Impact of deductibles on initiation and continuation of psychotherapy for treatment of depression

Objective

To estimate the impact of deductibles on the initiation and continuation of psychotherapy for depression.

Data Sources/Study Setting

Data from health care encounters and claims from Group Health Cooperative, a large integrated health care system in Washington State, was merged with information from a centralized behavioral health triage call center to conduct study analyses.

Study Design

A retrospective observational design using a hierarchical logistic regression model was used to estimate initiation and continuation probabilities for use of psychotherapy, adjusting for key sociodemographic/economic factors and prior use of behavioral health services relevant to individual decisions to seek mental health care.

Data Collection/Extraction Methods

Analyses were based on merged datasets on patient enrollment, insurance benefits, use of mental health and general medical services and information collected by a triage specialist at a centralized behavioral health call center.

Principal Findings

Among individuals with unmet deductibles between $100 and $500, we found a statistically significant lower likelihood of making an initial visit, but there was no statistically significant effect on making an initial or subsequent visit among individuals that had met their deductible.

Conclusions

Unmet deductibles appear to influence the likelihood of initiating psychotherapy for treating depression.     

抑郁症治疗的研究进展

抑郁症迄今已成为全球性的主要精神卫生问题,是危害全人类的常见病、多发病,给个人、家庭和社会带来巨大的损失。本研究侧重对抑郁症发病机制及各种抗抑郁药物的进展进行综述。     

Survey of regional health care providers on selection of treatment for bulimia nervosa

OBJECTIVE: To determine which treatments clinicians currently recommend for patients with bulimia nervosa (BN), to find out if they recommended evidence-based treatments, and to assess availability and clinician satisfaction with treatment options. METHODS: Surveys were sent to 1,263 health care providers in Minnesota, Iowa, and Wisconsin who were likely to encounter patients with BN. These health care providers comprised all primary care clinicians, physician assistants, advanced practice nurses, and all mental health/chemical dependency clinicians (MDs, Clinical Nurse Specialist (CNS), social workers, doctoral and masters-level therapists, and chemical dependency (CD) counselors) affiliated with the Mayo Clinic in Rochester, Minnesota. RESULTS: Evidence-based treatments for BN are recommended consistently and are generally perceived to be available, at least to practitioners affiliated with a large medical center in the Midwest. Clinician satisfaction with treatment options is modest. DISCUSSION: Clinicians are recommending evidence-based treatments for BN patients and find them to be generally available. Modest satisfaction with available treatments may reflect a realistic understanding of treatment options, which need further development.     

综合心理干预对抑郁症患者心理行为影响

目的探讨综合心理干预对抑郁症患者心理行为的影响,为抑郁症的临床干预提供依据。方法采用便利抽样方法抽取浙江省金华市第二医院的197例抑郁症患者为研究对象,随机分为干预组(99例)和对照组(98例),对照组采用单纯抗抑郁药物治疗,干预组在药物治疗基础上增加每周1次共12次的综合心理干预,分别于干预前、干预4周末、干预12周末、1年后随访时进行问卷调查。结果干预前,2组抑郁症患者汉密尔顿抑郁量表(HAMD)、简易应对方式问卷(SCSQ)、自杀态度问卷(QSA)各因子得分差异均无统计学意义(P>0.05);干预4周末,2组患者HAMD总分均低于干预前(P<0.01),干预组HAMD总分[(12.51±1.67)分]低于对照组[(13.44±2.03)分](t=3.50,P<0.01);干预12周末,除对照组SCSQ的积极应对及QSA 的对自杀者家属的态度因子外,对照组和干预组各量表各因子得分与干预前比较差异均有统计学意义(P<0.01),干预组与对照组各量表各因子得分差异也均有统计学意义(P<0.05);1年后随访,除对照组QSA的对自杀者家属的态度因子外,对照组和干预组各量表各因子得分与干预前比较,差异均有统计学意义(P<0.05),除QSA的对自杀者家属的态度因子外,干预组与对照组各量表各因子得分差异均有统计学意义(P<0.05);干预组和对照组患者的抑郁复发率分别为7.53%(7/93)和19.57%(18/92),差异有统计学意义(χ²=5.67,P<0.05);干预组和对照组患者自杀发生率分别为2.15%(2/93)和8.70%(8/92),差异有统计学意义(χ²=3.85,P<0.05)。结论抗抑郁药物联合综合心理干预,能更快地控制症状、更有效地改变态度和行为,使复发率、自杀率下降,是理想的治疗模式。     

氟西汀联合支持性心理治疗脑卒中后抑郁的疗效观察

目的 观察抗抑郁药物氟西汀联合支持性心理治疗对脑卒中后抑郁的临床疗效.方法 118例卒中后抑郁症患者随机分为治疗组和对照组各59例,两组均给支持性心理治疗;治疗组同时予以氟西汀（百忧解）20～40 mg/d,早餐后服用.治疗前和治疗后8周末分别用汉密尔顿抑郁量表（HAMD）、中国卒中量表（CSS）评定其疗效.结果 治疗前两组HAMD分值无差异,治疗8周后,两组的HAMD、CSS评分均明显低于治疗前,且治疗组均优于对照组,差异有显著性意义（P〈0.01）.治疗组抑郁总有效率、神经功能恢复总有效率分别为93.2%和91.5%,明显高于对照组的81.36%和79.66%（P〈0.01）.结论 氟西汀联合支持性心理治疗有良好的抗抑郁及促进神经功能恢复的作用,疗效优于单用支持性心理治疗,尤其是精力减退、愉快感缺乏、思维语言行动迟滞等抑郁症的低动力症状改善明显,使抑郁症状改善更彻底,康复动力激活更明显.     

认知行为疗法联合抗抑郁药改善产后抑郁症状的效果研究

目的系统评价认知行为疗法(cognitive behavioral therapy,CBT)联合抗抑郁药改善产后抑郁症(postpartum depression,PPD)患者抑郁症状的疗效。方法计算机检索Pubmed、Cochrane Library、OVID、中国知网(CNKI)、中国生物医学文献数据库(CBM)、中文科技期刊数据库(VIP)、万方数据库(Wanfang Data)中所有关于CBT联合抗抑郁药治疗PPD患者的随机对照试验,对符合纳入标准的文献用Rev Man 5.3软件对文献数据进行meta分析,对比两组的疗效。结果共纳入12个研究,共计849人。本文对CBT联合抗抑郁药治疗8周的疗效进行了分析,第1周、第2周、第4周、第6周及第8周的结果分别为[WMD=-1.31,95%CI(-2.53,-0.10),P=0.03]、[WMD=-2.87,95%CI(-3.46,-2.28),P0.00001]、[WMD=-3.40,95%CI(-3.98,-2.82),P0.00001]、[WMD=-2.66,95%CI(-3.67,-1.65),P0.00001]及[WMD=-3.60,95%CI(-3.95,-3.25),P0.00001]。CBT联合药物治疗组疗效优于单纯药物治疗组。结论CBT联合抗抑郁药较单纯使用抗抑郁药能更显著地改善PPD患者的抑郁症状,其疗效在治疗第1周开始便优于同期单纯药物治疗组。     

Patient ethnicity and perceptions of families and friends regarding depression treatment

Objective. Black Americans are less likely than white Americans to seek professional treatment for depression. Whether treatment recommendations are sought and implemented by patients will be influenced by the role families and friends play in diagnostic acceptance and treatment decisions. We investigated the association of ethnicity with the perceived need for treatment of depression by family and friends of older primary care patients.

Design. Cross-sectional survey of 355 older adults with and without significant depressive symptoms was conducted. At the baseline visit, family and friends’ ratings of apathy and need for depression treatment were obtained on 314 of the 355 patients (88% response rate) and examined according to ethnicity. Participants were interviewed using standardized measures of chronic medical conditions, functional status, and psychological status.

Results. Older black patients compared to older white patients were less likely to be rated as needing depression treatment by their family and friends (odds ratio (OR)=0.34; 95% confidence interval (CI)=[0.18, 0.64]) adjusting for depressive symptoms, cognition, functional status, and other potentially influential characteristics.

Conclusions. Our study suggests that patient ethnicity may play a role in a family member's or friend's perceived need for depression treatment of older adults who present in the primary care setting. Further study of attitudes, expectations, and values of patients and family members or friends in primary care settings may help elucidate the interplay of physician, patient, and family member or friend.     

Delays in initial treatment contact after first onset of a mental disorder

OBJECTIVE: To examine nationally representative patterns and predictors of delays in contacting a professional after first onset of a mental disorder. DATA SOURCES: The National Comorbidity Survey, a nationally representative survey of 8,098 respondents aged 15-54. STUDY DESIGN: Cross-sectional survey. DATA COLLECTION: Assessed lifetime DSM-III-R mental disorders using a modified version of the Composite International Diagnostic Interview (CIDI). Obtained reports on age at onset of disorders and age of first treatment contact with each of six types of professionals (general medical doctors, psychiatrists, other mental health specialists, religious professionals, human services professionals, and alternative treatment professionals). Used Kaplan-Meier (KM) curves to estimate cumulative lifetime probabilities of treatment contact after first onset of a mental disorder. Used survival analysis to study the predictors of delays in making treatment contact. PRINCIPAL FINDINGS: The vast majority (80.1 percent) of people with a lifetime DSM-III-R disorder eventually make treatment contact, although delays average more than a decade. The duration of delay is related to less serious disorders, younger age at onset, and older age at interview. There is no evidence that delay in initial contact with a health care professional is increased by earlier contact with other non-health-care professionals. CONCLUSIONS: Within the limits of recalling lifetime events, it appears that delays in initial treatment contact are an important component of the larger problem of unmet need for mental health care. Interventions are needed to decrease these delays.     

团体人际心理治疗产后抑郁症的疗效观察

目的:探讨团体人际心理治疗对减轻产后抑郁症患者抑郁症状和改善社会功能的效果。方法:人际心理治疗组38例产后抑郁症患者进行8周的团体人际心理治疗,对照组的35例产后抑郁症患者给予一般治疗。两组患者在治疗前及治疗后3个月采用爱丁堡产后抑郁量表(EPDS)、汉密顿抑郁量表(HAMD)、人际问题问卷(IIP)及社会功能缺陷筛选量表(SDSS)等进行评估。结果:与对照组比较,治疗后3个月末的人际心理治疗组人际能力和社会功能改善更明显(P<0.01),人际心理治疗组抑郁症状的缓解程度明显优于对照组(P<0.01)。结论:团体人际心理治疗能够改善产后抑郁症患者的人际能力和社会功能,对产后抑郁症有较好的疗效。     

Adolescent depression: diagnosis, treatment, and educational attainment

In this paper, I use nationally representative longitudinal data to examine adolescent depression and educational attainment. First, I examine the individual, family, and community-level determinants of adolescent depression, diagnosis, and treatment. I find that male and minority adolescents who score high on depression scales are less likely to be diagnosed as depressed or receive treatment than female and non-Hispanic white adolescents. Additionally, I find several community-level variables to be important determinants of depression, diagnosis, and treatment. Second, I examine the importance of adolescent depression for educational attainment. Although it is uncontroversial to expect a negative relationship, most previous research uses cross-sectional data, making it difficult to adequately determine the magnitude of the effect. I find that depressive symptoms are related to educational attainment along multiple margins: dropping out of high school, college enrollment, and college type. These relationships are only found for adolescent females, and there are several interesting results across income groups. Overall, these findings suggest that further attempts to diagnose and treat adolescents with depressive symptoms are needed and that additional treatment options may be required to combat the important relationship between adolescent depression and human capital accumulation for females.     

中医心理疗法在社区卫生服务中的运用与思考

祖国医学十分重视心理治疗的作用,在病因、病机、诊断、治疗、养生等环节,都贯穿着心理学的思想内容。中医心理疗法因其注重天人合一、心身并治的观点,简单易行、安全有效的方法,与社区卫生服务提供“六位一体”便捷、可及、有效的服务功能不谋而合,得到了广泛的运用。在心身疾病日益增多的今天,将中医心理治疗融入社区卫生服务体系,推动中医药社区卫生服务建设必将有越来越宽广的发展前景。     

Predictors of patient entry into alcohol treatment after initial diagnosis

To improve the quality of care for alcohol-related disorders, key transitions in the continuum of care, including treatment entry, must be fully understood. The purpose of this study was to investigate identifiable predictors of patient entry into a substance-use treatment program following the initial diagnosis of an alcohol-related disorder on a medical or surgical inpatient unit. An administrative computerized database was used to identify the sample for this study. Inpatient and outpatient records were obtained from the Little Rock VAMC/DHCP. Predictors of patient entry into treatment within six months of the initial diagnosis of an alcohol related disorder included age younger than than 60 (odds ratio [OR]=4.6), not married (OR=1.7), primary diagnosis of an alcohol-related disorder (OR=7.7), diagnosis of a comorbid drug (OR=4.3) or psychiatric disorder (OR=3.6), diagnosis by a medical as opposed to a surgical specialty (OR=6.0), and African American (OR=1.7).     

脑卒中偏瘫后遗症期老年患者抑郁的治疗研究

目的 评价道家认知疗法对脑卒中偏瘫后遗症期老年患者抑郁及生活质量的影响.方法 77例脑卒中偏瘫后遗症期伴发抑郁的老年患者,按随机数字表法分为常规治疗组(38例)和综合治疗组(39例),常规治疗组采用抗抑郁剂联合一般支持性心理治疗,综合治疗组在此基础上进行道家认知治疗,两组均治疗8周,随访6个月.于治疗前,治疗后2、4、8周末及随访期末,采用汉密尔顿抑郁分级量表(HAMD)、脑卒中专用生活质量量表(SS-QOL)分别对患者的抑郁症状及生活质量进行评定,并进行统计学分析.结果 常规治疗组治疗后HAMD评分逐渐下降,治疗后8周[(22.35±4.69)分]与治疗前[(29.62±5.95)分]比较差异有统计学意义(t=6.425,P＜0.01);随访期末HAMD评分[(24.48±4.12)分]又升高,与治疗后8周比较差异有统计学意义(t=2.014,P＜0.05),但较治疗前HAMD评分仍显著降低(t=4.836,P＜0.01).常规治疗组SS-QOL评分在治疗后逐渐升高,治疗后8周[(105.39±25.84)分]与治疗前[(86.63±23.84)分]比较差异有统计学意义(t=4.933,P＜0.01);随访期末SS-QOL评分[(96.09±21.37)分]较治疗后8周又有所下降(t=2.543,P＜0.05),但较治疗前仍显著升高(t=2.790,P＜0.05).综合治疗组治疗后HAMD评分持续下降,治疗后8周[(20.08±4.60)分]及随访期末[(15.21±3.42)分]与治疗前[(30.14±4.92)分]比较差异均有统计学意义(t=8.341、15.443,P＜0.01),并且随访期末HAMD评分显著低于治疗后8周(t=4.724,P＜0.01).综合治疗组治疗后SS-QOL评分呈逐渐升高趋势,治疗后8周[(117.56±26.22)分]及随访期末[(126.57±21.82)分]较治疗前[(86.54±23.90)分]显著升高(t=6.716、8.916,P＜0.01);随访期末SS-QOL评分也较治疗后8周显著升高(t=2.378,P＜0.05).综合治疗组治疗后8周及随访期末HAMD评分显著低于常规治疗组同时间点评分(t=2.118,P＜0.05;t=8.405,P＜0.01),SS-QOL评分显著高于常规治疗组同时间点评分(t=3.123,P＜0.05;t=6.580,P＜0.01).结论 抗抑郁剂联合一般支持性心理治疗或在此基础上进行的道家认知治疗均可不同程度地改善脑卒中偏瘫后遗症期老年患者的抑郁症状,提高其生活质量.道家认知疗法起效虽慢,但远期疗效好.

Abstract：

Objective To evaluate the effects of Taoist cognitive psychotherapy on depression of aged patients with cerebral stroke hemiplegia convalescence. Methods Seventy-seven hemiplegia convalescence patients with depression were divided into general treatment group (38 patients, received general back-up psychology therapy) and combined treatment group (39 patients, received general back-up psychology therapy and Taoist cognitive psychotherapy) by random digits table. All patients were treated for 8 weeks and followed up for 6 months. Two groups were evaluated with HAMD and SS-QOL before treatment and at the end of the 2 weeks,4 weeks, 8 weeks and 6 months after treatment. The results were analyzed with statistics. Results In general treatment group, the HAMD scores were gradually decreased, and the HAMD scores of patients after 8 weeks' treatment were significantly lower than those before treatment[(22.35 ± 4.69)scores vs. (29.62 ± 5.95 ) scores,t = 6.425 ,P ＜ 0.01]. At the end of 6 months after treatment, the scores increased [(24.48 ± 4.12 ) scores vs. (22.35 ± 4.69 ) scores, t = 2.014, P ＜ 0.05], but they were lower than those before treatment(t = 4.836, P ＜ 0.01 ). At the end of 6 months after treatment, the SS-QOL scores were lower than those after 8 weeks' treatment (t =2.543,P ＜0.05),but they were higher than those before treatment (t = 2.790,P ＜ 0.05 ). In combined treatment group, the HAMD scores decreased continuously,and the scores after 8 weeks' treatment [(20.08 ± 4.60) scores] and 6 months' treatment [( 15.21 ± 3.42)scores] were significantly lower than those before treatment [( 30.14 ± 4.92 ) scores] (t = 8.341,15.443, P ＜0.01). Meanwhile,the HAMD scores after 6 months'treatment were significantly Iower than those after 8 weeks' treatment (t =4.724,P ＜ 0.01 ). The SS-QOL scores after 8 weeks' treatment [( 117.56 ± 26.22)scores] and 6 months' treatment [(126.57 ±21.82) scores] were significantly higher than those before treatment[(86.54 ± 23.90) scores] (t = 6.716,8.916,P ＜ 0.01 ) ,and there was significantly difference(t=2.378,P ＜ 0.05). The HAMD scores of combined treatment group after 8 weeks' and 6 months' treatment were significantly lower than those of general treatment group at the same time(t = 2.118, P ＜ 0.05 ;t = 8.405,P＜ 0.01 ) ,and SS-QOL scores were significantly higher than those of general treatment group at the same time (t = 3.123,P ＜ 0.05 ;t = 6.580,P ＜ 0.01 ). Conclusions General back-up psychology therapy combined with Taoist cognitive psychotherapy can improve depression and life quality of cerebral stroke hemiplegia convalescence in aged patients. The effects of Taoist cognitive psychotherapy is slower, but it is more beneficial in the long time.     

An educational training program for physicians for diagnosis and treatment of depression

OBJECTIVE: The American Regional Office of the WHO has launched a major initiative to reduce the prevalence of affective disorders region-wide that includes focusing on the primary health care system. This study evaluated the results of an educational training program for Brazilian primary care physicians that measured changes in knowledge, attitudes, and practice. METHODS: A total of 17 primary care physicians and 1,224 patients participated in the study. Physician's knowledge, attitudes, and clinical practice were assessed one-month prior and one-month following the training program. In addition, the patients that visited the clinic during a typical week completed depression symptom self-ratings, including the Zung and a DSM-IV/ICD-10 major depression checklist at both times. RESULTS: The training program showed limited benefits in this small sample of physicians. The program was unable to demonstrate benefit in improving knowledge about depression and in changing disorder-related attitudes. There were no changes in the diagnostic rates of major depression. There was some evidence to support improvement in psychopharmacological management. The physicians seemed more confident in treating patients, as there was a reduction of referrals to the specialists. Lack of statistical power prevented the latter two findings from reaching statistical significance. CONCLUSIONS: The inclusion of primary care physicians is a central component of any initiative to reduce the treatment gap and lag of depression. However, more effective methods of training Brazilian primary care physicians in the management of major depression need to be tested.     

Accessibility of Occupational Therapy Community Services: A Legal,Ethical, and Clinical Analysis

ABSTRACT

Accessibility of health care services is a major concern in many countries. This paper examines the impact of limited access to occupational therapy community services on the right to services, distributive justice (resource distribution based on social solidarity), and service quality. Legal documents and relevant scientific papers were analyzed from three standpoints: legal, ethical, and clinical. Random use of criteria to prioritize requests, partial response to complex needs, task delegation, and long waiting times, all affect distributive justice and compromise the right to and quality of services. Various alternatives are suggested to ensure a balance between the distribution and quality of occupational therapy services.     

母亲妊娠期疾病对青少年抑郁情绪的影响

  目的  了解广州市青少年抑郁情绪发生情况及母亲妊娠期疾病对青少年抑郁情绪的影响,为青少年抑郁的预防提供科学依据。  方法  采用分层整群随机抽样的方法,于2017年在广州市11个区抽取808所中小学,调查96 756名10~20岁青少年的父母他评抑郁症状以及母亲妊娠期疾病情况。  结果  父母他评青少年存在轻微、中度、重度抑郁情绪的发生率分别为5.5%,3.5%和0.5%。单因素分析显示,青少年抑郁情绪的严重程度与母亲妊娠期高血压、糖尿病、胆汁淤积症、甲状腺功能减退、甲状腺功能亢进、贫血、病毒性肝炎关联均有统计学意义(χ2=12.42~158.91,P值均 < 0.01);多因素Logistic回归显示,母亲患有妊娠期糖尿病(OR=1.41,95%CI=1.18~1.68)、妊娠期甲状腺功能减低(OR=1.61,95%CI=1.15~2.26)、妊娠期甲状腺功能亢进(OR=1.40,95%CI=1.03~1.91)、妊娠期贫血(OR=1.46,95%CI=1.35~1.59)、妊娠期合并病毒性肝炎(OR=1.67,95%CI=1.38~2.02)与青少年父母他评抑郁严重程度呈正相关(P值均 < 0.05)。  结论  母亲妊娠期患糖尿病、甲状腺功能减退、甲状腺功能亢进、贫血以及病毒性肝炎可能对青少年抑郁情绪及严重性有影响。