初级保健提供者对青少年抑郁症的初始治疗决策和抗抑郁药处方。
Primary care providers' initial treatment decisions and antidepressant prescribing for adolescent depression.
机构信息
*Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; †Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; ‡RAND Corporation, Pittsburgh, PA; §Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA; ‖Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.
出版信息
J Dev Behav Pediatr. 2014 Jan;35(1):28-37. doi: 10.1097/DBP.0000000000000008.
OBJECTIVE
Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. This study examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network.
METHODS
A cross-sectional survey was administered to 58 PCPs within a large pediatric practice network. PCP reports of initial treatment decisions were compared in response to 2 vignettes describing depressed adolescents with either moderate or severe symptoms. PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics were measured.
RESULTS
Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (odds ratio [OR], 5.50; 95% confidence interval [CI], 2.47-12.2] p < .001). Depression severity did not affect the likelihood of antidepressant recommendation (OR, 1.58 [95% CI, 0.80-3.11] p = .19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR, 1.72 [95% CI, 1.14-2.59] p = .009) and access to an on-site mental health provider (OR, 5.13 [95% CI, 1.24-21.2] p = .02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR, 0.85 [95% CI, 0.75-0.98] p = .02).
CONCLUSION
PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs' antidepressant prescribing.
目的
青少年抑郁症是一个严重且未得到充分治疗的公共卫生问题。尽管如此，由于结构性和培训方面的障碍，儿科初级保健提供者（PCP）开抗抑郁药的可能性较低。本研究在一个结构性障碍较少的环境中，即一个综合性的行为健康网络中，考察了症状严重程度和提供者特征对初始抑郁症治疗决策的影响。
方法
对大型儿科实践网络中的 58 名 PCP 进行了横断面调查。比较了 PCP 对描述有中度或重度症状的抑郁青少年的 2 个案例报告的初始治疗决策。测量了 PCP 的抑郁知识、解决心理社会问题的态度、人口统计学和实践特征。
结果
只有少数 PCP（中度为 25%，重度为 32%）建议使用抗抑郁药。与中度抑郁症的治疗建议相比，重度抑郁症更有可能转介给儿童精神病学医生（优势比[OR]，5.50；95%置信区间[CI]，2.47-12.2；p <.001）。抑郁症严重程度并不影响抗抑郁药推荐的可能性（OR，1.58 [95% CI，0.80-3.11] p =.19）。抑郁症知识更丰富的 PCP（OR，1.72 [95% CI，1.14-2.59] p =.009）和能够获得现场心理健康提供者的 PCP 更有可能推荐使用抗抑郁药（OR，5.13 [95% CI，1.24-21.2] p =.02），而那些报告在解决心理社会问题时提供者负担较重的 PCP 更不可能推荐使用抗抑郁药（OR，0.85 [95% CI，0.75-0.98] p =.02）。
结论
无论抑郁症的严重程度如何，PCP 很少为青少年推荐使用抗抑郁药。通过体验式培训为 PCP 提供持续支持，在解决心理社会问题时考虑到提供者的负担，并与心理健康提供者共同管理，可能会增加 PCP 开抗抑郁药的可能性。
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