Park Tae Woo, Cheng Debbie M, Samet Jeffrey H, Winter Michael R, Saitz Richard
Dr. Park is with the Warren Alpert Medical School of Brown University, Providence, Rhode Island (e-mail:
Psychiatr Serv. 2015 Jan 1;66(1):72-9. doi: 10.1176/appi.ps.201300414. Epub 2014 Nov 17.
Co-occurring mental and substance use disorders are associated with worse outcomes than a single disorder alone. In this exploratory subgroup analysis of a randomized trial, the authors hypothesized that providing chronic care management (CCM) for substance dependence in a primary care setting would have a beneficial effect among persons with substance dependence and major depressive disorder or posttraumatic stress disorder (PTSD).
Adults (N=563) with alcohol dependence, drug dependence, or both were assigned to CCM or usual primary care. CCM was provided by a nurse care manager, social worker, internist, and psychiatrist. Clinical outcomes (any use of opioids or stimulants or heavy drinking and severity of depressive and anxiety symptoms) and treatment utilization (emergency department use and hospitalization) were measured at three, six, and 12 months after enrollment. Longitudinal regression models were used to compare randomized arms within the subgroups of participants with major depressive disorder or PTSD.
Among all participants, 79% met criteria for major depressive disorder and 36% met criteria for PTSD at baseline. No significant effect of CCM was observed within either subgroup for any outcome, including any use of opioids or stimulants or heavy drinking, depressive symptoms, anxiety symptoms, and any hospitalizations or number of nights hospitalized. Among participants with depression, those receiving CCM had fewer days in the emergency department compared with the control group, but the finding was of only borderline significance (p=.06).
Among patients with co-occurring substance dependence and mental disorders, CCM was not significantly more effective than usual care for improving clinical outcomes or treatment utilization.
共病精神障碍和物质使用障碍与单一障碍相比，预后更差。在这项随机试验的探索性子组分析中，作者假设在初级保健环境中为物质依赖提供慢性护理管理（CCM）对患有物质依赖和重度抑郁症或创伤后应激障碍（PTSD）的人会产生有益影响。
将患有酒精依赖、药物依赖或两者皆有的成年人（N = 563）分配至CCM组或常规初级保健组。CCM由一名护士护理经理、一名社会工作者、一名内科医生和一名精神科医生提供。在入组后的3个月、6个月和12个月测量临床结局（阿片类药物或兴奋剂的任何使用情况或大量饮酒以及抑郁和焦虑症状的严重程度）和治疗利用情况（急诊科就诊和住院情况）。使用纵向回归模型比较患有重度抑郁症或PTSD的参与者亚组内的随机分组。
在所有参与者中，79%在基线时符合重度抑郁症标准，36%符合PTSD标准。在任何结局方面，包括阿片类药物或兴奋剂的任何使用情况或大量饮酒、抑郁症状、焦虑症状以及任何住院情况或住院天数，在两个亚组中均未观察到CCM有显著效果。在患有抑郁症的参与者中，接受CCM的人与对照组相比，在急诊科的天数较少，但这一发现仅具有临界显著性（p = 0.06）。
在共病物质依赖和精神障碍的患者中，CCM在改善临床结局或治疗利用方面并不比常规护理显著更有效。
