Hassan Amany K, Farmer Kevin C, Brahm Nancy C, Neas Barbara R
Department of Pharmaceutical, Social and Administrative Sciences, School of Pharmacy, D'Youville College, Buffalo, NY, 14201, USA.
Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma, Oklahoma City, OK, 73117, USA.
Int J Clin Pharm. 2016 Apr;38(2):429-37. doi: 10.1007/s11096-016-0272-y. Epub 2016 Mar 2.
Patients with depression can be mistakenly labeled as treatment-resistant if they fail to receive an adequate first-line antidepressant trial. Adding second-line agents to the treatment regimens can create an additional burden on both the patients and the healthcare system.
To determine if depressed patients receive an adequate antidepressant trial prior to starting second-line therapy and to investigate the association between the type of second-line treatment and severity of illness or depression among unipolar versus bipolar patients.
Oklahoma Medicaid claims data between 2006 and 2011.
Subjects were depression-diagnosed adult patients with at least two prescriptions of antidepressants followed by a second-line agent. Patients were categorized into one of three groups: an atypical antipsychotic, other augmentation agents (lithium, buspirone, and triiodothyronine), or adding antidepressants, based on the type of second-line therapy. An adequate trial was defined per the American Psychiatric Association guidelines. Factors associated with the type of treatment were tested using multinomial logistic regression models stratified by type of depression (unipolar vs. bipolar patients).
Variables used to measure receiving an adequate antidepressant trial included: trial duration, adherence, dose adequacy, and number of distinct antidepressant trials.
A total of 3910 patients were included in the analysis. Most subjects reached the recommended antidepressant dose. However, 28 % of patients had an antidepressant trial duration <4 weeks and only 60 % tried at least two antidepressant regimens prior to adding second-line therapy. Approximately 50 % of the subjects were non-adherent across all groups. Severity of illness and receipt of an adequate antidepressant trial were not predictors of the type of second-line treatment.
Many patients do not receive an adequate antidepressant trial before starting a second-line agent. The type of second-line treatment was independent of severity of depression. These findings support policies that require reviewing the recommended dose and duration of the first-line antidepressant before adding second-line agents. Healthcare providers need to review the patient's history and reconsider the evidence for prescribing second-line agents.
如果抑郁症患者未能接受充分的一线抗抑郁药物试验，他们可能会被错误地标记为难治性患者。在治疗方案中添加二线药物会给患者和医疗系统带来额外负担。
确定抑郁症患者在开始二线治疗之前是否接受了充分的抗抑郁药物试验，并调查二线治疗类型与单相和双相患者疾病严重程度或抑郁之间的关联。
2006年至2011年俄克拉荷马州医疗补助索赔数据。
研究对象为被诊断患有抑郁症的成年患者，他们至少有两份抗抑郁药物处方，随后使用了二线药物。根据二线治疗类型，患者被分为三组之一：非典型抗精神病药物、其他增效剂（锂盐、丁螺环酮和三碘甲状腺原氨酸）或添加抗抑郁药物。根据美国精神病学协会指南定义充分试验。使用按抑郁类型（单相与双相患者）分层的多项逻辑回归模型测试与治疗类型相关的因素。
用于衡量是否接受充分抗抑郁药物试验的变量包括：试验持续时间、依从性、剂量充足性以及不同抗抑郁药物试验的次数。
共有3910名患者纳入分析。大多数受试者达到了推荐的抗抑郁药物剂量。然而，28%的患者抗抑郁药物试验持续时间<4周，只有60%的患者在添加二线治疗之前尝试了至少两种抗抑郁药物方案。所有组中约50%的受试者不依从。疾病严重程度和接受充分的抗抑郁药物试验不是二线治疗类型的预测因素。
许多患者在开始使用二线药物之前未接受充分的抗抑郁药物试验。二线治疗类型与抑郁严重程度无关。这些发现支持在添加二线药物之前需要审查一线抗抑郁药物推荐剂量和持续时间的政策。医疗保健提供者需要审查患者病史并重新考虑开具二线药物的证据。
