Klinkman M S, Schwenk T L, Coyne J C
Department of Family Medicine, University of Michigan, Ann Arbor, USA.
Can J Psychiatry. 1997 Nov;42(9):966-73. doi: 10.1177/070674379704200909.
To explore the relationships between detection, treatment, and outcome of depression in the primary care setting, based upon results from the Michigan Depression Project (MDP).
A weighted sample of 425 adult family practice patients completed a comprehensive battery of questionnaires exploring stress, social support, overall health, health care utilization, treatment attitudes, self-rated levels of stress and depression, along with the Center for Epidemiologic Studies Depression Scale (CES-D), the Hamilton Rating Scale for Depression (HAM-D), and the Structured Clinical Interview for DSM-III (SCID), which served as the criterion standard for diagnosis. A comparison sample of 123 depressed psychiatric outpatients received the same assessment battery. Family practice patients received repeated assessment of depressive symptoms, stress, social support, and health care utilization over a period of up to 60 months of longitudinal follow-up.
The central MDP findings confirm that significant differences in past history, severity, and impairment exist between depressed psychiatric and family practice patients, that detection rates are significantly higher for severely depressed primary care patients, and that clinicians use clinical cues such as past history, distress, and severity of symptoms to "detect" depression in patients at intermediate and mild levels of severity. As well, there is a lack of association between detection and improved outcome in primary care patients.
These results call into question the assumption that "depression is depression" irrespective of the setting and physician, and they are consistent with a model of depressive disorder as a subacute or chronic condition characterized by clinical parameters of severity, staging, and comorbidity, similar to asthma. This new model can guide further investigation into the epidemiology and management of mood disorders in the primary care setting.
基于密歇根抑郁项目（MDP）的结果，探讨基层医疗环境中抑郁症的检测、治疗与转归之间的关系。
425名成年家庭医疗患者的加权样本完成了一系列全面的问卷调查，内容涉及压力、社会支持、整体健康状况、医疗保健利用情况、治疗态度、自我评定的压力和抑郁水平，同时还使用了流行病学研究中心抑郁量表（CES-D）、汉密尔顿抑郁评定量表（HAM-D）以及《精神疾病诊断与统计手册》第三版（DSM-III）结构化临床访谈（SCID），后者作为诊断的标准参照。123名抑郁的精神科门诊患者的对照样本接受了相同的评估。家庭医疗患者在长达60个月的纵向随访期间接受了抑郁症状、压力、社会支持和医疗保健利用情况的重复评估。
MDP的核心研究结果证实，抑郁的精神科患者与家庭医疗患者在既往史、严重程度和功能损害方面存在显著差异，重度抑郁的基层医疗患者的检出率显著更高，并且临床医生会利用诸如既往史、痛苦程度和症状严重程度等临床线索来“检测”中度和轻度严重程度患者的抑郁症。此外，基层医疗患者的检测与改善的转归之间缺乏关联。
这些结果对“无论在何种环境及由哪位医生诊治，抑郁症都是一样的”这一假设提出了质疑，并且与将抑郁症视为一种亚急性或慢性疾病的模型相一致，该模型的特征包括严重程度、分期和共病等临床参数，类似于哮喘。这一新模型能够指导对基层医疗环境中情绪障碍的流行病学和管理进行进一步研究。
