Passik S D, Dugan W, McDonald M V, Rosenfeld B, Theobald D E, Edgerton S
Community Cancer Care, Inc, Indianapolis, IN 46202, USA.
J Clin Oncol. 1998 Apr;16(4):1594-600. doi: 10.1200/JCO.1998.16.4.1594.
This study was performed as part of a large depression screening project in cancer patients to determine the degree of physician recognition of levels of depressive symptoms in cancer patients and to describe patient characteristics that influence the accuracy of physician perception of depressive symptoms.
Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc of Indiana enrolled and surveyed 1,109 subjects treated by 12 oncologists. Subjects completed the Zung Self-Rating Depression Scale (ZSDS) and physicians were asked to rate their patients' level of depressive symptoms, anxiety, and pain using numerical rating scales. Subjects' sex, age, primary tumor type, medications, primary caregiver, and disease stage at diagnosis were also recorded.
Physician ratings of depression were significantly associated with their patients' levels of endorsement of depressive symptoms on the ZSDS. However, agreement between physicians and patients is most frequently clustered when patients report little or no depressive symptoms. While physician ratings are concordant with patient endorsement of no significant depressive symptomatology 79% of the time, they are only concordant 33% and 13% of the time in the mild-to-moderate/severe ranges, respectively. Physician ratings were most influenced by patient endorsement of frequent and obvious mood symptoms, ie, sadness, crying, and irritability. Physician ratings also appeared to be influenced by medical correlates of patients' level of depressive symptoms (functional status, stage of disease, and site of tumor). Additionally, patients whose depression was inaccurately classified reported significantly higher levels of pain and had higher levels of disability. Physicians' ratings of depression were most highly correlated with physicians' ratings of patients' anxiety and pain.
Physicians' perceptions of depressive symptoms in their patients are correlated with patient's ratings, but there is a marked tendency to underestimate the level of depressive symptoms in patients who are more depressed. They are most influenced by symptoms such as crying and depressed mood, and medical factors that are useful, but not the most reliable, indicators of depression in this population. Physicians' ratings of their patients' distress symptoms seem to be global in nature--they are highly correlated with anxiety, pain, and global dysfunction. Physician assessment might be improved if they were instructed to assess and probe for the more reliable cognitive symptoms such as anhedonia, guilt, suicidal thinking, and hopelessness. Screening instruments and the use of brief follow-up interviews would help to identify patients who are depressed.
本研究作为癌症患者大型抑郁筛查项目的一部分进行，以确定医生对癌症患者抑郁症状程度的认知程度，并描述影响医生对抑郁症状认知准确性的患者特征。
印第安纳州社区癌症护理公司下属的25家门诊肿瘤诊所招募并调查了12位肿瘤学家治疗的1109名受试者。受试者完成了zung自评抑郁量表（ZSDS），并要求医生使用数字评分量表对患者的抑郁症状、焦虑和疼痛程度进行评分。还记录了受试者的性别、年龄、原发性肿瘤类型、用药情况、主要照顾者以及诊断时的疾病阶段。
医生对抑郁的评分与患者在ZSDS上对抑郁症状的认可程度显著相关。然而，当患者报告很少或没有抑郁症状时，医生和患者之间的一致性最为常见。虽然医生的评分在79%的时间里与患者对无明显抑郁症状的认可一致，但在轻度至中度/重度范围内，它们分别仅在33%和13%的时间里一致。医生的评分受患者对频繁和明显情绪症状（即悲伤、哭泣和易怒）的认可影响最大。医生的评分似乎也受患者抑郁症状程度的医学相关因素（功能状态、疾病阶段和肿瘤部位）影响。此外，抑郁分类不准确的患者报告的疼痛水平显著更高，残疾程度也更高。医生对抑郁的评分与医生对患者焦虑和疼痛的评分相关性最高。
医生对患者抑郁症状的认知与患者的评分相关，但对于抑郁程度较高的患者，存在明显低估其抑郁症状水平的倾向。他们受哭泣和情绪低落等症状以及医学因素的影响最大，这些医学因素在该人群中是有用的，但不是最可靠的抑郁指标。医生对患者痛苦症状的评分似乎具有全局性——它们与焦虑、疼痛和整体功能障碍高度相关。如果指导医生评估和探究更可靠的认知症状，如快感缺失、内疚、自杀念头和绝望感，医生的评估可能会得到改善。筛查工具和简短随访访谈的使用将有助于识别抑郁患者。
