Habtamu Kassahun, Medhin Girmay, Selamu Medhin, Tirfessa Kebede, Hanlon Charlotte, Fekadu Abebaw
1School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, P.O.BOX: 1176, Addis Ababa, Ethiopia.
2Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
Int J Ment Health Syst. 2019 Jul 17;13:50. doi: 10.1186/s13033-019-0305-8. eCollection 2019.
There have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs). The aim of this study was to identify factors associated with functional impairment among people diagnosed with depression in PHC in Ethiopia as part of implementation of a task-shared model of mental healthcare.
A comparative cross-sectional study was conducted. As part of the Programme for Improving Mental health carE (PRIME), PHC clinicians were trained to diagnose depression using an adapted version of the World Health Organization (WHO) mental health Gap Action Programme (mhGAP). A total of 2038 adult consecutive PHC attendees were screened for depressive symptoms using the 9-item Patient Health Questionnaire (PHQ-9). Those who scored five or above on the PHQ-9 (n = 131) were assessed by PHC workers. Of these, 92 were diagnosed to have depression ("PHC diagnosed cases") and the remaining 39 people were PHQ positive but considered not to have depression ("non-diagnosed controls"). PHC diagnosed cases were also compared to a community representative sample of adult healthy controls (n = 197; "community controls"). The 12-item version of the WHO Disability Assessment Schedule (WHODAS-2.0) was used to assess functional impairment. Multivariable negative binomial regression models were fitted to examine the association of demographic, social, economic and clinical characteristics with functional impairment.
No significant difference in functional impairment was found between diagnosed cases and non-diagnosed controls. PHC diagnosed cases were found to have higher depressive symptom severity and suicidality, but lower social support compared to non-diagnosed controls (P < 0.05). In the multivariable model, greater functional impairment was associated with higher depressive symptoms (RR = 1.04; 95% CI 1.02, 1.05) and lower social support (RR = 0.96; 95% CI 0.95, 0.98). Diagnosed cases were found to have higher functional impairment compared to community controls (RR = 1.91; 95% CI 1.74, 2.09).
In this study, PHC clinicians identified cases of depression with high symptom burden, suicidality and functional impairment. These findings support current initiatives to scale-up mental health services at the PHC level; and indicate that social support is an important target for intervention.
在低收入和中等收入国家（LMICs），很少有研究考察初级卫生保健（PHC）中临床诊断为抑郁症的患者的功能状况。本研究的目的是确定埃塞俄比亚初级卫生保健中诊断为抑郁症的患者功能损害的相关因素，作为精神卫生保健任务分担模式实施的一部分。
进行了一项比较横断面研究。作为改善精神卫生保健计划（PRIME）的一部分，初级卫生保健临床医生接受培训，使用世界卫生组织（WHO）精神卫生差距行动规划（mhGAP）的改编版来诊断抑郁症。总共2038名连续的成年初级卫生保健就诊者使用9项患者健康问卷（PHQ - 9）进行抑郁症状筛查。PHQ - 9得分5分及以上的患者（n = 131）由初级卫生保健工作人员进行评估。其中，92人被诊断为患有抑郁症（“初级卫生保健诊断病例”），其余39人PHQ呈阳性但被认为未患抑郁症（“未诊断对照”）。初级卫生保健诊断病例还与成年健康对照的社区代表性样本（n = 197；“社区对照”）进行比较。使用世界卫生组织残疾评估量表（WHODAS - 2.0）的第12项版本来评估功能损害。采用多变量负二项回归模型来检验人口统计学、社会、经济和临床特征与功能损害之间的关联。
诊断病例与未诊断对照在功能损害方面未发现显著差异。与未诊断对照相比，初级卫生保健诊断病例的抑郁症状严重程度和自杀倾向更高，但社会支持更低（P < 0.05）。在多变量模型中，功能损害程度越高与抑郁症状越严重（RR = 1.04；95% CI 1.02，1.05）和社会支持越低（RR = 0.96；95% CI 0.95，0.98）相关。与社区对照相比，诊断病例的功能损害更高（RR = 1.91；95% CI 1.74，2.09）。
在本研究中，初级卫生保健临床医生识别出了症状负担重、有自杀倾向和功能损害的抑郁症病例。这些发现支持当前在初级卫生保健层面扩大精神卫生服务的举措；并表明社会支持是一个重要的干预目标。
