Leff Maija S, Vrubļevska Jeļena, Lūse Agita, Rancāns Elmārs
a Department of Communication Studies , Riga Stradiņš University , Riga , Latvia.
b Department of Psychiatry and Narcology , Riga Stradiņš University , Riga , Latvia.
Eur J Gen Pract. 2017 Dec;23(1):91-97. doi: 10.1080/13814788.2017.1291626.
Depression continues to be under-diagnosed in primary care settings. One factor that influences physicians' likelihood of diagnosing depression is patients' presentation style. Patients who initially present with somatic symptoms are diagnosed at a lower rate and with greater delay than patients who present with psychosocial complaints.
To identify the barriers preventing depression diagnosis in somatically presenting patients in an Eastern European primary care setting.
Thematic analysis of semi-structured interviews with 16 family physicians (FPs) in Latvia. FPs were sampled using a maximum variation strategy, varying on patient load, urban/rural setting, FP gender, presence/absence of on-site mental health specialists, and FP years of practice.
FPs observed that a large subgroup of depression patients presented with solely somatic complaints. FPs often did not recognize depression in somatically presenting patients until several consultations had passed without resolution of the somatic complaint. When FPs had psychosocial information about the somatically presenting patient, they recognized depression more quickly. Use of depression screening questionnaires was rare. Barriers to diagnosis continued beyond recognition. Faced with equivocal symptoms that undermined clinical certainty, FPs postponed investigating their clinical suspicion that the patient had depression and pursued physical examinations that delayed depression diagnosis. FPs also used negative physical examination results to convince reluctant patients of a depression diagnosis.
Delayed recognition, the need to rule out physical illness, and the use of negative physical examination results to discuss depression with patients all slowed the path to depression diagnosis for somatically presenting patients in Latvian primary care.
在基层医疗环境中，抑郁症的诊断仍然不足。影响医生诊断抑郁症可能性的一个因素是患者的表现方式。最初表现为躯体症状的患者比表现为心理社会问题的患者被诊断的比例更低，且诊断延迟更久。
确定在东欧基层医疗环境中，阻止对表现为躯体症状的患者进行抑郁症诊断的障碍。
对拉脱维亚16名家庭医生进行半结构化访谈的主题分析。采用最大差异抽样策略对家庭医生进行抽样，在患者数量、城市/农村环境、家庭医生性别、是否有现场心理健康专家以及家庭医生的执业年限等方面存在差异。
家庭医生观察到，很大一部分抑郁症患者仅表现为躯体症状。在没有解决躯体症状的情况下经过几次会诊后，家庭医生才往往能识别出表现为躯体症状的患者患有抑郁症。当家庭医生掌握了表现为躯体症状患者的心理社会信息时，他们能更快地识别出抑郁症。很少使用抑郁症筛查问卷。诊断障碍不仅存在于识别阶段之后。面对削弱临床确定性的模糊症状，家庭医生推迟对患者患有抑郁症的临床怀疑进行调查，而是进行体格检查，这延误了抑郁症的诊断。家庭医生还利用阴性体格检查结果来说服不情愿的患者接受抑郁症诊断。
在拉脱维亚基层医疗中，识别延迟、需要排除躯体疾病以及利用阴性体格检查结果与患者讨论抑郁症，都减缓了表现为躯体症状患者的抑郁症诊断进程。
