注意缺陷多动障碍门诊就诊的12年回顾性分析.pdf

doi:10.3969/j.issn.1002-0829.2013.04.005Shanghai Mental Health Center,Shanghai Jiao Tong University School of Medicine,Shanghai,China*correspondence:Lingxiao JIANG,Yan LI,Xiyan ZHANG,Wenqing JIANG,Caohua YANG,Nan HAO,Lili HAO,Mengyao LI,Wenwen LIU,Linna ZHANG,Yasong DU*Twelve-year retrospective analysis of outpatients with Attention-Deficit/Hyperactivity Disorder in ShanghaiOriginal articleBackground:Attention-Deficit/Hyperactivity Disorder(ADHD)is the most common diagnosis among children treated in outpatient psychiatric clinics in China,accounting for up to 50%of all patients.Objective:Understand changes over time in the characteristics and treatment of children with ADHD seen at specialty psychiatric clinics in China.Methods:For each year from 2000 through 2011,250 charts of patients who made their initial visit to the Child and Adolescent Psychological Counseling Clinic of the Shanghai Mental Health Center were randomly selected.Among the 3000 selected patients,998(33%)had a diagnosis of ADHD.Results:About 80%of the ADHD patients were male and the majority of them fell ill prior to the age of seven.The mean(sd)age at the time of first attendance at the clinic was 10.0(2.6)years and the mean duration of illness at the time of the initial visit was 2.9(1.2)years;both of these values decreased significantly over time.About 20%of them were non-residents of Shanghai and about 11%had comorbid psychiatric diagnoses(primarily depression and tic disorder);both of these proportions increased significantly over time.Among the 576(58%)who visited the clinic more than once,77%were treated with central nervous system stimulants,but the proportion administered behavioral treatments(either solely on in combination with medications)increased significantly over time.Conclusion:ADHD remains the most common diagnosis of children seen in specialty psychiatric clinics in China but the proportion of clinic attendees with ADHD is gradually declining as non-specialty treatment services expand and other diagnoses become more prominent.There are encouraging trends of earlier identification and treatment of ADHD and of increasing use of non-pharmacological interventions.Nevertheless,most children with ADHD have been ill for at least two years at the time of the initial diagnosis,so continued research efforts are needed to identify the best ways to speed up the recognition and treatment of this disabling condition.1.IntroductionAttention-Deficit/Hyperactivity Disorder(ADHD)was first recognized as a distinct condition in the late 1960s.Over the last two decades there have been several improvements in the diagnostic criteria for the disorder and in the interventions available to treat the condition.1-3 In China,in parallel with the recent rapid development of child and adolescent psychiatry,ADHD has been recognized as one of the most common psychiatric disorders among children.4,5 To describe secular trends in the characteristics of ADHD treatment in China,the current paper summarizes clinical data on children with ADHD treated at the Child and Adolescent Psychological Counseling Clinic of the Shanghai Mental Health Center one of the leading child psychiatric centers in the country.6 2.Methods2.1 SampleThe identification of cases included in the analysis is shown in Figure 1.Data were abstracted from the case records of patients who sought treatment from January 2000 to December 2011 at the Child and Adolescent Psychological Counseling Clinic of the Shanghai Mental Health Center at the Shanghai Jiao Tong University School of Medicine.Two hundred and fifty patients first treated in the clinic during each of the twelve years from 2000 to 2011 were randomly selected from all patients first treated in each year using computer-generated random numbers.As shown in Table 1,a total of 998(33.3%)of the 3000 medical records identified were for children diagnosed with ADHD.236 Shanghai Archives of Psychiatry,2013,Vol.25,No.43.Results 3.1 Characteristics of the identified ADHD patientsThe characteristics of the ADHD patients over the 12 years considered are shown in Table 2.Over the 12-year-period the proportion of patients with the ADHD diagnosis varied from a low of 26.4%in 2005 to a high of 46.8%in 2006.Thus,there were significant variations in the proportion of patients with the diagnosis over the 12 years(2=44.68,df=11,p0.001).However,there was no clear increasing or decreasing trend in the proportion of patients with the ADHD diagnoses over time(2trend=0.02,p=0.877).Only 2 of the 998 ADHD patients(0.2%)received inpatient treatment and both had comorbid conditions(one had conduct disorder and the other had an eating disorder);in comparison to this,4.1%(82/2002)of the non-ADHD patients received inpatient treatment.Among children diagnosed with ADHD over the 12-year period considered,836 were males and 162 were females,which results in a male:female ratio of 5.2:1.This gender ratio did not vary significantly over the 12 years assessed(2=14.88,df=11,p=0.109).These patients included 800 from Shanghai and 198 from other cities or provinces,which results in an overall ratio of local to non-local patients of 4:1.This local:non-local ratio varied significantly over the 12 years from a high of 25.1:1 in 2001 to a low of 1.8:1 in 2008(2=40.96,df=11,Medical charts of children treated at the Child and Adolescent Psychological Counseling Clinic of the Shanghai Mental Health Center from 1 January 2000 to 31 December 2011250 charts of patients from each of the twelve years(total of 3000 charts)selected from all patients first treated in each year using computer-generated random numbers998 children given the diagnosis of Attention Deficit Hyperactivity Disorder(ADHD)based on criteria of the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association(DSM-IV)Standardized data about patient characteristics,treatment(s)received,and the effectiveness of treatment were abstracted from each chartFigure 1.Flowchart of the identification ofcases included in the analysisTable 1.Primary diagnoses of 3000 randomly selected patients at the time of first outpatient treatment at the Child and Adolescent Psychological Counseling Clinic of Shanghai Mental Health Center from 2000 to 2011Diagnosisn%Attention Deficit/Hyperactivity Disorder99833.3Mood disorder31410.5Mental retardation2227.4Childhood autism1655.5Schizophrenia1585.3Tic disorder1063.5Depression953.2Obsessive compulsive disorder541.8Asperger Syndrome331.1Other mental disordera1755.8General psychological problem32911.0Borderline intelligence331.1Physical diseaseb331.1Unspecified diagnosis2859.5a Other mental disorder includes conduct disorder,Tourette syndrome and other disorders with a prevalence of less than 1%.b Physical disease includes neurological and endocrine system diseases such as epilepsy and infantile convulsions.2.2 Data collectionThe information abstracted from the charts included the gender,age,residence(Shanghai v.elsewhere),duration of symptoms at the time of the initial visit,diagnosis(at the time of the final visit),number of clinic visits,type of treatment(medication alone v.non-pharmacological methods v.both pharmacological and non-pharmacological methods),and clinical status at the time of the last recorded visit.The diagnoses reported in the charts were made by an attending level(or higher)psychiatrist using the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders 4th Edition(DSM-IV).7 To maintain the anonymity of the collected data,patients names,addresses and contact information were not included in the extracted information.2.3 Statistical methodsA database created using EXCEL was analyzed using SPSS statistical software.Proportions of patients with different characteristics in the 12 years considered were assessed using Chi-square tests and trends in changes over these 12 years were assessed using Chi-square for trend analyses.The age of first treatment at the clinic,the duration of illness(reported by the accompanying family member),and the estimated age of onset were not normally distributed,so we used Mann-Whitney rank tests to assess changes in these values from the first six-year period(2000 through 2005)to the second six-year period(2006 through 2011)considered in the analysis.237 Shanghai Archives of Psychiatry,2013,Vol.25,No.4p0.001);the proportion of local patients from Shanghai decreased significantly over time(2trend=15.26,p0.001).Among the 998 patients with ADHD,the mean(sd)age of first treatment at our clinic was 10.0(2.6)years,the mean duration of illness(as reported by the parents)at the time of first treatment at our clinic was 2.9(1.2)years and,thus,the estimated mean age of onset was 7.1(2.3)years.The age at the time of the first attendance at the clinic of patients seen in the second five-year period(2006-2011)(median=9.2 year,interquartile range=7.6-11.5 years)was significantly younger than that of patients seen in the first five-year period(2001-2005)(median=10.2 years,interquartile range=7.9-12.4 years;Mann-Whitney U=4.69,p0.001).In parallel with this earlier age of attendance at our clinic over time,the duration of illness at the time of coming to the clinic decreased over time:the median(interquartile range)duration of illness at the time of first clinic visit among patients first seen from 2000 through 2005 was 4.0(1.0-6.0)years while that of patients seen from 2006 through 2011 was 3.0(1.0-5.0)years(Mann-Whitney U=3.80,p0.001).The estimated age of onset did not vary significantly over time.Overall,576 of the 998 ADHD patients(57.7%)had an onset of illness prior to 7 years of age,397(39.8%)first fell ill from 7 to 12 years of age,and 25(2.5%)first fell ill after the age of 12.Among these 998 patients,10.6%(106 individuals)had comorbid psychiatric conditions.The proportion of patients with comorbid conditions varied over the 12 years from a low of 6.5%in 2002 to a high of 25.4%in 2011(2=20.94,df=11,p=0.034);there was a significantly increasing trend in the proportion of patients with comorbid diagnoses(2trend=4.05,p=0.044).The specific comorbid diagnoses in the ADHD patients are shown in Table 3.The most common comorbid diagnoses were tic disorders and mood disorders(primarily depression);these two disorders accounted for 75.5%(80/106)of all comorbid conditions recorded.Increases in the proportion of patients with a comorbid mood disorder over time was the main factor that lead to the increase in the proportion of patients with any comorbid condition over time.3.2 Care-seeking and treatment of ADHD patientsAmong the 998 patients,42.3%(n=422)only made a single visit to the clinic;57.7%(n=576)made two or more visits(15.0%made two visits,8.4%made three visits and 34.3%made more than three visits).The proportion of patients with multiple visits varied from a low of 29.5%in 2000 to a high of 89.4%in 2005.There is statistically significant variation in the proportion of patients with Table 2.Characteristics of patients treated at the Child and Adolescent Psychological Counseling Clinic of Shanghai Mental Health Center with Attention Deficit/Hyperactivity Disorder(ADHD)from 2000 to 2011Year%patients with ADHDanumber of patients with ADHDCharacteristics of patients with ADHDMalegenderShanghairesidentAge of onsetAge of first clinic visitDuration of illness at first clinic visit in year(s)Has other psychiatric diagnosisHad two or more clinic visitsn(%)n(%)mean(sd)mean(sd)mean(sd)n(%)n(%)200031.2%7865(83.3)68(87.2)7.0(2.9)11.0(3.0)4.0(1.4)5(6.8)23(29.5)200134.4%8666(76.7)82(95.3)8.0(2.8)10.3(3.1)2.3(0.9)8(10.3)41(47.7)200239.2%9876(77.6)87(88.8)6.8(2.7)10.7(2.9)3.9(1.7)6(6.5)78(79.6)200333.6%8470(83.3)63(75.0)7.1(2.0)10.2(2.2)3.1(1.5)7(9.1)32(38.1)200434.0%8572(84.7)72(84.7)6.1(2.3)9.9(2.5)3.8(1.7)12(16.4)62(72.9)200526.4%6658(87.9)51(77.3)6.9(2.5)9.7(2.7)2.8(1.2)5(8.2)59(89.4)200646.8%117105(89.7)88(75.2)6.6(1.9)9.6(2.2)3.0(1.0)8(7.3)88(75.2)200728.0%7057(81.4)57(81.4)7.0(2.3)9.6(2.4)2.6(0.8)10(16.7)50(71.4)200839.2%9892(93.9)63(64.3)6.9(2.1)9.7(2.2)2.8(1.2)17(21.0)34(34.7)200927.6%6956(81.2)52(75.4)6.8(2.0)9.2(2.2)2.4(1.4)6(9.5)44(63.8)201029.2%7361(83.6)57(78.1)7.7(2.1)9.9(2.5)2.2(0.9)7(10.6)34(46.6)201129.6%7458(78.4)60(81.1)7.5(2.5)9.4(2.7)1.9(0.7)15(20.2)31(41.9)2000-200533.1%497407(81.9)423(85.1)7.0(2.5)10.3(2.8)3.3(1.4)43(8.7)295(59.4)2006-201133.4%501429(85.6)377(75.2)7.1(2.2)9.6(2.4)2.5(1.0)63(12.6)281(56.1)Total(%)33.3%998836(83.8)800(80.2)7.1(2.3)10.0(2.6)2.9(1.2)106(10.6)576(57.7)a The proportion of 250 randomly selected patients who first received treatment at the study site in the corresponding year(s)with a primary diagnosis of ADHD 238 Shanghai Archives of Psychiatry,2013,Vol.25,No.4multiple visits over the 12 years(2=150.40,df=11,p0.001),but there was no clear trend in this proportion over time(2trend=2.42,p=0.491).The proportion of ADHD patients who made multiple visits to the clinic that had comorbid diagnoses(70/576,12.2%)was higher than the proportion of ADHD patients who only made a single clinic visit that had comorbid diagnoses(36/422,8.5%),but this difference was not statistically significant(2=3.37,p=0.067).The proportions of the different types of treatment provided over time are shown in Table 4.Treatments provided to these patients included pharmacological treatment(mainly central nervous system stimulants),non-pharmacological treatment(mainly behavioral therapy),and combined pharmacological and non-pharmacological treatment.Medication treatment was the most common form of treatment in each of the 12 years,accounting for 76.5%of all treatments provided to the 998 patients;but there was a significant decrease in the use of pharmacological agents over time(2trend=8.93,p=0.003)and a corresponding increase in the use of non-pharmacological treatments(2trend=6.51,p=0.011)and in the use of combined treatments(2trend=5.59,p=0.018).Among the 576 patients who made multiple visits,at the time of the last clinic visit the treatment provided was considered effective in 45.1%(n=260)and the patients condition was considered improved in a further 43.8%(n=252).Over the 12 years considered,there was a significant increase in the proportion of patients who benefited from treatment(that is,the treatment was considered effective or the patient was considered improved by the treating clinician)(2trend=5.98,p=0.014).The proportions of patients who benefitted from pharmacological treatment(385/434;88.7%),non-pharmacological treatment(37/45;82.2%),and combined pharmacological and non-pharmacological treatment(89/97,91.8%)did not differ significantly(2=2.84,df=2,p=0.241).4.Discussion4.1 Main findingsADHD is,by far,the most common condition seen in child psychiatric outpatient services in urban China,1,8 accounting for one-third of new cases identified in the current study.However,the proportion of all new cases diagnosed as ADHD identified in this study,which covered the period from 2000 through 2011,is m