Swindle Ralph W, Rao Jaya K, Helmy Ahdy, Plue Laurie, Zhou X H, Eckert George J, Weinberger Morris
Roudebush VAMC, USA.
Int J Psychiatry Med. 2003;33(1):17-37. doi: 10.2190/QRY5-B61V-QE4R-8141.
To examine the effectiveness of integrating generalist and specialist care for veterans with depression.
We conducted a randomized trial of patients screening positive for depression at two Veterans Affairs Medical Center general medicine clinic firms. Control firm physicians were notified prior to the encounter when eligible patients had PRIME-MD depression diagnoses. In the intervention firm, a mental health clinical nurse specialist (CNS) was to: design a treatment plan; implement that plan with the primary care physician; and monitor patients via telephone or visits at two weeks, one month and two months. Primary outcomes (depressive symptoms, patient satisfaction with health care) were collected at 3 and 12 months.
Of 268 randomized patients, 246 (92%) and 222 (83%) completed 3- and 12-month follow-up interviews. There were no between-group differences in depressive symptoms or satisfaction at 3 or 12 months. The intervention group had greater chart documentation of depression at baseline (63% versus 33%, p = 0.003) and a higher referral rate to mental health services at 3 months (27% versus 9%, p = 0.019). There was no difference in the rate of new prescriptions for, or adequate dosing of, anti-depressant medications. In 40% of patients, CNSs disagreed with the PRIME-MD depression diagnosis, and their rates of watchful waiting were correspondingly high.
Implementing an integrated care model did not occur as intended. Experienced CNSs often did not see the need for treatment in many primary care patients identified by the PRIME-MD. Integrating integrated care models in actual practice may prove challenging.
研究综合全科与专科护理对患有抑郁症退伍军人的有效性。
我们在两家退伍军人事务医疗中心的普通内科诊所对抑郁症筛查呈阳性的患者进行了一项随机试验。当符合条件的患者被PRIME-MD诊断为抑郁症时，会在会诊前通知对照诊所的医生。在干预诊所，一名心理健康临床护士专家（CNS）要：设计治疗方案；与初级保健医生共同实施该方案；并在两周、一个月和两个月时通过电话或上门访视对患者进行监测。在3个月和12个月时收集主要结局指标（抑郁症状、患者对医疗保健的满意度）。
在268名随机分组的患者中，246名（92%）和222名（83%）完成了3个月和12个月的随访访谈。在3个月或12个月时，两组在抑郁症状或满意度方面没有差异。干预组在基线时抑郁症的病历记录更多（63%对33%，p = 0.003），且在3个月时转介至心理健康服务的比例更高（27%对9%，p = 0.019）。抗抑郁药物的新处方率或适当剂量率没有差异。在40%的患者中，CNS不同意PRIME-MD的抑郁症诊断，他们的观察等待率相应较高。
综合护理模式未按预期实施。经验丰富的CNS在许多被PRIME-MD识别出的初级保健患者中往往看不到治疗的必要性。在实际实践中整合综合护理模式可能具有挑战性。
