Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
now with Department of Health Services Research, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.
JAMA Pediatr. 2018 Jan 1;172(1):49-56. doi: 10.1001/jamapediatrics.2017.3808.
Depression during childhood and adolescence is heterogeneous. Treatment patterns are often examined in aggregate, yet there is substantial variability across individual treatment trajectories. Understanding this variability can help identify treatment gaps among youths with depression.
To characterize heterogeneity in 12-month trajectories of psychotherapy and antidepressant treatment in youths with depression.
DESIGN, SETTING, AND PARTICIPANTS: This is a longitudinal-cohort study of youths 18 years or younger with a new diagnosis of depression and at least 12 months of follow-up following diagnosis, as determined from commercial insurance claims filed from 2007 to 2014. Latent class models were fit to summary measures of psychotherapy and antidepressant use in the 12 months following the index diagnosis. We examined variation in baseline health, health care utilization, and health outcomes across classes with similar patterns of psychotherapy and antidepressant use. Data analysis took place between June 2016 and March 2017.
Psychotherapy and antidepressant use.
The cohort included 84 909 individuals with a mean (SD) age at index diagnosis of 15.0 (2.6) years, of whom 49 995 (59%) were female. Attention-deficit/hyperactivity disorder (n = 14 625; 17%) and anxiety (n = 12 358; 15%) were the most common comorbid diagnoses. During the assessment period, 59 023 individuals (70%) received psychotherapy at any point, and 33 997 individuals (40%) were dispensed antidepressants at any point. Eight classes with distinct treatment trajectories were identified, which we classified into 4 broad groups: 3 classes that received dual therapy (n = 18 710; 22%), 2 classes that received antidepressant monotherapy (n = 15 287; 18%), 2 classes that received psychotherapy monotherapy (n = 40 313; 48%) and 1 class that received no treatment (n = 10 599; 13%). The most common class received psychotherapy monotherapy (n = 35 243; 42%) and had the lowest incidence of attempted suicide (0.8 per 100 person-years [PY]) and inpatient hospitalization (3.5 per 100 PY) during the assessment period and postassessment period (0.5 per 100 PY and 1.3 per 100 PY, respectively). The group receiving dual therapy had the highest incidence of attempted suicide during the assessment period (4.7-7.1 per 100 PY, depending on the class) and postassessment period (1.5-1.7 per 100 PY).
In our sample, 13% of youths received no treatment, and 18% received antidepressants without concomitant psychotherapy. Summary measures of treatment can mask informative patterns of psychotherapy and antidepressant use. Latent class analysis can be used to identify subgroups of individuals with similar treatment trajectories and help identify treatment gaps under current practice patterns.
儿童和青少年时期的抑郁症具有异质性。治疗模式通常是综合检查的，但个体治疗轨迹之间存在很大的差异。了解这种差异可以帮助识别抑郁症青少年的治疗差距。
描述青少年抑郁症患者 12 个月心理治疗和抗抑郁药物治疗轨迹的异质性。
设计、地点和参与者：这是一项纵向队列研究，纳入了 2007 年至 2014 年期间从商业保险理赔中确定的年龄在 18 岁或以下、新诊断为抑郁症且至少有 12 个月随访的青少年。在指数诊断后 12 个月内，使用心理治疗和抗抑郁药物使用的综合指标对潜在类别模型进行拟合。我们检查了具有相似心理治疗和抗抑郁药物使用模式的类别的基线健康、医疗保健利用和健康结果的差异。数据分析于 2016 年 6 月至 2017 年 3 月进行。
心理治疗和抗抑郁药物的使用。
队列包括 84909 名平均（SD）年龄为 15.0（2.6）岁的个体，其中 49995 名（59%）为女性。最常见的合并诊断是注意力缺陷/多动障碍（n=14625；17%）和焦虑症（n=12358；15%）。在评估期间，59023 名患者（70%）在任何时候都接受了心理治疗，33997 名患者（40%）在任何时候都接受了抗抑郁药物治疗。确定了 8 个具有不同治疗轨迹的类别，我们将其分为 4 个广泛的组：接受双重治疗的 3 个类别（n=18710；22%）、接受抗抑郁药物单药治疗的 2 个类别（n=15287；18%）、接受心理治疗单药治疗的 2 个类别（n=40313；48%）和未接受治疗的 1 个类别（n=10599；13%）。最常见的类别是接受心理治疗单药治疗（n=35243；42%），在评估期间和评估后期间自杀未遂的发生率最低（每 100 人年[PY]0.8 次）和住院治疗（每 100 PY3.5 次），分别为（每 100 PY0.5 次和 1.3 次）。接受双重治疗的组在评估期间（每 100 PY4.7-7.1 次，取决于类别）和评估后期间（每 100 PY1.5-1.7 次）自杀未遂的发生率最高。
在我们的样本中，13%的青少年没有接受治疗，18%的青少年接受了抗抑郁药物治疗而没有同时接受心理治疗。治疗的综合衡量标准可能掩盖了有意义的心理治疗和抗抑郁药物使用模式。潜在类别分析可用于识别具有相似治疗轨迹的亚组，并有助于在当前实践模式下发现治疗差距。
