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Ishtiak-Ahmed K, Christensen KS, Mortensen EL, Nierenberg AA, Gasse C. Sociodemographics and clinical factors associated with depression treatment outcomes in 65,741 first-time users of selective serotonin reuptake inhibitors: A Danish cohort study in older adults. J Affect Disord 2024; 367:244-254. [PMID: 39233244 DOI: 10.1016/j.jad.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/25/2024] [Accepted: 09/01/2024] [Indexed: 09/06/2024]
Abstract
OBJECTIVE To investigate a wide range of sociodemographic and clinical factors associated with treatment outcomes in older adults who initiated an SSRI for depression treatment in a real-world setting. METHODS This cohort study used Danish registry data covering all older adults (aged ≥65) who initiated SSRIs for depression from 2006 to 2017, first-time (since 1995). We followed the individuals for one year after their SSRI prescription. Six different outcomes were analyzed, including treatment discontinuation, switching, augmentation, psychiatric hospital contacts for depression, psychiatric hospital admission, and suicide attempt/self-harm. Association analyses employed Poisson regression, estimating incidence rate ratios with 95 % confidence intervals. RESULTS The study included 65,741 individuals with a mean age of 78.23 years, and 55.6 % were females. During follow-up, 40.1 % discontinued, 4.8 % switched, 20.3 % received augmentation, 3.0 % had psychiatric hospital contacts for depression, 3.2 % had psychiatric admission, and 0.1 % had suicide attempt/self-harm records. Differential treatment outcomes were observed based on sociodemographic and clinical factors. For example, being female, residing predominantly in rural areas, having psychiatric or somatic diagnoses, and using medications acting on blood/blood-forming organs, the cardiovascular system, or musculo-skeletal systems were linked to fewer unfavorable clinical outcomes. Conversely, marital status as being single or separated and the use of nervous system drugs were associated with a higher risk of unfavorable outcomes. LIMITATIONS Confounding by indication might remain a problem, and depression severity data was not unavailable. CONCLUSIONS Our findings emphasize considering patient characteristics in clinical decisions, as they can influence the clinical course of those undergoing depression treatment.
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Affiliation(s)
- Kazi Ishtiak-Ahmed
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus 8000 Aarhus C, Denmark; Research Unit for General Practice, Aarhus University, Aarhus 8000 Aarhus C, Denmark
| | | | - Andrew A Nierenberg
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, Denmark; Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, USA; Harvard Medical School, Boston, MA, USA
| | - Christiane Gasse
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Psychosis Research Unit, Aarhus University Hospital - Psychiatry, Aarhus, Denmark
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Teigland C, Mohammadi I, Agatep BC, Boskovic DH, Velligan D. Relationship between social determinants of health and hospitalizations and costs in patients with major depressive disorder. J Manag Care Spec Pharm 2024; 30:978-990. [PMID: 39213148 PMCID: PMC11365563 DOI: 10.18553/jmcp.2024.30.9.978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND The relationship of patient characteristics and social determinants of health (SDOH) with hospitalizations and costs in patients with major depressive disorder (MDD) has not been assessed using real-world data. OBJECTIVE To identify factors associated with higher hospitalizations and costs in patients with MDD. METHODS A retrospective observational study identified patients aged 18 years and older newly diagnosed with MDD between July 1, 2016, and December 31, 2018. SDOH were linked to patients at the "near-neighborhood" level. Multivariable models assessed association of patient characteristics with hospitalizations (incidence rate ratios [95% CI]) and costs (cost ratios [95% CI]). RESULTS Of 1,958,532 patients with MDD, 49.6% had Commercial and 50.4% Medicaid insurance; mean ages were similar (43.9; 43.4) with more female patients (67.6%; 70.5%). MDD patients with Commercial insurance had a mean household income of $75,044; 53.2% were married; 76.5% owned their home; 64.4% completed high school or less; and 2.8% had limited English-language proficiency (LEP). Patients covered by Medicaid had a household income of $46,708; 68.1% lived alone with 41.6% married; 54.6% owned their home; more than 4-in-5 patients (80.8%) completed high school or less, and 6.3% had LEP. Nearly one-third of Medicaid insured patients with MDD had at least 1 hospitalization (29.6%) with a mean length of stay 6.8 days; total health care costs were $21,467 annually. Commercially insured patients with MDD had 14.7% hospitalization rates with a length of stay of 5.9 days; total costs were $14,531. Multivariable models show female patients are less likely (Commercial 0.87; Medicaid 0.80; P < 0.05), and patients with more comorbidities are more likely to be hospitalized (Commercial 1.33; Medicaid 1.27; P < 0.05). All treatment classes relative to antidepressants only increased likelihood of hospitalizations-particularly antipsychotic+antianxiety use (Commercial 2.99; Medicaid 2.29)-and costs (Commercial 2.32; Medicaid 2.00) (all P < 0.05). Household income was inversely associated with hospitalizations for both insured populations. LEP reduced the likelihood of hospitalizations by more than 70% among Medicaid patients (0.27, P < 0.05) and was associated with higher costs for Commercial (2.01) but lower costs for Medicaid (0.37) (P < 0.05). Living in areas with no shortage of mental health practitioners was associated with higher hospitalizations and costs. CONCLUSIONS We identified patient characteristics associated with higher rates of hospitalizations and costs in patients with MDD in 2 insured populations. Female sex, higher comorbidities, and living in areas with no shortage of mental health practitioners were associated with higher hospitalizations and costs, whereas income was inversely associated with hospitalizations. The findings suggest disparities in access to care related to income, LEP, and availability of mental health practitioners that should be addressed to assure equitable care for patients with MDD.
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Affiliation(s)
| | | | | | | | - Dawn Velligan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio
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Carona C, Pereira M, Araújo-Pedrosa A, Monteiro F, Cristina Canavarro M, Fonseca A. For Whom and for How Long Does the "Be a Mom" Intervention Work? A Secondary Analysis of Data From a Randomized Controlled Trial Exploring the Mid-Term Efficacy and Moderators of Treatment Response. Behav Ther 2024; 55:768-785. [PMID: 38937049 DOI: 10.1016/j.beth.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 06/29/2024]
Abstract
This study explored clinical and sociodemographic moderators of treatment response to "Be a Mom", an internet-based cognitive behavioral therapy (iCBT) intervention, from baseline to postintervention, in women at high risk for postpartum depression (PPD). The study also assessed the stability of women's treatment gains from baseline to 4-months postintervention (follow-up). This open-label randomized controlled trial (RCT) involved a sample of 1,053 postpartum Portuguese women identified as being at high risk for PPD (i.e., having a score of 5.5 or higher on the Postpartum Depression Predictors Inventory-Revised); participants were allocated to "Be a Mom" intervention group or a waiting-list control group, and completed self-report measures at baseline, postintervention, and a 4-month follow-up (554 women completed follow-up assessments). Depressive and anxiety symptoms were measured using the Edinburgh Postnatal Depression Scale and the anxiety subscale of the Hospital Anxiety and Depression Scale, and flourishing/positive mental health was assessed with the Mental Health Continuum. Regression models and linear mixed models were used to examine moderators of treatment and the mid-term efficacy of the "Be a Mom" intervention, respectively. The results revealed that treatment completion, higher depression scores at baseline, and higher income levels were linked to greater symptom reduction and positive mental health enhancement. Moreover, the efficacy of the "Be a Mom" intervention was supported at the 4-month follow-up. The "Be a Mom" intervention appears to be an effective iCBT tool for reducing psychological distress and enhancing positive mental health in women at risk for PPD, with therapeutic improvements maintained over a 4-month period.
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Lopes FV, Ravesteijn B, Van Ourti T, Riumallo-Herl C. Income inequalities beyond access to mental health care: a Dutch nationwide record-linkage cohort study of baseline disease severity, treatment intensity, and mental health outcomes. Lancet Psychiatry 2023; 10:588-597. [PMID: 37451293 DOI: 10.1016/s2215-0366(23)00155-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/06/2023] [Accepted: 04/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Existing literature shows low and unequal access to mental health treatment globally, resulting in policy efforts to promote access for vulnerable groups. Yet, there is little evidence about how inequalities develop once individuals start treatment. The greater use of mental health care among individuals with low income, such as in the Dutch system, might be driven by differences in need and might not necessarily lead to better treatment outcomes. In this study, we aimed to examine income inequalities in four stages of the mental health treatment pathway while adjusting for need. METHODS We constructed a nationwide retrospective cohort study, examining all patients aged older than 18 years with a first specialist mental health treatment record in the Netherlands between 2011 and 2016, excluding those who did not receive any treatment minutes. We linked patient-level data from treatment records to administrative data on income, demographics from municipal registries, and health insurance claims. We used multivariate models to estimate adjusted associations between household income quintile (standardised for household size) and outcomes characterising four stages of mental health treatment: severity at baseline assessment based on the Global Assessment of Functioning (GAF) score, treatment minutes received, functional improvement by the end of the initial record, and additional treatment in a subsequent record. Estimates were adjusted for patient need (97 categories of primary diagnosis and severity at baseline assessment measured by GAF) and demographic covariates. FINDINGS Our study population consisted of 951 530 adults with a first specialist mental health treatment record in the Netherlands between Jan 1, 2011, and Dec 31, 2016. Patients in our cohort were on average aged 45·0 years (range 19-107) and mostly female (529 859 [55·7%] women and 421 671 [44·3%] men; no ethnicity data were available). First, we found that patients with the lowest income had the greatest initial therapist-assessed disease severity (5·545 GAF points), which was 0·353 GAF points (95% CI 0·347-0·360) lower than those in the highest income quintile. Second, we found that the negative association between income and treatment minutes was reversed once we adjusted for diagnosis and severity at baseline, with patients with the lowest income receiving 1·8% fewer treatment minutes (95% CI 1·1-2·4) than those in the highest quintile. Third, those in the highest income quintile were 17·3 percentage points (95% CI 17·0-17·6) more likely to have functional improvements by the end of the initial record, compared with 25·8% of patients with an improvement in the lowest income quintile. Fourth, while 35·7% of patients in the lowest income quintile received additional treatment in a subsequent record, this was only 3·0 percentage points (95% CI 2·7-3·3) lower for those in the highest quintile. None of these patterns were explained by diagnosis, severity at baseline, or treatment minutes received. INTERPRETATION Disparities favourable to patients with a higher income persist through the different stages of mental health treatment. These differences highlight the limitations of solely focusing on improving access to care to reduce the mental health gap. Our findings call for a better understanding of the role of social environment and quality of care as complementary mechanisms explaining inequalities during mental health treatment. FUNDING Erasmus Initiative Smarter Choices for Better Health (Erasmus University Rotterdam), European Union's Horizon 2020, and Nederlandse Organisatie voor Wetenschappelijk Onderzoek (Dutch Research Council). TRANSLATION For the Dutch translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Francisca Vargas Lopes
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, Netherlands.
| | - Bastian Ravesteijn
- Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Netherlands; Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Tom Van Ourti
- Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Netherlands; Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Carlos Riumallo-Herl
- Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Netherlands; Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, Netherlands
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Mills JA, Suresh V, Strawn JR. Socioeconomic Predictors of Treatment Outcomes Among Adults With Major Depressive Disorder: In Reply. Psychiatr Serv 2023; 74:215-216. [PMID: 36722091 DOI: 10.1176/appi.ps.23074003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Cohen A. Socioeconomic Predictors of Treatment Outcomes Among Adults With Major Depressive Disorder. Psychiatr Serv 2023; 74:214-215. [PMID: 36722094 DOI: 10.1176/appi.ps.20220512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Alex Cohen
- London School of Hygiene & Tropical Medicine, University of London, London
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Community Initiated Care: A blue-print for the practical realization of contextual behavioral science. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2022. [DOI: 10.1016/j.jcbs.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Grummitt L, Barrett E, Kelly E, Newton N. An Umbrella Review of the Links Between Adverse Childhood Experiences and Substance Misuse: What, Why, and Where Do We Go from Here? Subst Abuse Rehabil 2022; 13:83-100. [PMID: 36411791 PMCID: PMC9675346 DOI: 10.2147/sar.s341818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/09/2022] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVES A wealth of research has identified adverse childhood experiences (ACEs; abuse, neglect, violence or disorder in the home) as a strong risk factor for substance misuse. Synthesis of the existing evidence is critical to shape policy and inform directions for future research. Existing reviews have focused on specific substances or substance use outcomes (eg, disorder), and do not include discussion of the mechanisms that operate between ACEs and substance misuse. The current umbrella review aims to synthesize reviews on the relationship between ACEs and substance misuse, review the evidence on the mechanisms linking these, identify existing gaps in our knowledge, and discuss critical directions for future research, practice, and public policy. METHODS Two electronic databases (PsycINFO and Medline) were searched for reviews published between 1998 and 2022 on the link between ACEs and substance misuse. Twenty articles met eligibility criteria and were qualitatively synthesized. RESULTS Results overwhelmingly demonstrated an elevated risk of substance misuse or disorder, among adolescents and adults exposed to ACEs. Research on the mechanisms that explain this link highlights a multitude of potential intervention targets, with childhood stress propelling a cascade of effects across neurobiological, endocrine, immune, metabolic, and nervous systems, impacting psychosocial and cognitive functioning. Nonetheless, the literature is subject to limitations surrounding potential unmeasured cofounders and causality, as well as decontextualizing childhood adversity from broader structural issues that influence the link between ACEs and substance misuse. Research, policy, and practice that seek to holistically understand and address the relationship between ACEs and substance misuse within the broader social determinants of health is crucial.
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Affiliation(s)
- Lucinda Grummitt
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Camperdown, NSW, Australia
| | - Emma Barrett
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Camperdown, NSW, Australia
| | - Erin Kelly
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Camperdown, NSW, Australia
| | - Nicola Newton
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Camperdown, NSW, Australia
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