Klinkman M S, Coyne J C, Gallo S, Schwenk T L
Department of Family Practice, University of Michigan, Ann Arbor, USA.
Arch Fam Med. 1998 Sep-Oct;7(5):451-61. doi: 10.1001/archfami.7.5.451.
To explore the issues of diagnostic specificity and psychiatric "caseness" (i.e., whether a patient meets the conditions to qualify as a "case" of a disease or syndrome) for major depression in the primary care setting.
A cross-sectional study comparing the demographic, clinical, and mental health characteristics of patients identified as depressed by their family physicians with those meeting diagnostic criteria for major depression on the criterion standard Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.
The offices of 50 family physicians from private and academic practice in southeast Michigan.
A total of 1580 consecutive adult patients being seen for routine primary care services, from whom a weighted sample of 372 patients completed a set of mental health screening and diagnostic instruments.
Patients were assigned to 1 of 4 groups (true positive, false positive, false negative, and true negative) based on clinician identification and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnosis. Differences between the 4 groups in demographic and clinical characteristics, scores on mental health instruments and mental health history were explored.
Physician identification of depression was strongly associated with increased familiarity with the patient and the presence of suggestive clinical cues, such as history of or treatment for depression, patient distress, and presence of vegetative symptoms. Patients in the false-positive group displayed significantly higher levels of distress and impairment and were significantly more likely to have a history of mental health problems and treatment than were those in the true-negative group. The 2 "misidentified" groups, false positives and false negatives, were indistinguishable in their clinical characteristics (impairment, distress, or mental health history). Both groups' scores occupied the middle ground between true positives and true negatives on most clinical characteristics. Physicians appeared to discriminate between these 2 groups on the basis of their knowledge of the patient's clinical history.
Misidentification of depression in primary care may be in part an artifact of the use of the psychiatric model of caseness in the primary care setting. Our results are most consistent with a chronic disease-based model of depressive disorder, in which patients classified as false positive and false negative occupy a clinical middle ground between clearly depressed and clearly nondepressed patients. Family physicians appear to respond to meaningful clinical cues in assigning the diagnosis of depression to these distressed and impaired patients.
探讨基层医疗环境中重度抑郁症的诊断特异性及精神疾病“病例”问题（即患者是否符合某种疾病或综合征“病例”的条件）。
一项横断面研究，比较家庭医生认定为抑郁的患者与依据《精神疾病诊断与统计手册》第三版修订本标准结构化临床访谈符合重度抑郁症诊断标准的患者在人口统计学、临床及心理健康特征方面的差异。
密歇根州东南部50名来自私人诊所和学术机构的家庭医生的办公室。
总共1580名接受常规基层医疗服务的成年患者，从中抽取372名加权样本患者完成了一套心理健康筛查和诊断工具。
根据临床医生的认定和《精神疾病诊断与统计手册》第三版修订本的诊断结果，将患者分为四组（真阳性、假阳性、假阴性和真阴性）之一。探讨四组在人口统计学和临床特征、心理健康工具得分及心理健康史方面的差异。
医生对抑郁症的认定与对患者的熟悉程度增加以及存在提示性临床线索密切相关，如抑郁症病史或治疗史、患者痛苦及存在躯体症状。假阳性组患者的痛苦和损害水平显著更高，且比真阴性组患者更有可能有心理健康问题和治疗史。两个“误诊”组，即假阳性和假阴性组，在临床特征（损害、痛苦或心理健康史）方面难以区分。两组在大多数临床特征上的得分处于真阳性和真阴性之间的中间水平。医生似乎根据对患者临床病史的了解来区分这两组。
基层医疗中抑郁症的误诊可能部分是在基层医疗环境中使用精神疾病病例模型的人为结果。我们的结果最符合基于慢性病的抑郁症模型，其中被归类为假阳性和假阴性的患者处于明显抑郁和明显非抑郁患者之间的临床中间地带。家庭医生在将抑郁症诊断归因于这些痛苦和受损患者时似乎对有意义的临床线索做出了反应。
