迈向衡量有效治疗覆盖率：重度抑郁症质量调整和用户调整覆盖率的关键瓶颈
Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder.
作者信息
Vigo Daniel, Haro Josep Maria, Hwang Irving, Aguilar-Gaxiola Sergio, Alonso Jordi, Borges Guilherme, Bruffaerts Ronny, Caldas-de-Almeida Jose Miguel, de Girolamo Giovanni, Florescu Silvia, Gureje Oye, Karam Elie, Karam Georges, Kovess-Masfety Viviane, Lee Sing, Navarro-Mateu Fernando, Ojagbemi Akin, Posada-Villa Jose, Sampson Nancy A, Scott Kate, Stagnaro Juan Carlos, Ten Have Margreet, Viana Maria Carmen, Wu Chi-Shin, Chatterji Somnath, Cuijpers Pim, Thornicroft Graham, Kessler Ronald C
机构信息
Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
出版信息
Psychol Med. 2020 Oct 20:1-11. doi: 10.1017/S0033291720003797.
BACKGROUND
Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.
METHODS
Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.
RESULTS
MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.
CONCLUSIONS
Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.
背景
重度抑郁症（MDD）是发病和死亡的主要原因。治疗数量和质量的不足已得到充分证实，但药物治疗和心理治疗的具体差距却知之甚少。本文分析了MDD治疗覆盖方面的差距，并确定了关键瓶颈。
方法
世界卫生组织-世界心理健康调查倡议在15个国家进行了17项调查。在35012名受访者中，3341人符合DSM-IV标准的12个月MDD。分析了有效治疗覆盖的以下组成部分：（a）任何心理健康服务的使用情况；（b）充分的药物治疗；（c）充分的心理治疗；（d）针对特定严重程度的两者充分结合。
结果
MDD患病率为4.8%（标准误，0.2）。共有41.8%（标准误，1.1）的人接受了任何心理健康服务，其中23.2%（标准误，1.5）被认为是有效的。有效治疗方面90%的差距是由于未使用（58%）以及质量或依从性不足（32%）。关键瓶颈在于心理治疗利用不足（覆盖范围降低26个百分点）、精神药理学利用不足（降低13个百分点）、医生监测不足（降低13个百分点）以及药物类型不足（降低10个百分点）。在任何心理健康服务使用、充分的药物治疗、充分的心理治疗以及两者的充分结合方面，高收入国家是低收入国家的两倍。重度病例比轻度至中度病例更有可能接受充分的药物治疗或心理治疗，但接受充分联合治疗的可能性较小。
结论
决策者需要提高药物治疗和心理治疗的利用率和质量。诸如通过远程医疗进行培训和监督以及利用非专科或社区资源提供药物治疗和心理治疗等创新措施可以解决这些瓶颈问题。
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