Antidepressant Medication Use for Primary Care Patients with and without Medical Comorbidities: A National Electronic Health Record (EHR) Network Study

The Journal of the American Board of Family Medicine

Michael S. Klinkman¹  James M. Gill²  Ying Xia Chen² 

[1] Departments of Family and Community Medicine and the Department of Psychiatry, University of Michigan, Ann Arbor (MSK);Delaware Valley Outcomes Research, Newark, DE (JMG, YXC)

关键词: Practice-based Research;    PBRN;    Electronic Medical Records;    Primary Health Care;    Chronic Disease;   

DOI  :  10.3122/jabfm.2010.04.090299

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

Background: Because comorbid depression can complicate medical conditions (eg, diabetes), physicians may treat depression more aggressively in patients who have these conditions. This study examined whether primary care physicians prescribe antidepressant medications more often and in higher doses for persons with medical comorbidities.

Methods: This secondary data analysis of electronic health record data was conducted in the Centricity Health Care User Research Network (CHURN), a national network of ambulatory practices that use a common outpatient electronic health record. Participants included 209 family medicine and general internal medicine providers in 40 primary care CHURN offices in 17 US states. Patients included adults with a new episode of depression that had been diagnosed during the period October 2006 through July 2007 (n = 1513). Prescription of antidepressant medication and doses of antidepressant medication were compared for patients with and without 6 comorbid conditions: diabetes, coronary heart disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, and cancer.

Results: 20.7% of patients had at least one medical comorbidity whereas 5.8% had multiple comorbidities. Overall, 77% of depressed patients were prescribed antidepressant medication. After controlling for age and sex, patients with multiple comorbidities were less likely to be prescribed medication (adjusted odds ratio, 0.58; 95% CI, 0.35–0.96), but there was no significant difference by individual comorbidities. Patients with cerebrovascular disease were less likely to be prescribed a full dose of medication (adjusted odds ratio, 0.26; 95% CI, 0.08–0.88), but there were no differences for other comorbidities or for multiple comorbidities, and there was no difference for any comorbidities in the prescription of minimally effective doses.

Conclusions: Patients with new episodes of depression who present to a primary care practice are not treated more aggressively if they have medical comorbidities. In fact, patients with multiple comorbidities are treated somewhat less aggressively.

• Practice-based Research
• PBRN
• Electronic Medical Records
• Primary Health Care
• Chronic Disease

Depression is among the most common chronic conditions seen in primary care, with nearly 17% of the adult population in the community meeting criteria for major depressive disorder (MDD) during their lifetime¹ and nearly 7% experiencing MDD during a 12-month period.² The prevalence of MDD is even higher among those persons who receive care in the primary care setting,³ which is where most persons who seek care for their depression receive this care.^3,4

Although depression is common among all populations, it is more common in persons with chronic medical conditions.⁵ In particular, studies have shown the prevalence of depression to be higher for persons with diabetes mellitus,^6,7 heart disease,^8–11 stroke,⁷ chronic obstructive pulmonary disease (COPD),¹² and cancer.^13–15

Comorbid depression can exacerbate the chronic medical condition or even increase mortality in persons with these chronic medical conditions. For example, studies have shown that depression is associated with worse glycemic control¹⁶ and higher mortality^17,18 in those with diabetes; higher morbidity¹⁹ and mortality²⁰ in patients after myocardial infarction; higher rates of hospitalization among stroke patients;²¹ and reduced survival among cancer patients.²² Therefore, some authors have argued that physicians should be particularly vigilant in the diagnosis and treatment of depression in persons with chronic diseases such as cancer²³ and heart disease.¹⁰

However, there is little evidence that primary care physicians treat depression more aggressively in patients who have comorbid medical conditions. It could be that physicians actually treat depression less aggressively in patients who have serious comorbidities, partly because of concerns about the adverse effects of antidepressant medications.^8,24 One recent study found that depressed patients who had diabetes were more likely to be prescribed antidepressant medications than patients who did not have diabetes, but patients who had coronary heart disease (CHD) were less likely to be prescribed antidepressant medications and that there was no difference for patients who had cancer or cerebrovascular disease (CVD).²⁵ However, that study was limited in its applicability to primary care because many of the physicians studied were specialists who do not normally treat depression.

The purpose of this analysis was to examine antidepressant treatment for patients who experienced new episodes of depression and were diagnosed in primary care offices that are part of a national research network. It was hypothesized that these patients would be more likely to be treated with antidepressants if they had chronic comorbid medical conditions including diabetes, CHD, congestive heart failure, CVD, COPD, or cancer. Second, it was hypothesized that patients who had comorbid medical conditions would be more likely to be treated with higher doses of antidepressant medications than patients who did not have these comorbid conditions.

【 授权许可】

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