David A. Sclar

Trends in the rate of depressive illness and use of antidepressant pharmacotherapy by ethnicity/race: an assessment of office-based visits in the United States, 1992–1997

OBJECTIVE This study was undertaken to determine ethnicity/race-specific (white, black, and Hispanic) population-adjusted rates of US office-based physician visits in which a diagnosis of a depressive disorder was recorded or in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. METHODS Data from the National Ambulatory Medical Care Survey for 1992 through 1997 were partitioned into three 2-year periods: 1992-1993, 1994-1995, and 1996-1997. For each 2-year period, data from office-based physician visits for patients aged 20 to 79 years were extracted to assess, by ethnicity/race, (1) the number of visits in which a diagnosis of a depressive illness was recorded (International Classification of Diseases, Ninth Revision, Clinical Modification codes 296.2-296.36, 300.4, or 311) and (2) the number of visits in which a diagnosis of a depressive illness was recorded and antidepressant pharmacotherapy was prescribed. We calculated ethnicity/race-specific rates (per 100 US population aged 20 to 79 years) of office-based visits in which a diagnosis of a depressive disorder was recorded and in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. The specialty of the reporting physician and the proportion of patients receiving a selective serotonin reuptake inhibitor (SSRI) were also discerned. RESULTS From 1992-1993 to 1996-1997, the rate of office-based visits (per 100 US population aged 20 to 79 years) in which a diagnosis of a depressive disorder was recorded increased 3.7% for whites (from 10.9 to 11.3; P = 0.001), 31.0% for blacks (from 4.2 to 5.5; P = 0.001), and 72.9% for Hispanics (from 4.8 to 8.3; P = 0.001). The rate of office-based visits in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed increased 18.5% for whites (from 6.5 to 7.7 per 100; P = 0.001), 38.5% for blacks (from 2.6 to 3.6 per 100; P = 0.001). and 106.7% for Hispanics (from 3.0 to 6.2 per 100; P = 0.001). Between 1992-1993 and 1996-1997, use of an SSRI increased among whites and blacks (from 50.0% to 65.8% and from 40.5% to 58.2%, respectively), but declined among Hispanics (from 51.4% to 48.6%; all comparisons P = 0.001). CONCLUSION By 1996-1997, the population-adjusted rates for Hispanics were within a quartile of those observed for whites, whereas the rates for blacks remained at less than half those observed in whites. The observed divergence in population-adjusted rates by ethnicity/race may reflect the nature of the patient-physician relationship, sensitivity and specificity of diagnostic techniques and instruments, and the wider social context in which an office-based visit occurs, including access to and type of health insurance and coverage for mental health services.

Cancer-Screening Determinants Among Hispanic Women Using Migrant Health Clinics

This study was designed to identify determinants of breast and cervical cancer screening among rural, low-income Hispanic women using migrant health clinics in eastern Washington state. Five hundred and twelve foreign-born Hispanic women were interviewed. Odds ratios and 95 percent confidence intervals generated via logistic regression analysis were used to discern the influence of independent factors on use or nonuse of Papanicolaou (Pap) smear, breast self-examination (BSE), and mammography. Being married, having a higher income, more years of education, and longer U.S. residency predicted receipt of Pap smear. Women who performed BSE had higher incomes and were more likely to have been taught how to perform the procedure. Low concern for direct expenditure and increasing years of U.S. residency predicted receipt of mammogram. On the basis of these findings, implications for developing cancer-screening interventions using inreach and outreach strategies to target this high-risk subgroup are discussed.

Ethnicity/race and the diagnosis of depression and use of antidepressants by adults in the United States

The objective of this study is to discern ethnic/race-specific (black, Hispanic, white) population-adjusted rates of US office-based visits documenting a diagnosis of depression, and the extent of the use of antidepressant pharmacotherapy for its treatment. Data from the National Ambulatory Medical Care Survey for the time-frames 1992–1997, and 2003–2004, were partitioned into four, 2-year time intervals for trend analysis among patients aged 20–79 years. From 1992–1993 to 2003–2004, the annualized rate of visits documenting a diagnosis of depression increased from 10.9 to 15.4 per 100 US population for whites, from 4.2 to 7.6 for blacks, and from 4.8 to 7.0 for Hispanics. A concomitant diagnosis of depression and antidepressant use increased from 6.5 to 11.4 per 100 for whites, from 2.6 to 5.2 for blacks, and from 3.0 to 5.6 for Hispanics. It can be concluded that by 2003–2004, diagnostic and treatment rates were comparable among blacks and Hispanic, but were less than half the observed rates for whites.

Proton pump inhibitors increase the risk for hospital-acquired Clostridium difficile infection in critically ill patients

IntroductionProton pump inhibitors (PPI) have been linked to Clostridium difficile infection (CDI) but there are few data specific to ICU patients. We evaluated duration of PPI exposure as a potential risk factor for hospital-acquired CDI in the ICU.MethodsThis retrospective, case-control study was conducted using the Multiparameter Intelligent Monitoring in Intensive Care II database, a large publically available database of more than 35,000 ICU patients. Adult patients with CDI were identified using the ICD-9 code for Clostridium difficile listed as a secondary diagnosis. To be included, patients had to be present in an ICU for ≥48 hours prior to Clostridium difficile acquisition. These patients were then matched to patients without CDI using the ICD-9 primary diagnosis, age (+/−5 years) and SOFA score (+/−1). Successfully matched patients were reviewed for PPI exposure and other potential confounding variables for CDI. PPI exposure was characterized as short (<2 days) or long (≥2 days). Multivariate modeling was performed to identify independent risk factors for CDI.ResultsThere were 408 patients evaluated and 81% received a PPI. The percentage of patients who had a long exposure to PPIs was 83% in the CDI group compared to 73% with controls (P = 0.012). Upon inclusion of the following variables into a multivariate analysis (long PPI exposure, histamine-2-receptor antagonist administration, antibiotic administration, immunosuppression and study duration), long PPI exposure (odds ratio (OR) (95% confidence interval (CI) = 2.03 (1.23 to 3.36), P = 0.006) and antibiotic use (OR (95% CI) = 2.52 (1.23 to 5.18), P = 0.012) were identified as independent predictors of CDI.ConclusionsProton pump inhibitors are independent risk factors for the development of CDI in ICU patients. This risk is particularly exposed after two or more days of therapy.

Anaphylaxis: Underdiagnosed, Underreported, and Undertreated

Diagnostic criteria and administrative codes for anaphylaxis have evolved in recent years, partly reflecting the challenges in recognizing anaphylaxis and understanding its symptoms. Before the diagnostic criteria were disseminated by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network, several studies showed that a substantial proportion of anaphylaxis cases presenting to the emergency department (ED) were not recognized as such. Furthermore, epinephrine, the first-line treatment, was used in fewer than half of cases, especially if anaphylaxis was not diagnosed at the time. Although management practices may have improved since that time, anaphylaxis continues to be underrecognized and undertreated in the US. Of particular concern are findings that the majority of patients who visited the ED for an acute allergic reaction or anaphylaxis were not given a prescription for an epinephrine autoinjector, educated about avoiding the offending allergen, or advised to consult with an allergist. Improvements in the recognition and management of anaphylaxis have the potential to reduce the substantial burden that it currently places on the health care system. The articles in this supplement cover a wide range of issues surrounding anaphylaxis and seek to disseminate information helpful to health care professionals in general and primary care providers in particular.

Treatment modalities among US children diagnosed with attention-deficit hyperactivity disorder: 1995-99.

The objective of this study was to determine the prevalence of single and combination treatment modalities among US children aged 5–18 years who were diagnosed with attention-deficit hyperactivity disorder (ADHD). Treatments included: (i) stimulant pharmacotherapy alone; (ii) psychotherapy and/or mental health counselling alone; (ii) a combination; or (iv) no treatment. Data from the US National Ambulatory Medical Care Survey (NAMCS) for the years 1995–99, were used for this analysis. Office-based physician-patient visits documenting a recorded diagnosis of ADHD (ICD-9-CM codes 314.00 or 314.01) were extracted from the NAMCS. Findings are presented for children diagnosed with ADHD with or without comorbid mental illness, for children diagnosed with ADHD without comorbid mental illness, by gender, and by age groups. Over the timeframe 1995–99, an estimated 14 402 090 office-based visits documented a diagnosis of ADHD, with (24%) or without (76%) comorbid mental illness, among children aged 5–18 years. Overall, the most frequent treatment was stimulant medication alone (42.0%). This was followed by the combination treatment of stimulant medication plus psychotherapy and/or mental health counselling (32.1%). Only 10.8% of the children received psychotherapy and/or mental health counselling alone; 15.1% received no treatment beyond the office-based visit. This pattern was consistent for boys and girls; however, a larger proportion of boys (11.7%) were receiving psychotherapy and/or mental health counselling alone than girls (8.2%). More girls (18.7%) were receiving no treatment option compared to boys (13.9%). The percentage of children receiving psychotherapy and/or mental health counselling alone increased with each age group (6.7%, 5–8 years; 11.3%, 9–12 years; 13.6%, 13–18 years), as did the combination treatment of stimulant medication plus psychotherapy and/or mental health counselling (28.2%, 31%, 37.3%, respectively). Only 8.2% of children age 13–18 years were receiving no treatment option compared to 16.9% of children age 9–12 years, and 19.5% of those aged 5–8 years. The reasons for the gender and age group differences discerned in this study require further investigation, as does the reason why 15.1% of children were receiving no treatment beyond the office-based visit.

Trends in Prescriptions for Antidepressant Pharmacotherapy Among US Children and Adolescents Diagnosed With Depression, 1990 Through 2001: An Assessment of Accordance With Treatment Recommendations From the American Academy of Child and Adolescent Psychiatry

BACKGROUND In 1998, the American Academy of Child and Adolescent Psychiatry (AACAP) published a position paper supporting the use of selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacotherapy for the treatment of depression among children and adolescents. Tricyclic antidepressants (TCAs) were not recommended because of insufficient efficacy evidence, as well as adverse events. OBJECTIVE The present study was designed to discern the prescribing patterns for antidepressants among US children and adolescents aged 5 to 18 years diagnosed with depression between 1990 and 2001 (ie, before and after the publication of the AACAP paper). METHODS Data derived from the US National Ambulatory Medical Care Survey for the years 1990 through 2001 were used for this retrospective, cross-sectional analysis examining children and adolescents aged 5 to 18 years. Information from physician-patient encounters (office-based visits), documenting a diagnosis of depression (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 296.2-296.36, 300.4, or 311) were extracted. Data were categorized into three 4-year time intervals: 1990 through 1993; 1994 through 1997; and 1998 through 2001. RESULTS Overall, the rate of antidepressant prescriptions for US patients who received a diagnosis of depression increased from 44.4% (1,138,689/2,561,890) in the period from 1990 through 1993 to 59.3% (4,103,683/6,923,040) in the period from 1998 through 2001. SSRI prescriptions increased from 20.7% (530,642/2,561,890) in the period from 1990 through 1993 to 39.7% (2,745,293/6,923,040) in the period from 1998 through 2001; TCA prescriptions decreased from 21.0% (537,906/2,561,890) in the period from 1990 through 1993 to 2.7% (188,823/6,923,040) in the period from 1998 through 2001. The US population-adjusted rate of a diagnosis of depression with or without comorbid mental illness (ICD-9-CM codes 290-296.19, 296.4-300.39, 300.5-310.99, or 312.0-319) increased 2.4-fold from 12.9 per 1000 in the period from 1990 through 1993 to 31.1 in the period from 1998 through 2001. Among these patients, the prescribing of an antidepressant increased 3.2-fold (5.7 per 1000 in the period from 1990 through 1993 to 18.4 in the period from 1998 through 2001). The population-adjusted rate of SSRI prescribing increased 4.6-fold from 2.7 per 1000 children and adolescents in the period from 1990 through 1993 to 12.3 in the period from 1998 through 2001. CONCLUSIONS From 1990 through 2001, prescription patterns for antidepressant pharmacotherapy among children and adolescents aged 5 to 18 years changed. In accordance with the recommendation made by the AACAP in 1998, prescriptions for SSRIs increased, whereas prescriptions for TCAs all but disappeared.

Concomitant Triptan and SSRI or SNRI Use: A Risk for Serotonin Syndrome

Objective.— To discern the prevalence of concomitant use of a triptan and a selective serotonin reuptake inhibitor (SSRI) or a selective serotonin/norepinephrine reuptake inhibitor (SNRI) in the USA.

Economic appraisal of citalopram in the management of single-episode depression

A retrospective intent-to-treat analysis (N = 1,339) was conducted to discern the natural course of antidepressant use and direct health service expenditures for the treatment of single-episode depression (DSM-IV code 296.20) among patients initiating antidepressant pharmacotherapy with either a tricyclic antidepressant (TCA) (amitriptyline, N = 237) or a selective serotonin reuptake inhibitor (SSRI) (citalopram, N = 71; fluoxetine, N = 411; paroxetine, N = 334; or sertraline, N = 286). Data were derived from the computer archive of a network-model health maintenance organization for the period of January 1, 1996, through April 30, 1999. Comparisons at the end of the 6-month post-period (180 days) were undertaken between cohorts initiating antidepressant pharmacotherapy with citalopram and each SSRI or TCA. Consistent with the intent-to-treat design, all accrued health service expenditures were assigned to the pharmacotherapeutic option initially prescribed. Multivariate models were adjusted for patients age, gender, number of concomitant disease state processes, use of health services in the 6-month time frame (180 days) before initiating antidepressant pharmacotherapy, specialty of physician recording a diagnosis of single-episode depression, and the presence or absence of a previous diagnosis of single-episode depression and receipt of antidepressant pharmacotherapy. Patients initiating antidepressant pharmacotherapy with citalopram were far more likely to (1) have been diagnosed by a psychiatrist (37%; p < or = 0.05); (2) continue with the original pharmacotherapeutic option (79%) compared with patients originally prescribed amitriptyline (51%; chi2 = 17.29, df = 1, p < or = 0.05) or sertraline (65%; chi2 = 36.91, df = 1, p < or = 0.05); no significant difference was found compared with patients initiating antidepressant pharmacotherapy with paroxetine (72%; p = not significant [NS]) or fluoxetine (83%; p = NS); (3) obtain 90 days or more of antidepressant pharmacotherapy (86%) compared with those prescribed amitriptyline (69%; chi2 = 8.09, df = 1, p < or = 0.05); no significant difference was found compared with sertraline (77%), paroxetine (81%), or fluoxetine (84%); and (4) obtain 6 months (180 days) of antidepressant pharmacotherapy (68%) compared with those prescribed amitriptyline (39%; chi2 = 18.26, df = 1, p < or = 0.05) or sertraline (51%; chi2 = 6.02, df = 1, p < or = 0.05); no significant difference was found compared with paroxetine (56%) or fluoxetine (59%). Receipt of amitriptyline or sertraline as initial medication was associated with a per capita increase (p < or = 0.05) in health service utilization (17% and 9%, respectively) relative to citalopram. No significant difference (p > 0.05) in health service utilization was discerned between citalopram and either fluoxetine or paroxetine. Multivariate models adjusted for nonrandom assignment to the initial pharmacotherapeutic option confirmed these findings. Further research over a longer time course is warranted.

Concomitant use of triptan, and SSRI or SNRI after the US Food and Drug Administration alert on serotonin syndrome.

Objective.— The present study was designed to discern the prevalence of concomitant use of a 5‐hydroxytryptamine receptor agonist (triptan), and a selective serotonin reuptake inhibitor (SSRI) or a selective serotonin/norepinephrine reuptake inhibitor (SNRI) after the US Food and Drug Administration issued an alert regarding serotonin syndrome in 2006 and to contrast findings with data published prior to the federal warning.