient adherence to medications, but not lack of treatment intensification by physicians.
目的
提出假设，即患有抑郁症和糖尿病且疾病控制不佳的患者对疾病控制药物的依从性较差，医生加强治疗的可能性较小。许多糖尿病患者未能达到美国糖尿病协会关于血糖、血压和血脂控制的指南。抑郁症是一种常见的合并症，可能通过对依从性和医生加强治疗的不利影响来影响疾病控制。
方法
在一组4117名糖尿病患者中，在基线时使用患者健康问卷-9（PHQ-9）测量抑郁症。在这5年期间，对那些有疾病控制不佳证据（糖化血红蛋白[HbA(1c)]≥8.0%、低密度脂蛋白[LDL]≥130mg/dL、收缩压≥140mmHg）的患者测量患者依从性和医生加强治疗的情况。依从性差被定义为针对每种这些情况所开药物的覆盖天数中有≥20%的天数存在药物 refill 间隔。治疗强化被定义为在记录上述目标水平之前和之后的3个月内，某一类药物的剂量增加、药物类别数量增加或换用不同类别药物。
结果
在患有糖尿病且疾病控制不佳的患者中，抑郁症与对糖尿病控制药物依从性差的可能性增加相关（优势比[OR]=1.98；95%置信区间[CI]=1.31，2.98），与抗高血压药物（OR=2.06；95%CI=1.47，2.88）以及LDL控制药物（OR=2.43；95%CI=1.19，4.97）依从性差的可能性增加相关。在疾病控制不佳但依从药物治疗或尚未开始用药的患者中，抑郁症与医生加强治疗可能性的差异无关。
结论
在患有糖尿病且疾病控制不佳的患者中，抑郁症是患者对药物依从性差的重要危险因素，但不是医生不加强治疗的危险因素。
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