Adjustment to antidepressant utilization rates to account for depression in remission

Depressive symptoms in long term care facilities in Western Canada: a cross sectional study

BACKGROUND

The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC.

METHODS

11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: < 80 beds, medium: 80-120 beds, large > 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers.

RESULTS

Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management.

CONCLUSIONS

Depressive symptoms are common in LTC residents -particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.

Systematic Review of Clinical Practice Guidelines for Failed Antidepressant Treatment Response in Major Depressive Disorder, Dysthymia, and Subthreshold Depression in Adults

OBJECTIVE

This systematic review critically evaluated clinical practice guidelines (CPGs) for treating adults with major depressive disorder, dysthymia, or subthreshold or minor depression for recommendations following inadequate response to first-line treatment with selective serotonin reuptake inhibitors (SSRIs).

METHOD

Searches for CPGs (January 2004 to November 2014) in English included 7 bibliographic databases and grey literature sources using CPG and depression as the keywords. Two raters selected CPGs on depression with a national scope. Data extraction included definitions of adequate response and recommended treatment options. Two raters assessed quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

From 46,908 citations, 3167 were screened at full text. From these 21 CPG were applicable to adults in primary care and outpatient settings. Five CPGs consider patients with dysthymia or subthreshold or minor depression. None provides recommendations for those who do not respond to first-line SSRI treatment. For adults with MDD, most CPGs do not define an "inadequate response" or provide specific suggestions regarding how to choose alternative medications when switching to an alternative antidepressant. There is variability between CPGs in recommending combination strategies. AGREE II ratings for stakeholder involvement in CPG development, editorial independence, and rigor of development are domains in which depression guidelines are often less robust.

CONCLUSIONS

About half of patients with depression require second-line treatment to achieve remission. Consistency and clarity in guidelines for second-line treatment of depression are therefore important for clinicians but lacking in most current guidelines. This may reflect a paucity of primary studies upon which to base conclusions.

Exploration of Undertreatment and Patterns of Treatment of Depression in Multiple Sclerosis

BACKGROUND

Depression is a common comorbid condition with multiple sclerosis (MS). Historically, however, it has been undertreated. Little is known about the characteristics of those who receive, or do not receive, treatment for depression in the MS population. This study evaluated depression treatment in patients with MS, associated patient characteristics, and probable determinants of antidepressant drug use in those with and without depression.

METHODS

A total of 152 patients with MS completed questionnaires and the Structured Clinical Interview for DSM-IV-TR (SCID) to determine depression status. Tabular analyses and a binary regression model were used to identify patient characteristics associated with antidepressant drug use.

RESULTS

Of participants with major depression according to the SCID, 65% were taking antidepressant medications. With adjustment for successful treatment (antidepressant drug use by those not currently depressed and currently depressed), the prevalence of treated depression increased to 85.7%. Of those receiving treatment for depression, 19% were receiving nonpharmacologic treatment alone, 38% were taking antidepressant drugs only, and 44% were receiving both pharmacologic and nonpharmacologic treatments. Demographic and clinical variables were not statistically significantly associated with antidepressant drug use in those with depression.

CONCLUSIONS

A large proportion of participants with depression in MS are now receiving treatment, a change from previous reports. The adequacy of treatment has become a bigger question because many of the treated patients continued to have depressive symptoms. Further research is needed to identify ways to achieve better outcomes for depression.

Patterns and frequency of the treatment of depression in persons with epilepsy

OBJECTIVE

Though depression is common in persons with epilepsy, it often remains undiagnosed and/or untreated. The current study aimed to determine the proportion of persons with epilepsy receiving depression-related treatment and to characterize the type of treatment received.

METHODS

Persons with epilepsy (n=185) from the only epilepsy clinic in a city of 1.2 million people completed questionnaires and the gold-standard Structured Clinical Interview for DSM Disorders (SCID) to assess current and past depression. Treatment for depression (pharmacological and nonpharmacological) was ascertained through patient self-report and chart review.

RESULTS

Of those with current depression (n=27), the majority (70.3%) were not on any depression-related treatment. In persons with current depression, nonpharmacological management was the most common treatment method, followed by treatment with psychotropic medications such as selective serotonin reuptake inhibitors. More individuals with a past history of depression but without a current episode (n=43) were treated (37.2%); it was more common for these individuals to be treated with pharmacological measures. After using an algorithm that adjusts the treated prevalence for those who are successfully treated, the adjusted proportion of depression treatment was 53.1%.

CONCLUSIONS

The proportion of people treated for current depression in this cohort was very low. Future studies should investigate barriers to treatment and how depression treatment can be optimized for those with epilepsy.

Can administrative data provide insights into the mental health of Indigenous Queenslanders?

INTRODUCTION

The Australian Government has provided $20 million to establish the Population Health Research Network (PHRN), with representation from all States and Territories to facilitate population health research through data linkage. Health LinQ is part of the Queensland node involving four Queensland universities, Queensland Health and the Australian e-Health Research Centre.

METHOD

This paper reviews the potential for using administrative databases to study the mental health experience of Indigenous Queenslanders. Researchers can define cohorts for study within the administrative data or link them to their own data. Robust protocols preserve confidentiality so that researchers only receive anonymized data. Indigenous status can be defined either through place of residence or through the recording of Indigenous status in datasets such as the Queensland Hospital Admitted Patient Data Collection.

RESULTS

Available data include hospital morbidity, mental health data and mortality. Indigenous status is correctly identified in about 89% of cases with variation by definition used.

CONCLUSIONS

Administrative data provide researchers and decision makers with accessible, cost-effective information without the intrusion and cost of additional data collection. These techniques are especially useful in studying regional, rural and remote populations where access may be difficult.

Frequency of antidepressant use in relation to recent and past major depressive episodes

OBJECTIVE

There has been a trend toward increasing antidepressant (AD) use in recent decades. We used data from the National Population Health Survey (NPHS) to determine whether this trend is continuing and to provide updated estimates of the frequency of use.

METHODS

The NPHS is a longitudinal general health survey that began collecting data in 1994. The NPHS evaluates past-year major depressive episodes (MDEs) using a brief diagnostic instrument. At each biannual interview (from 1994 to 2006) current medication use is recorded. We estimated the frequency with which ADs were taken by respondents (aged 12 years and older) with and without past-year MDEs. These frequencies were cross-tabulated by sex, year of interview, and the reported duration of symptoms.

RESULTS

ADs are taken by about 5.4% of the household population at any point in time. Most respondents taking ADs did not report past-year MDEs but 63.9% of respondents taking ADs in the absence of past-year episodes reported previous episodes or being diagnosed by a health professional with depression. This pattern is consistent with long-term treatment for relapse prevention. The overall frequency of use of ADs is increasing only in respondents without past-year episodes.

CONCLUSIONS

AD use among community residents with past-year MDEs is no longer increasing. The continued increase in the overall frequency of use may point toward broadening indications for AD treatment and may indicate that people are taking these medications for longer periods of time.

Use of administrative data for the surveillance of mood and anxiety disorders

OBJECTIVE

There is increasing interest in the use of administrative data for surveillance and research in Australia. The purpose of the present study was to evaluate the usefulness of such data for the surveillance of mood and anxiety disorder using databases from the following Canadian provinces: British Columbia, Ontario, Quebec and Nova Scotia.

METHOD

A population-based record-linkage analysis was done using data from physician billings and hospital discharge abstracts, and community-based clinics using a case definition of ICD-9 diagnoses of 296.0-296.9, 311.0, and 300.0-300.9.

RESULTS

The prevalence of treated mood and/or anxiety disorder was similar in Nova Scotia, British Columbia, and Ontario at approximately 10%. The prevalence for Quebec was slightly lower at 8%. Findings from the provinces showed consistency across age and sex despite variations in data coding. Women tended to show a higher prevalence overall of mood and anxiety disorder than men. There was considerably more variation, however, when treated anxiety (300.0-300.9) and mood disorders (296.0-296.9, 311.0) were considered separately. Prevalence increased steadily to middle age, declining in the 50s and 60s, and then increased after 70 years of age.

CONCLUSIONS

Administrative data can provide a useful, reliable and economical source of information for the surveillance of treated mood and/or anxiety disorder. Due to the lack of specificity, however, in the diagnoses and data capture, it may be difficult to conduct surveillance of mood and anxiety disorders as separate entities. These findings may have implications for the surveillance of mood and anxiety disorders in Australia with the development of a national network for the extraction, linkage and analysis of administrative data.

Use of administrative data for the surveillance of mental disorders in 5 provinces

OBJECTIVE

To evaluate the usefulness of administrative data for the surveillance of mental illness in Canada using databases in the following 5 provinces: British Columbia, Ontario, Quebec, Nova Scotia, and Alberta.

METHOD

We used a population-based record-linkage analysis with data from physician billings, hospital discharge abstracts, and community-based clinics. The following diagnostic codes from the International Classification of Diseases, Ninth Edition, were used to define cases: 290 to 319, inclusive.

RESULTS

The prevalence of treated psychiatric disorder was similar in Nova Scotia, British Columbia, Alberta, and Ontario at about 15%. The prevalence for Quebec was slightly lower at 12%. Findings from the provinces showed remarkable consistency across age and sex, despite variations in data coding. Women tended to show a higher prevalence overall of treated mental disorders than men. Prevalence increased steadily to middle age, declining in the 50s and 60s, and then increasing again after age 70 years.

CONCLUSIONS

Provincial and territorial administrative data can provide a useful, reliable, and economical source of information for the surveillance of treated mental disorders. Such a surveillance system can provide longitudinal data at little cost to support health service provision and planning.

Frequency and adequacy of depression treatment in a Canadian population sample

OBJECTIVE

Population-based data about depression treatment are largely restricted to estimates of the frequency of antidepressant (AD) use. Such frequencies are difficult to interpret in the absence of information about dosages, reasons for taking the medications, and participation in nonpharmacologic treatment. The objective of this study was to describe the pattern of treatment for major depression (MD) in Alberta.

METHOD

Telephone survey methods were employed. Random digit dialing was used to select a sample of 3345 household residents aged 18 to 64 years in Alberta. A computer-assisted telephone interview that included the Mini Neuropsychiatric Diagnostic Interview and questions about pharmacotherapy and psychotherapy was administered. Estimates were weighted for design features and population demographics.

RESULTS

The point prevalence of MD was 4.4% (95% confidence interval [CI], 3.4% to 5.5%), and the overall prevalence of current AD use was 7.4% (95% CI, 6.2% to 8.6%). The ADs taken most commonly, serotonin-specific reuptake inhibitors, were taken at therapeutic dosages 87.4% of the time. Most (80.7%) of those taking ADs reported taking them for more than 1 year. The frequency of receiving counselling, psychotherapy, or talk therapy was 3.9% overall and 14.3% in respondents with MD. However, most of these subjects were unable to name the type of counselling they were receiving.

CONCLUSIONS

When compared with previous estimates, these results suggest continued progress in the delivery of evidence-based care to the population. There is room for additional improvement, especially in the provision of nonpharmacologic treatment.

Reasons for antidepressant prescriptions in Canada

PURPOSE

To describe reasons reported by physicians making recommendations for treatment with antidepressant medications.

METHODS

Data collected by IMS Health Canada in a database called the Canadian Disease and Therapeutic Index (CDTI) were used in this analysis. CDTI data are collected from a representative sample of office-based physicians who complete diaries in their practices during selected sampling periods. A drug recommendation is recorded each time a treatment is recommended. The data are weighted to produce national estimates of the frequency of such recommendations.

RESULTS

The frequency of recommendations for antidepressant treatment increased between 2000 and 2004. However, there was a slight decrease in 2005. Two types of antidepressant medications, tricyclic antidepressants (TCAs) and trazodone showed distinct patterns of use. TCAs were more commonly used for non-psychiatric indications than for psychiatric indications, especially for sleep- and pain-related reasons. Trazodone was frequently recommended for sleep problems. The proportion of recommendations for depressive disorders for antidepressants as a group remained stable over the 5-year study period.

CONCLUSIONS

About one-third of antidepressant recommendations are for reasons other than depression. It can no longer be assumed that the frequency of antidepressant use is a measure of the frequency of pharmacological depression treatment. However, prescription data may be useful for tracking trends.

Antidepressant utilization in Canada

OBJECTIVE

Antidepressant utilization can be used as an indicator of appropriate treatment for major depression. The objective of this study was to characterize antidepressant utilization in Canada, including the relationships of antidepressant use with sociodemographic variables, past-year and lifetime depression, number of past depressive episodes, and other possible indications for antidepressants.

METHOD

We examined data from the Canadian Community Health Survey (CCHS) Cycle 1.2. The CCHS was a nationally representative mental health survey (N=36,984) conducted in 2002 that included a diagnostic instrument for past-year and lifetime major depressive episodes and other psychiatric disorders and a record of past-year antidepressant use.

RESULTS

Overall, 5.8% of Canadians were taking antidepressants, higher than the annual prevalence of major depressive episode (4.8%) in the survey. Among persons with a past-year major depressive episode, the frequency of antidepressant use was 40.4%. After application of adjustments for probable successful outcomes of treatment, the estimated frequency of antidepressant use for major depression was more than 50%. Frequency of antidepressant treatment among those with a history of depression but without a past-year episode increased with the number of previous episodes. Among those taking antidepressants over the past year, only 33.1% had had a past-year episode of major depression. Migraine, fibromyalgia, anxiety disorder, or past depression was present in more than 60% of those taking antidepressants without a past-year episode of depression.

CONCLUSIONS

The CCHS results suggest that antidepressant use has increased substantially since the early 1990s, and also that these medications are employed extensively for indications other than depression.