Ziobrowski Hannah N, Leung Lucinda B, Bossarte Robert M, Bryant Corey, Keusch Janelle N, Liu Howard, Puac-Polanco Victor, Pigeon Wilfred R, Oslin David W, Post Edward P, Zaslavsky Alan M, Zubizarreta Jose R, Kessler Ronald C
Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, 02115 Boston, MA, USA.
Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
J Affect Disord. 2021 Jul 1;290:227-236. doi: 10.1016/j.jad.2021.04.033. Epub 2021 Apr 27.
Psychiatric comorbidities may complicate depression treatment by being associated with increased role impairments. However, depression symptom severity might account for these associations. Understanding the independent associations of depression severity and comorbidity with impairments could help in treatment planning. This is especially true for depressed Veterans, who have high psychiatric comorbidity rates.
2,610 Veterans beginning major depression treatment at the Veterans Health Administration (VHA) were administered a baseline self-report survey that screened for diverse psychiatric comorbidities and assessed depression severity and role impairments. Logistic and generalized linear regression models estimated univariable and multivariable associations of depression severity and comorbidities with impairments. Population attributable risk proportions (PARPs) estimated the relative importance of depression severity and comorbidities in accounting for role impairments.
Nearly all patients (97.8%) screened positive for at least one comorbidity and half (49.8%) for 4+ comorbidities. The most common positive screens were for generalized anxiety disorder (80.2%), posttraumatic stress disorder (77.9%), and panic/phobia (77.4%). Depression severity and comorbidities were significantly and additively associated with impairments in multivariable models. Associations were attenuated much less for depression severity than for comorbidities in multivariable versus univariable models. PARPs indicated that 15-60% of role impairments were attributable to depression severity and 5-32% to comorbidities.
The screening scales could have over-estimated comorbidity prevalence. The cross-sectional observational design cannot determine either temporal or causal priorities.
Although positive screens for psychiatric comorbidity are pervasive among depressed VHA patients, depression severity accounts for most of the associations of these comorbidities with role impairments.
精神疾病共病可能会因导致角色功能损害增加而使抑郁症治疗复杂化。然而，抑郁症状的严重程度可能是这些关联的原因。了解抑郁严重程度和共病与功能损害之间的独立关联有助于治疗规划。对于患有高精神疾病共病率的退伍军人抑郁症患者来说尤其如此。
对2610名在退伍军人健康管理局（VHA）开始接受重度抑郁症治疗的退伍军人进行了一项基线自我报告调查，该调查筛查了各种精神疾病共病，并评估了抑郁严重程度和角色功能损害。逻辑回归和广义线性回归模型估计了抑郁严重程度和共病与功能损害的单变量和多变量关联。人群归因风险比例（PARP）估计了抑郁严重程度和共病在解释角色功能损害方面的相对重要性。
几乎所有患者（97.8%）至少有一种共病筛查呈阳性，一半（49.8%）有4种及以上共病。最常见的阳性筛查是广泛性焦虑障碍（80.2%）、创伤后应激障碍（77.9%）和惊恐/恐惧症（77.4%）。在多变量模型中，抑郁严重程度和共病与功能损害显著且呈相加关联。与单变量模型相比，多变量模型中抑郁严重程度的关联减弱程度远小于共病。PARP表明，15 - 60%的角色功能损害归因于抑郁严重程度，5 - 32%归因于共病。
筛查量表可能高估了共病患病率。横断面观察设计无法确定时间或因果优先级。
尽管在VHA抑郁症患者中精神疾病共病的阳性筛查很普遍，但抑郁严重程度是这些共病与角色功能损害之间大多数关联的原因。
