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Clarke G, Sheppler CR, Firemark AJ, Rawlings AM, Dickerson JF, Leo MC. Augmenting usual care SSRIs with cognitive behavioral therapy for insomnia to improve depression outcomes in youth: Design of a randomized controlled efficacy-effectiveness trial. Contemp Clin Trials 2020; 91:105967. [PMID: 32114185 PMCID: PMC7263975 DOI: 10.1016/j.cct.2020.105967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Extant treatments for youth depression are only modestly effective. Alternative approaches are needed to improve health outcomes. A novel approach to improve depression outcomes is suggested by epidemiological studies finding that insomnia often predates and may contribute to depression risk. We test whether treating insomnia among youth starting a new course of SSRI antidepressants improves depression outcomes. This paper describes our study design. DESIGN 2-arm randomized controlled efficacy-effectiveness trial. SETTING A large non-profit health maintenance organization. PARTICIPANTS 165 adolescents aged 12-19 with research-confirmed depression and insomnia diagnoses, starting a new episode of selective serotonin reuptake inhibitor (SSRI) antidepressant treatment prescribed by their usual care provider. INTERVENTIONS Two sleep interventions, each 6-7 sessions, both overlaying "treatment as usual" (TAU) SSRIs: a sleep hygiene (SH) attention control condition, and cognitive-behavioral therapy for insomnia (CBTI). CONCLUSIONS AND RELEVANCE If CBT-I improved sleep is shown to improve depression-related outcomes, this may provide an additional, easily tolerated intervention for an important public health target. TRIAL REGISTRATION clinicaltrials.gov, NCT02290496, https://clinicaltrials.gov/ct2/show/NCT02290496.
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Affiliation(s)
- Greg Clarke
- Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA.
| | - Christina R Sheppler
- Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA.
| | - Alison J Firemark
- Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA.
| | - Andreea M Rawlings
- Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA.
| | - John F Dickerson
- Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA.
| | - Michael C Leo
- Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA.
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Lu CY, Penfold RB, Toh S, Sturtevant JL, Madden JM, Simon G, Ahmedani BK, Clarke G, Coleman KJ, Copeland LA, Daida YG, Davis RL, Hunkeler EM, Owen-Smith A, Raebel MA, Rossom R, Soumerai SB, Kulldorff M. Near Real-time Surveillance for Consequences of Health Policies Using Sequential Analysis. Med Care 2018; 56:365-372. [PMID: 29634627 PMCID: PMC5896783 DOI: 10.1097/mlr.0000000000000893] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND New health policies may have intended and unintended consequences. Active surveillance of population-level data may provide initial signals of policy effects for further rigorous evaluation soon after policy implementation. OBJECTIVE This study evaluated the utility of sequential analysis for prospectively assessing signals of health policy impacts. As a policy example, we studied the consequences of the widely publicized Food and Drug Administration's warnings cautioning that antidepressant use could increase suicidal risk in youth. METHOD This was a retrospective, longitudinal study, modeling prospective surveillance, using the maximized sequential probability ratio test. We used historical data (2000-2010) from 11 health systems in the US Mental Health Research Network. The study cohort included adolescents (ages 10-17 y) and young adults (ages 18-29 y), who were targeted by the warnings, and adults (ages 30-64 y) as a comparison group. Outcome measures were observed and expected events of 2 possible unintended policy outcomes: psychotropic drug poisonings (as a proxy for suicide attempts) and completed suicides. RESULTS We detected statistically significant (P<0.05) signals of excess risk for suicidal behavior in adolescents and young adults within 5-7 quarters of the warnings. The excess risk in psychotropic drug poisonings was consistent with results from a previous, more rigorous interrupted time series analysis but use of the maximized sequential probability ratio test method allows timely detection. While we also detected signals of increased risk of completed suicide in these younger age groups, on its own it should not be taken as conclusive evidence that the policy caused the signal. A statistical signal indicates the need for further scrutiny using rigorous quasi-experimental studies to investigate the possibility of a cause-and-effect relationship. CONCLUSIONS This was a proof-of-concept study. Prospective, periodic evaluation of administrative health care data using sequential analysis can provide timely population-based signals of effects of health policies. This method may be useful to use as new policies are introduced.
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Affiliation(s)
- Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Robert B Penfold
- Department of Health Services Research, Kaiser Permanente Washington Health Research Institute, University of Washington, Seattle, WA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Jessica L Sturtevant
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Jeanne M Madden
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- School of Pharmacy, Northeastern University, Boston, MA
| | - Gregory Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research and Behavioral Health Services, Henry Ford Health System, Detroit, MI
| | - Gregory Clarke
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Karen J Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Laurel A Copeland
- Center for Applied Health Research, Baylor Scott & White Health jointly with Central Texas Veterans Health Care System, Temple, TX
| | - Yihe G Daida
- Center for Health Research, Kaiser Permanente Hawaii, Honolulu, HI
| | - Robert L Davis
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN
| | - Enid M Hunkeler
- Emeritus, Division of Research, Kaiser Permanente, Oakland, CA
| | - Ashli Owen-Smith
- Health Management & Policy, Georgia State University School of Public Health, Atlanta, GA
- Kaiser Permanente Georgia, The Center for Clinical and Outcomes Research, Atlanta, GA
| | - Marsha A Raebel
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO
| | | | - Stephen B Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Martin Kulldorff
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School and Brigham and Women's Hospital, Boston, MA
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Dickerson JF, Lynch FL, Leo MC, DeBar LL, Pearson J, Clarke GN. Cost-effectiveness of Cognitive Behavioral Therapy for Depressed Youth Declining Antidepressants. Pediatrics 2018; 141:peds.2017-1969. [PMID: 29351965 PMCID: PMC5810604 DOI: 10.1542/peds.2017-1969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adolescents with depression identified in primary care settings often have limited treatment options beyond antidepressant (AD) therapy. We assessed the cost-effectiveness of a brief cognitive behavioral therapy (CBT) program among depressed adolescents who declined or quickly stopped using ADs. METHODS A total of 212 youth with depression were randomly assigned to treatment as usual (TAU) or TAU plus brief individual CBT. Clinical outcomes included depression-free days (DFDs) and estimated quality-adjusted life-years (QALYs). Costs were adjusted to 2008 US dollars. Incremental cost-effectiveness ratios (ICERs) comparing CBT to TAU were calculated over 12- and 24-month follow-up periods. RESULTS Youth randomly assigned to CBT had 26.8 more DFDs (P = .044) and 0.067 more QALYs (P = .044) on average compared with TAU over 12 months. Total costs were $4976 less (P = .025) by the end of the 24-month follow-up among youth randomly assigned to CBT. Total costs per DFD were -$51 (ICER = -$51; 95% confidence interval [CI]: -$394 to $9) at 12 months and -$115 (ICER = -$115; 95% CI: -$1090 to -$6) at 24 months. Total costs per QALY were -$20 282 (ICER = -$20 282; 95% CI: -$156 741 to $3617) at 12 months and -$45 792 (ICER = -$45 792; 95% CI: -$440 991 to -$2731) at 24 months. CONCLUSIONS Brief primary care CBT among youth declining AD therapy is cost-effective by widely accepted standards in depression treatment. CBT becomes dominant over TAU over time, as revealed by a statistically significant cost offset at the end of the 2-year follow-up.
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Affiliation(s)
| | - Frances L. Lynch
- Kaiser Permanente Center for Health Research, Portland, Oregon; and
| | - Michael C. Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon; and
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - John Pearson
- Kaiser Permanente Center for Health Research, Portland, Oregon; and
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Coryell W, Yolken R, Butcher B, Burns T, Dindo L, Schlechte J, Calarge C. Toxoplasmosis Titers and past Suicide Attempts Among Older Adolescents Initiating SSRI Treatment. Arch Suicide Res 2016; 20:605-13. [PMID: 27045220 PMCID: PMC5067776 DOI: 10.1080/13811118.2016.1158677] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Latent infection with toxoplasmosis is a prevalent condition that has been linked in animal studies to high-risk behaviors, and in humans, to suicide and suicide attempts. This analysis investigated a relationship between suicide attempt history and toxoplasmosis titers in a group of older adolescents who had recently begun treatment with an SSRI. Of 108 participants, 17 (15.7 %) had a lifetime history of at least one suicide attempt. All were given structured and unstructured diagnostic interviews and provided blood samples. Two individuals (11.9%) with a past suicide attempt, and two (2.1%) without this history, had toxoplasmosis titers ≥ 10 IU/ml (p = 0.166). Those with a past suicide attempt had mean toxoplasmosis titers that were significantly different (p = 0.018) from those of patients who lacked this history. An ROC analysis suggested a lower optimal threshold for distinguishing patients with and without suicide attempts (3.6 IU/ml) than that customarily used to identify seropositivity. Toxoplasmosis titers may quantify a proneness to suicidal behavior in younger individuals being treated with antidepressants.
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Clarke G, DeBar LL, Pearson JA, Dickerson JF, Lynch FL, Gullion CM, Leo MC. Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial. Pediatrics 2016; 137:e20151851. [PMID: 27244782 PMCID: PMC4845864 DOI: 10.1542/peds.2015-1851] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Health care providers have few alternatives for youth depression other than antidepressants. We examined whether brief cognitive behavioral therapy (CBT) is a viable alternative in primary care. METHODS A total of 212 adolescents aged 12 to 18 with major depression who had recently declined or quickly discontinued new antidepressant treatment were randomized to self-selected treatment as usual (TAU) control condition or TAU plus brief individual CBT. Blinded evaluators followed youth for 2 years. The primary outcome was time to major depression diagnostic recovery. RESULTS CBT was superior to the control condition on the primary outcome of time to diagnostic recovery from major depression, with number needed to treat from 4 to 10 across follow-up. A similar CBT advantage was found for time to depression diagnosis response, with number needed to treat of 5 to 50 across time points. We observed a significant advantage for CBT on many secondary outcomes over the first year of follow-up but not the second year. Cohen's d effect sizes for significant continuous measures ranged from 0.28 to 0.44, in the small to medium effect range. Most TAU health care services did not differ across conditions, except for psychiatric hospitalizations, which occurred at a significantly higher rate in the control condition through the first year of follow-up. CONCLUSIONS Observed results were consistent with recent meta-analyses of CBT for youth depression. The initial year of CBT superiority imparted an important clinical benefit and may reduce the risk of future recurrent depression episodes.
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Affiliation(s)
- Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland Oregon
| | - Lynn L DeBar
- Kaiser Permanente Center for Health Research, Portland Oregon
| | - John A Pearson
- Kaiser Permanente Center for Health Research, Portland Oregon
| | | | - Frances L Lynch
- Kaiser Permanente Center for Health Research, Portland Oregon
| | | | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland Oregon
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Torio CM, Encinosa W, Berdahl T, McCormick MC, Simpson LA. Annual report on health care for children and youth in the United States: national estimates of cost, utilization and expenditures for children with mental health conditions. Acad Pediatr 2015; 15:19-35. [PMID: 25444653 DOI: 10.1016/j.acap.2014.07.007] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/24/2014] [Accepted: 07/31/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine national trends in hospital utilization, costs, and expenditures for children with mental health conditions. METHODS The analyses of children aged 1 to 17 are based on AHRQ's 2006 and 2011 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) databases, and on AHRQ's pooled 2006 to 2011 Medical Expenditure Panel Survey (MEPS). All estimates are nationally representative, and standard errors account for the complex survey designs. RESULTS Although overall all-cause children's hospitalizations did not increase between 2006 and 2011, hospitalizations for all listed mental health conditions increased by nearly 50% among children aged 10 to 14 years, and by 21% for emergency department (ED) visits. Behavioral disorders experienced a shift in underlying patterns between 2006 and 2011: inpatient stays for alcohol-related disorders declined by 44%, but ED visits increased by 34% for substance-related disorders and by 71% for impulse control disorders. Inpatient visits for suicide, suicidal ideation, and self-injury increased by 104% for children ages 1 to 17 years, and by 151% for children ages 10 to 14 years during this period. A total of $11.6 billion was spent on hospital visits for mental health during this period. Medicaid covered half of the inpatient visits, but with 50% to 30% longer length of stays in 2006 and 2011, respectively, than private payers. Medicaid's overall share of the ED visits increased from 45% in 2006 to 53% in 2011. CONCLUSIONS These alarming trends highlight the renewed need for research on mental health care for children. This study also provides a baseline for evaluating the impact of the Affordable Care Act and the mental health parity legislation on mental health utilization and expenditures for children.
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Affiliation(s)
- Celeste Marie Torio
- Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md.
| | - William Encinosa
- Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md
| | - Terceira Berdahl
- Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md
| | - Marie C McCormick
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Mass
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Mittal M, Harrison DL, Miller MJ, Brahm NC. National antidepressant prescribing in children and adolescents with mental health disorders after an FDA boxed warning. Res Social Adm Pharm 2014; 10:781-90. [DOI: 10.1016/j.sapharm.2013.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/05/2013] [Accepted: 11/05/2013] [Indexed: 10/26/2022]
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Gest S, Legenbauer T, Bogen S, Schulz C, Pniewski B, Holtmann M. Chronotherapeutics: An alternative treatment of juvenile depression. Med Hypotheses 2014; 82:346-9. [DOI: 10.1016/j.mehy.2014.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/11/2013] [Accepted: 01/03/2014] [Indexed: 01/25/2023]
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Antidepressant Use in Children, Adolescents, and Young Adults: 10 Years After the Food and Drug Administration Black Box Warning. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2013.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Chirdkiatgumchai V, Xiao H, Fredstrom BK, Adams RE, Epstein JN, Shah SS, Brinkman WB, Kahn RS, Froehlich TE. National trends in psychotropic medication use in young children: 1994-2009. Pediatrics 2013; 132:615-23. [PMID: 24082002 PMCID: PMC4074650 DOI: 10.1542/peds.2013-1546] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine recent national trends in psychotropic use for very young children at US outpatient medical visits. METHODS Data for 2- to 5-year-old children (N = 43 598) from the 1994-2009 National Ambulatory and National Hospital Ambulatory Medical Care Surveys were used to estimate the weighted percentage of visits with psychotropic prescriptions. Multivariable logistic regression was used to identify factors associated with psychotropic use. Time effects were examined in 4-year blocks (1994-1997, 1998-2001, 2002-2005, and 2006-2009). RESULTS Psychotropic prescription rates were 0.98% from 1994-1997, 0.83% from 1998-2001, 1.45% from 2002-2005, and 1.00% from 2006-2009. The likelihood of preschool psychotropic use was highest in 2002-2005 (1994-1997 adjusted odds ratio [AOR] versus 2002-2005: 0.67; 1998-2001 AOR versus 2002-2005: 0.63; 2006-2009 AOR versus 2002-2005: 0.64), then diminished such that the 2006-2009 probability of use did not differ from 1994-1997 or from 1998-2001. Boys (AOR versus girls: 1.64), white children (AOR versus other race: 1.42), older children (AOR for 4 to 5 vs 2 to 3 year olds: 3.87), and those lacking private insurance (AOR versus privately insured: 2.38) were more likely than children from other groups to receive psychotropic prescriptions. CONCLUSIONS Psychotropic prescription was notable for peak usage in 2002-2005 and sociodemographic disparities in use. Further study is needed to discern why psychotropic use in very young children stabilized in 2006-2009, as well as reasons for increased use in boys, white children, and those lacking private health insurance.
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Affiliation(s)
- Vilawan Chirdkiatgumchai
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Mail Location 4002, Cincinnati, OH 45229.
| | - Hong Xiao
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Bridget K. Fredstrom
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Ryan E. Adams
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Jeff N. Epstein
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Samir S. Shah
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - William B. Brinkman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Robert S. Kahn
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Tanya E. Froehlich
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
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Affiliation(s)
- Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
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