자연주의적 탐구조사(Naturalistic Inquiry)

Basics of qualitative research: Grounded theory procedures and techniques

ContextUncertainties exist about prevalence and correlates of major depressive
disorder (MDD).ObjectiveTo present nationally representative data on prevalence and correlates
of MDD by Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) criteria, and on study
patterns and correlates of treatment and treatment adequacy from the recently
completed National Comorbidity Survey Replication (NCS-R).DesignFace-to-face household survey conducted from February 2001 to December
2002.SettingThe 48 contiguous United States.ParticipantsHousehold residents ages 18 years or older (N = 9090) who responded
to the NCS-R survey.Main Outcome MeasuresPrevalence and correlates of MDD using the World Health Organization's
(WHO) Composite International Diagnostic Interview (CIDI), 12-month severity
with the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR),
the Sheehan Disability Scale (SDS), and the WHO disability assessment scale
(WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.ResultsThe prevalence of CIDI MDD for lifetime was 16.2% (95% confidence interval
[CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95%
CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases
were independently classified as clinically significant using the QIDS-SR,
with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean
episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured
by SDS was substantial as indicated by 59.3% of 12-month cases with severe
or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%)
cases had comorbid CIDI/DSM-IV disorders, with MDD
only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases
received health care treatment for MDD, treatment was adequate in only 41.9%
(95% CI, 35.9-47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2)
of 12-month MDD being adequately treated. Sociodemographic correlates of treatment
were far less numerous than those of prevalence.ConclusionsMajor depressive disorder is a common disorder, widely distributed in
the population, and usually associated with substantial symptom severity and
role impairment. While the recent increase in treatment is encouraging, inadequate
treatment is a serious concern. Emphasis on screening and expansion of treatment
needs to be accompanied by a parallel emphasis on treatment quality improvement.

/pdf/the-epidemiology-of-major-depressive-disorder-results-from-2kfxdgis3p.pdf

The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R).

Dementia prevention, intervention, and care

Statistical Analysis with Missing Data

ContextRecent advances in pharmacotherapy and changing health care environments
have focused increased attention on trends in outpatient treatment of depression.ObjectiveTo compare trends in outpatient treatment of depressive disorders in
the United States in 1987 and 1997.Design and SettingAnalysis of service utilization data from 2 nationally representative
surveys of the US general population, the 1987 National Medical Expenditure
Survey (N = 34 459) and the 1997 Medical Expenditure Panel Survey (N
= 32 636).ParticipantsRespondents who reported making 1 or more outpatient visits for treatment
of depression during that calendar year.Main Outcome MeasuresRate of treatment, psychotropic medication use, psychotherapy, number
of outpatient treatment visits, type of health care professional, and source
of payment.ResultsThe rate of outpatient treatment for depression increased from 0.73
per 100 persons in 1987 to 2.33 in 1997 (P<.001).
The proportion of treated individuals who used antidepressant medications
increased from 37.3% to 74.5% (P<.001), whereas
the proportion who received psychotherapy declined (71.1% vs 60.2%, P = .006). The mean number of depression treatment visits
per user declined from 12.6 to 8.7 per year (P =
.05). An increasingly large proportion of patients were treated by physicians
for their condition (68.9% vs 87.3%, P<.001),
and treatment costs were more often covered by third-party payers (39.3% to
55.2%, P<.001).ConclusionsBetween 1987 and 1997, there was a marked increase in the proportion
of the population who received outpatient treatment for depression. Treatment
became characterized by greater involvement of physicians, greater use of
psychotropic medications, and expanding availability of third-party payment,
but fewer outpatient visits and less use of psychotherapy. These changes coincided
with the advent of better-tolerated antidepressants, increased penetration
of managed care, and the development of rapid and efficient procedures for
diagnosing depression in clinical practice.

https://jamanetwork.com/journals/jama/articlepdf/194548/JOC11356.pdf

National trends in the outpatient treatment of depression

Context Antidepressants have recently become the most commonly prescribed class of medications in the United States. Objective To compare sociodemographic and clinical patterns of antidepressant medication treatment in the United States between 1996 and 2005. Design Analysis of antidepressant use data from the 1996 (n = 18 993) and 2005 (n = 28 445) Medical Expenditure Panel Surveys. Setting Households in the United States. Participants Respondents aged 6 years or older who reported receiving at least 1 antidepressant prescription during that calendar year. Main Outcome Measures Rate of antidepressant use and adjusted rate ratios (ARRs) of year effect on rate of antidepressant use adjusted for age, sex, race/ethnicity, annual family income, self-perceived mental health, and insurance status. Results The rate of antidepressant treatment increased from 5.84% (95% confidence interval [CI], 5.47-6.23) in 1996 to 10.12% (9.58-10.69) in 2005 (ARR, 1.68; 95% CI, 1.55-1.81), or from 13.3 to 27.0 million persons. Significant increases in antidepressant use were evident across all sociodemographic groups examined, except African Americans (ARR, 1.13; 95% CI, 0.89-1.44), who had comparatively low rates of use in both years (1996, 3.61%; 2005, 4.51%). Although antidepressant treatment increased for Hispanics (ARR, 1.75; 95% CI, 1.60-1.90), it remained comparatively low (1996, 3.72%; 2005, 5.21%). Among antidepressant users, the percentage of patients treated for depression did not significantly change (1996, 26.25% vs 2005, 26.85%; ARR, 0.95; 95% CI, 0.83-1.07), although the percentage of patients receiving antipsychotic medications (5.46% vs 8.86%; ARR, 1.77; 95% CI, 1.31-2.38) increased and those undergoing psychotherapy declined (31.50% vs 19.87%; ARR, 0.65; 95% CI, 0.56-0.72). Conclusions From 1996 to 2005, there was a marked and broad expansion in antidepressant treatment in the United States, with persisting low rates of treatment among racial/ethnic minorities. During this period, individuals treated with antidepressants became more likely to also receive treatment with antipsychotic medications and less likely to undergo psychotherapy.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/483159/yoa90007_848_856.pdf

National Patterns in Antidepressant Medication Treatment

Objectives Little information exists on national trends in the use of psychotropic medication by children and adolescents. The objective of this report is to compare patterns and predictors of psychotropic medication use by children and adolescents in the United States in 1987 and 1996. Method An analysis of medication use data is presented from two nationally representative surveys of the general population focusing on children 18 years of age and younger who used one or more prescribed psychotropic medication during the survey years. Rates of stimulant, antidepressant, and other psychotropic medication use are reported. Results The overall annual rate of psychotropic medication use by children increased from 1.4 per 100 persons in 1987 to 3.9 in 1996 ( p Conclusion Between 1987 and 1996, there was a marked expansion in use of psychotropic medications by children, especially stimulants and antidepressants.

National Trends in the Use of Psychotropic Medications by Children

Context.—Psychotropic medications are widely prescribed, but how new classes
of psychotropic medications have affected prescribing patterns has not been
well documented.Objective.—To examine changes between 1985 and 1994 (data from 1993 and 1994 were
combined) in the prescribing patterns of psychotropic medications by office-based
primary care physicians, psychiatrists, and other medical specialists.Design.—National estimates for the number of visits during which a physician
prescribed a psychotropic medication based on the National Ambulatory Medical
Care Surveys conducted in 1985, 1993, and 1994.Setting.—Office-based physician practices in the United States.Participants.—A systematically sampled group of office-based physicians.Main Outcome Measures.—National estimates of visits that included a psychotropic medication.Results.—The number of visits during which a psychotropic medication was prescribed
increased from 32.73 million to 45.64 million; the proportion of such visits,
as a proportion of all visits, increased from 5.1% to 6.5% (P≤.01). Antianxiety or hypnotic drug visits, previously the largest
category, decreased as a proportion of psychotropic drug visits (P≤.01) and are now surpassed by antidepressant visits. Visits for
depression increased from 10.99 million in 1988 to 20.43 million in 1993 and
1994 (P≤.01). Stimulant drug visits increased
from 0.57 million to 2.86 million (P≤.01). Although
visits for depression doubled for both primary care physicians and psychiatrists,
the proportion of visits for depression during which an antidepressant was
prescribed increased for psychiatrists but not for primary care physicians.Conclusions.—The patterns of psychotropic medication use in outpatient medical practice
changed dramatically during the study period, especially in psychiatric practice.

https://jamanetwork.com/journals/jama/articlepdf/187256/JOC7421.pdf

Prescribing Trends in Psychotropic Medications Primary Care, Psychiatry, and Other Medical Specialties

Context A decade of increasing antidepressant medication treatment for adolescents and corresponding declines in suicide rates raise the possibility that antidepressants have helped prevent youth suicide. Objective To evaluate the relationship between regional changes in antidepressant medication treatment and suicide in adolescents from 1990 to 2000. Design Analysis of prescription data from the nation's largest pharmacy benefit management organization, national suicide mortality files, regional sociodemographic data from the 1990 and 2000 US Census, and regional data on physicians per capita. Participants Youth aged 10 to 19 years who filled a prescription for antidepressant medication and same-aged completed suicides from 588 three-digit ZIP code regions in the United States. Main Outcome Measures The relationship between regional change in antidepressant medication treatment and suicide rate stratified by sex, age group, regional median income, and regional racial composition. Results There was a significant adjusted negative relationship between regional change in antidepressant medication treatment and suicide during the study period. A 1% increase in adolescent use of antidepressants was associated with a decrease of 0.23 suicide per 100 000 adolescents per year (β= −.023, t = −5.14, P t =−3.81, P t = −3.43, P t = −3.73, P Conclusions An inverse relationship between regional change in use of antidepressants and suicide raises the possibility of a role for using antidepressant treatment in youth suicide prevention efforts, especially for males, older adolescents, and adolescents who reside in lower-income regions.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/207944/yoa30185.pdf

Steven C. Marcus

Papers

National trends in the outpatient treatment of depression

National Patterns in Antidepressant Medication Treatment

National Trends in the Use of Psychotropic Medications by Children

Prescribing Trends in Psychotropic Medications Primary Care, Psychiatry, and Other Medical Specialties

Relationship Between Antidepressant Medication Treatment and Suicide in Adolescents