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Medicines for Treating Depression: A Review of the Research for Adults
Medicines for Treating Depression: A Review of the Research for Adults
Source: Agency for Healthcare Research and Quality
Antidepressants are only one kind of medicine used to treat depression. They are the most common medicine used for this condition. Your doctor may prescribe other types of medicines to treat depression. This summary will review only the research on antidepressants. It does not review research on non-medicine therapies. The research studies also did not look at patients with bipolar disorder, substance abuse, bulimia nervosa, or schizophrenia.
Trends in Anticonvulsants Utilization and Expenditures for the U.S. Civilian Noninstitutionalized Population, 1999 and 2009
Rising health care costs in general and prescribed medicine costs in particular continue to be a concern for U.S. policymakers and consumers of care. Analyzing down total prescription drug costs into therapeutic classes and subclasses provides decision makers and the public with an understanding of the costs and extent to which specific therapeutic classes and subclasses of drugs are contributing to the upturn in total costs. This Statistical Brief provides trends for one therapeutic subclass of prescribed drugs—anticonvulsants.This Brief presents trends in utilization and expenditures for outpatient prescription anticonvulsants for the years 1999 and 2009. The estimates are for the U.S. civilian noninstitutionalized population and are derived from the 1999 and 2009 Household Component of the Medical Expenditure Panel Survey (MEPS-HC). For outpatient prescription anticonvulsants, the Brief compares, for 1999 and 2009, the number of persons obtaining at least one prescription, total expenditures, and total number of prescriptions, as well as average annual cost per person and average drug cost.Only prescriptions purchased or obtained in an outpatient setting are included in these estimates. Prescription medicines administered in an inpatient setting or in a clinic or physician’s office are excluded. Expenditure estimates are presented in real dollars; estimates for 1999 were inflated to 2009 dollars based on the GDP Price Index (http://www.meps.ahrq.gov/mepsweb/about_meps/ Price_Index.shtml). All differences discussed in the text are statistically significant at the 0.05 level.
Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse
Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse
Source: Agency for Healthcare Research and Quality
Alcohol misuse, which includes the full spectrum from drinking above recommended limits (i.e., risky/hazardous drinking) to alcohol dependence, is associated with numerous health and social problems and more than 85,000 deaths per year in the United States and an estimated annual cost to society of more than $220 billion. Alcohol misuse is estimated to be the third leading cause of preventable mortality in the United States following tobacco use and being overweight. Alcohol misuse contributes to a variety of conditions, including hypertension, cirrhosis, gastritis and gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, and suicide. Excessive alcohol consumption is a major factor in injury and violence.
Though estimating the prevalence of alcohol misuse is challenging, it has been estimated that about 30 percent of the U.S. population is affected, with the majority of these individuals engaging in what is considered risky drinking. Older studies report a range of risky drinkers from 4 to 29 percent across primary care populations, with prevalence estimates of 0.3 to 10.0 percent for harmful drinkers and 2.0 to 9.0 percent for alcohol dependence. More recent data from the American Academy of Family Physicians National Research Network reveal that 21.3 percent of primary care patients reported risky/hazardous drinking (based on the three quantity and frequency questions from the Alcohol Use Disorders Identification Test [AUDIT-C]). Alcohol dependence has lifetime prevalence rates on the order of 17 percent for men and 8 percent for women;16 prevalence of current dependence (within the last 12 months and as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) is approximately 4 percent in the general adult population.17 Some studies have reported that one in five of those who screen positive for unhealthy alcohol use in primary care will have alcohol dependence (four in five will not). Rates of alcohol-use disorders among medical outpatients are similar to those seen in the general population and are generally higher in males and younger people of all races/ethnicities.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has proposed epidemiologically based alcohol-use guidelines to limit risks for drinking-related consequences by establishing age- and sex-specific recommended consumption thresholds. Maximum recommended consumption is three or fewer standard drinks per day (seven per week) for adult women and for anyone older than 65 years of age, and four or fewer standard drinks per day (14 per week) for adult men. A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits. These guidelines do not apply to certain people (such as adolescents, pregnant women, and people with alcohol dependence or medical conditions or medication use) for whom alcohol intake is contraindicated, or to circumstances (driving) in which no consumption is considered safe.
Disparities Report Highlights Health Care Challenges For Racial and Ethnic Minorities
Disparities Report Highlights Health Care Challenges For Racial and Ethnic Minorities
Source: Agency for Healthcare Research and Quality (AHRQ)
The latest National Healthcare Disparities Report released today by the Agency for Healthcare Research and Quality (AHRQ) shows that access to health care was not improving for most racial and ethnic groups in the years 2002 through 2008 leading up to enactment of the Affordable Care Act.
The data contained in the National Healthcare Disparities Report and the companion National Healthcare Quality Report predate the Affordable Care Act; however, some provisions in the new health care law are aimed at improving health care quality and addressing health care disparities. The HHS Action Plan to Reduce Health Disparities, announced in April 2011, outlines goals and actions HHS will take to reduce health disparities among racial and ethnic minorities, building on important efforts made possible by the Affordable Care Act and other ongoing private-sector and state-led initiatives.
"The health care law’s groundbreaking policies will reduce health disparities identified in the report and help achieve health equity," said Carolyn M. Clancy, M.D. director of AHRQ. "We are releasing the report during National Minority Health Month to raise awareness about the steps being taken to help ensure every American receives safe and appropriate health care to help them achieve their best possible health."
The congressionally mandated disparities and quality reports, which AHRQ has produced annually since 2003, are based on over 40 different national sources that collect data regularly. Today’s reports, which include about 250 health care measures, show the persistent challenges in access to care faced by most racial and ethnic groups. Fifty percent of the measures that tracked disparities in health care access showed no improvement between the years 2002 and 2008, while 40 percent of those measures were getting worse.
Specifically, for 2002 through 2008, Latinos, American Indians and Alaska Natives experienced worse access to care than Whites on more than 60 percent of the access measures, while African Americans experienced worse access on slightly more than 30 percent of the access measures. Asian Americans experienced worse access to care than non-Latino Whites on only 17 percent of the access measures.
Treatment for Glaucoma: Comparative Effectiveness
Treatment for Glaucoma: Comparative Effectiveness (PDF)
Source: Agency for Healthcare Research and Quality
Objectives. Glaucoma is a leading cause of visual impairment and blindness worldwide. Treatment focuses on the reduction of intraocular pressure (IOP), which secondarily prevents worsening of visual field loss; in this way, available treatments may prevent visual impairment and blindness. The objective of this Comparative Effectiveness Review is to summarize the evidence regarding the safety and effectiveness of medical, laser, and other surgical treatments for open-angle glaucoma in adults.
Data Sources. We searched MEDLINE®, Embase, LILACS, and CENTRAL through October 6, 2011 to identify clinical trials. We searched MEDLINE and CENTRAL (from 2009 to March 2, 2011) and screened an existing database to identify relevant systematic reviews.
Review Methods. Two reviewers independently assessed citations for eligibility. One reviewer assessed the risk of bias and extracted descriptions of the study. A second reviewer verified the data. Two reviewers also screened the results for systematic reviews. Details about the eligible systematic reviews were abstracted, including elements related to the methodological rigor.
Results. We identified 23 systematic reviews. Twelve reviews addressed medical treatments, 9 addressed surgical treatment, and 1 compared medical versus surgical treatments. One review addressed different surgical treatments as well as medical versus surgical treatments. We identified 73 RCTs and 13 observational studies addressing adverse effects. We identified no studies that evaluated treatments with regard to their impact on visual impairment. We also found insufficient evidence comparing treatment versus no treatment on patient-reported outcomes. No studies addressed the possible link between intermediate outcomes (IOP, optic nerve structure, or visual field) and visual impairment or patient-reported outcomes. There is moderate evidence that medical and surgical treatments can lower IOP and reduce the risk of progression by both visual field and optic nerve criteria. Among medical treatments, the prostaglandin agents are superior to other classes with regard to lowering IOP. While laser trabeculoplasty decreases IOP, the technology used does not make a difference in pressure lowering. With regard to incisional surgeries, trabeculectomy provides more pressure lowering than the class of nonpenetrating procedures. As expected, incisional surgeries produce more significant side effects than do medical treatments.
Conclusions. We did not find evidence addressing direct or indirect links between glaucoma treatment and visual impairment or patient-reported outcomes. This should be an area of focus in future trials of adequate size and duration to detect differences between treatment groups. However, we did find that a number of medical and surgical treatments clearly lower IOP and can prevent visual field loss and optic nerve damage. While we found direct comparisons between some treatments, there are significant gaps in our knowledge of comparative effectiveness.
Treatment To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report
Treatment To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report
Source: Agency for Healthcare Research and Quality
This topic is an update to the original topic, “Comparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis.” Please click on the the title to view the original research review and associated products.
+ Full Document (PDF)
Therapies for Treatment-Resistant Depression: A Review of the Research
What does this summary cover?
This summary explains treatment-resistant depression. It tells you what the most recent research says about the treatments available when medicines do not help. It gives questions to ask about these treatment options.
Where does the information come from?
The information comes from a report that reviewed 63 studies published between January 1980 and November 2010 for the Agency for Healthcare Research and Quality, a Federal Government research agency. You can read the full report at http://www.effectivehealthcare.ahrq.gov/trd.cfm.
AHRQ — Just Released — Analgesics for Osteoarthritis
Analgesics for OsteoarthritisSource: Agency for Healthcare Research and Quality
As an update to a 2006 report, a systematic review of 273 clinical studies published between January 2005 and January 2011 examined the comparative effectiveness, benefits, and adverse effects of analgesics and the supplements glucosamine and chondroitin for osteoarthritis. The review did not include studies on opioid medications or nonpharmacological interventions for osteoarthritis. The full report, listing all studies, is available at www.effectivehealthcare.ahrq.gov/analgesicsupdate.cfmwww.effectivehealthcare.ahrq.gov/analgesicsupdate.cfm. This summary, based on the full report of research evidence, is provided to inform discussions with patients of options and to assist in decisionmaking along with a patient’s values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.
Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults
Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults
Source: Agency for Healthcare Research and Quality
Our review suggests that comparative clinical research on nonpharmacologic interventions in a TRD population is early in its infancy, and many clinical questions about efficacy and effectiveness remain unanswered. Interpretation of the data is substantially hindered by varying definitions of TRD and the paucity of relevant studies. The greatest volume of evidence is for ECT and rTMS. However, even for the few comparisons of treatments that are supported by some evidence, the strength of evidence is low for benefits, reflecting low confidence that the evidence reflects the true effect and indicating that further research is likely to change our confidence in these findings. This finding of low strength is most notable in two cases: ECT and rTMS did not produce different clinical outcomes in TRD, and ECT produced better outcomes than pharmacotherapy. No trials directly compared the likelihood of maintaining remission for nonpharmacologic interventions. The few trials addressing adverse events, subpopulations, subtypes, and health-related outcomes provided low or insufficient evidence of differences between nonpharmacologic interventions. The most urgent next steps for research are to apply a consistent definition of TRD, to conduct more head-to-head clinical trials comparing nonpharmacologic interventions with themselves and with pharmacologic treatments, and to delineate carefully the number of treatment failures following a treatment attempt of adequate dose and duration in the current episode.
Screening and Treatment of Subclinical Hypothyroidism or Hyperthyroidism
Screening and Treatment of Subclinical Hypothyroidism or Hyperthyroidism (PDF)
Source: Agency for Healthcare Research and Quality
Conclusions. Currently there are no studies that evaluate the benefits and harms of screening for subclinical thyroid dysfunction in the primary care setting. Studies of treatment tend to be small and of short duration, and they have failed to demonstrate improvement in quality of life, blood pressure, and weight. The data concerning lipids is inconsistent, but at best, treatment might cause a modest (about 5-percent) improvement in lipid measurements. The lack of any formal data on the harms of treatment makes it difficult to balance the benefits against the harms of treatment. Further research is needed to determine if screening and/or treating subclinical thyroid dysfunction is beneficial or harmful.
Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention
Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention (PDF)
Source: Agency for Healthcare Research and Quality
A total of 62 articles representing 44 studies were included for data abstraction. Transition of care interventions were grouped into four categories: (1) hospital-initiated support for discharge was the initial stage in the transition of care process, (2) patient and family education interventions were started during hospitalization but were continued at the community level, (3) community-based models of support followed hospital discharge, and (4) chronic disease management models of care assumed the responsibility for long-term care. Early supported discharge after stroke was associated with reduced total hospital length of stay without adverse effects on functional recovery, and specialty care after MI was associated with reduced mortality. Because of several methodological shortcomings, most studies did not consistently demonstrate that any specific intervention resulted in improved patient- or system-based outcomes. Some studies included more than one intervention, which made it difficult to determine the effect of individual components on clinical outcomes. There was inconsistency in the definition of what constituted a component of transition of care compared to “standard care.” Standard care was poorly defined, and nearly all studies were underpowered to demonstrate a statistical benefit. The endpoints varied greatly from study to study. Nearly all the studies were single-site based, and most (26 of 44) were conducted in countries with national health care systems quite different from that of the U.S., therefore limiting their generalizability.
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
Source: U.S. Preventive Service Task Force (Agency for Healthcare Research and Quality)
The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. This is a grade D recommendation.
This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer. This recommendation also does not consider the use of the PSA test for surveillance after diagnosis and/or treatment of prostate cancer.
Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
Diagnosis and Treatment of Obstructive Sleep Apnea in Adults (PDF)
Source: Agency for Healthcare Research and Quality (HHS)
Portable monitors and questionnaires may be effective screening tools, but assessments with clinical outcomes are necessary to prove their value over polysomnography. CPAP is highly effective in minimizing AHI and improving sleepiness. Oral devices are also effective, although not as effective as CPAP. Other interventions, including those to improve compliance, have not been adequately tested.
New Guides Compare Benefits and Risks of GERD Treatments
New Guides Compare Benefits and Risks of GERD Treatments
Source: Agency for Healthcare Research and Quality
New plain-language publications from the U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) compare the benefits and risks of treatments for gastroesophageal reflux disease (GERD), a digestive condition that affects millions of Americans and can be treated with medications or surgery. The publications are based on an updated evidence report also released today.
The report concluded that established drug-based therapy is effective. It also concluded that a type of surgical treatment known as laparoscopic fundoplication is at least as effective as drug-based medical treatment for some patients, but also had a higher risk of serious side effects. Another surgical treatment using an endoscopic variation of fundoplication also has been used to treat GERD, but AHRQ’s analysis found there is not enough evidence to compare this type of surgery’s effectiveness with other treatments.
GERD affects as many as 4 percent of Americans, making it one of the most common conditions in the United States. Those who have GERD can spend a significant amount of money on treatments—estimated at $3,355 annually per patient, the report noted. Approximately two-thirds of these costs are related to prescription drugs, but it is commonly recognized that some drugs used to treat GERD, such as proton pump inhibitors (PPIs), are overused, according to the report.
“Because it affects so many Americans, GERD is an important disease both in terms of public health and cost,” said AHRQ Director Carolyn M. Clancy, M.D. “These new publications will help patients and their clinicians work together to find the best treatment option based on patient preferences and needs.”
The AHRQ report found that PPIs tend to be more effective than other drugs, but comparisons show few consistent differences between PPI types or dosages. PPIs cause some side effects, such as diarrhea and headaches, but these were generally not serious.
+ Management Strategies for Gastroesophageal Reflux Disease: An Update
Hospital Readmissions for COPD Highest Among Black Patients
Hospital Readmissions for COPD Highest Among Black Patients
Source: Agency for Healthcare Research and Quality
For patients age 40 and over with chronic obstructive pulmonary disease (COPD), hospital readmissions within 30 days of initial treatment were 30 percent higher among Blacks than Hispanics or Asians and Pacific Islanders and about 9 percent higher than Whites in 2008, according to the latest News and Numbers from the Agency for Healthcare Research and Quality (AHRQ).
Based on data for patients who were hospitalized with COPD in 15 States during 2008:
- About 7 percent of patients were readmitted within 30 days principally for COPD, but 21 percent were readmitted for any health condition (all-cause readmission). There were 190,700 initial hospital admissions specifically to treat COPD at an average cost of $7,100. The average readmission cost principally for COPD was 18 percent higher—$8,400 per stay—but all-cause readmissions were 50 percent more expensive than the initial stay—$11,100.
- Readmissions were 22 percent higher among patients from the poorest communities than among those from the highest income areas.
- Readmissions were about 13 percent higher among male patients compared to females.
+ Statistical Brief #121: Readmissions for Chronic Obstructive Pulmonary Disease, 2008 (PDF)
Heart Disease, Cancer and Mental Disorders Among the Most Costly Conditions for Women
Heart Disease, Cancer and Mental Disorders Among the Most Costly Conditions for Women
Source: Agency for Healthcare Research and Quality
The cost of treating women for heart disease in 2008 was $43.6 billion, leading a list of the top 10 most expensive conditions for women, according to the latest News and Numbers from the Agency for Healthcare Research and Quality (AHRQ).
According to the analysis by the Federal agency, in 2008, the top 10 most costly conditions in terms of health care expenditures for women were:
- Heart disease.
- Cancer.
- Mental disorders.
- Trauma-related disorders.
- Osteoarthritis.
- Chronic obstructive pulmonary disease and asthma.
- Hypertension (high blood pressure).
- Diabetes.
- Back problems.
- Hyperlipidemia (high cholesterol levels).
The Agency also found that in 2008 for women among the 10 costliest conditions:
- The second most costly disease to treat was cancer ($37.7 billion), followed by mental disorders ($37.3 billion), and trauma-related disorders ($34.1 billion).
- The lowest expenditures among the top 10 costliest conditions were for hyperlipidemia ($18.0 billion).
- The most common condition was high blood pressure (29.5 million women reporting).
- The least common condition was cancer (8.4 million women reporting).
Nursing Home Survey on Patient Safety Culture
Nursing Home Survey on Patient Safety Culture
Source: Agency for Healthcare Research and Quality (HHS)
Based on data from 226 nursing homes in the United States, the Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report provides initial results that nursing homes can use to compare their patient safety culture to other U.S. nursing homes. The report consists of a narrative description of the findings and four appendixes, presenting data by nursing home characteristics and respondent characteristics for the database nursing homes.
Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
Source: Agency for Healthcare Research and Quantity
The strength of evidence is moderate that fixed CPAP is an effective treatment to minimize AHI and improve sleepiness symptoms, as supported by more than 40 trials of patients treated with CPAP or no treatment. However, no trial reported long-term clinical outcomes, and compliance with CPAP treatment is poor. Because patients frequently do not tolerate CPAP, many alternative treatments have been proposed. First, several alternative CPAP machines have been designed to vary the pressure during the patient’s inspiratory cycle or to titrate the pressure to a minimum necessary level. Other modifications include different masks, nasal pads, and added humidification. The large majority of relevant trials have compared autotitrating CPAP (autoCPAP) with fixed CPAP and the strength of evidence of no clinical differences between them is moderate. The strength of evidence is insufficient for other device comparisons and, overall, the evidence does not support the use of one device for all patients, since such decisions should be individualized.
The second alternative to CPAP therapeutic option is the use of oral devices, which have been designed with the goal of splinting open the oropharynx to prevent obstruction. The most commonly tested are the mandibular advancement devices (MAD), for which the strength of evidence for their efficacy in sleep outcomes is moderate. Based on direct and indirect comparisons, CPAP appeared to be more effective than MAD. However, given the issues with noncompliance with CPAP, the decision as to whether to use CPAP or MAD will likely depend on patient preference.
The third major alternative to OSA treatment includes surgical interventions to alleviate airway obstruction. Given the very few randomized trials and the differences in the populations that choose to undergo surgery versus conservative treatment, the strength of evidence is insufficient to determine the relative value of surgery to no treatment, to CPAP, to MAD, or to alternative types of surgery. Additional interventions were also evaluated in randomized trials, (including weight loss programs, atrial overdrive pacing, eight different drugs, and other interventions) but in general the strength of evidence is insufficient to determine the effects of these potential treatments.
Clinical practice guideline: tonsillectomy in children
Clinical practice guideline: tonsillectomy in children
Source: Agency for Healthcare Research and Quality
Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.
…
Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A β-hemolytic streptococcus (GABHS).
Comparative Effectiveness of Therapies for Children With Autism Spectrum Disorders
Comparative Effectiveness of Therapies for Children With Autism Spectrum Disorders
Source: Agency for Healthcare Research and Quality
Efforts toward early intervention for ASDs have been encouraging. Research evidence on the effectiveness of therapies for ASDs has shown promise in some areas, but since this is a young field, these results need to be replicated and expanded. There is some evidence to guide choices among medical interventions (for challenging and repetitive behaviors) and early intensive behavioral interventions. There is little or no comparative evidence on which to make decisions about: medical interventions for social or communication symptoms; most behavioral interventions; and educational, allied health, and complementary and alternative medicine (CAM) interventions. For most interventions, the evidence is insufficient to permit an estimate of their benefits or harms. This does not mean that these interventions are not associated with benefits or harms but that further study is required. Evidence suggests that there is an undefined subgroup of children for whom early and intensive behavioral interventions may elicit robust gains while others may not demonstrate marked improvement.
+ Full Document (PDF)
