上海市综合性医院精神科门诊医师对抑郁症识别及治疗的对照研究

A controlled study on identification for depression and effectiveness of its treatment in psychiatric clinics of general hospitals

目的比较综合性医院精神科门诊中专科和非专科医生对抑郁症的不同识别情况及治疗效果，分析影响抑郁症识别的相关因素。方法对就诊于上海市9所综合性医院精神科门诊的680例初诊患者使用复合式国际诊断检查（CIDI）抑郁标准进行筛查，与首诊医师诊断进行比较。共收集抑郁症患者297例，并对这些患者进行汉密顿抑郁量表24项（HAMD）、汉密顿焦虑量表（HAMA）的评估，利用“上海市综合医院精神科门诊非专科医师基本情况调查表”对非专科医师进行调查。结果680例初诊患者中，专科医师正确识别337例，非专科医师正确识别216例，两者对抑郁症的识别率差异有统计学意义（x^2=30．73，P=0．000）。专科医师对抑郁症的识别能力高于非专科医师，专科医师与CIDI及专家复核诊断的一致性高，Kappa值为0．774，非专科医师与CIDI及专家复核诊断的一致性偏低，Kappa值为0．439。专科组的治疗效果优于非专科组，在治疗后第4周、第8周、第12周随访时HAMD总分及各因子分比较差异均有统计学意义（P〈0．05或P〈0．01）。非专科医师从事精神科工作的年限和每年接受精神科知识培训的时间，对抑郁症的识别有显著影响（P〈0．05）。结论综合医院精神科中的非专科医师对抑郁症的识别和治疗能力偏低，接受精神卫生专科知识培训不足，需加强对综合医院精神卫生科室服务质量的管理。

Objective The study is designed to evaluate the difference in identification for depression and clinical effectiveness of its treatment between psychiatrists and non-psychiatric physicians at out-patient departments of general hospitals and to analyze its related factors. Methods Totally, 680 patients who visited psychiatric clinics in nine general hospitals of Shanghai at first time were screened by psychiatrists using Composite International Diagnostic Interview （ CIDI ） for depression and the screening results were compared to the diagnosis made by non-psychiatric physicians as goal-keepers there. Altogether 297 patients with depression were recruited and assessed using Hamilton Depression Rating Scale （HAMD） and Hamilton Anxiety Rating Scale （HAMA）. A serf-made questionnaire for basic information was used to assess the ability for identification of depression in non-psychiatric physicians of general hospitals. Results Psychiatrists identified depression correctly in 337 of 680 patients who visited psychiatric clinics in general hospitals at their first visit, but non-psychiatric physicians only identified 216 patients, with statistically significant difference （ x^2 = 30. 73, P = 0. 000）. A consistent agreement on depression diagnosis between the findings by psychiatrists and by CIDI was reached with Kappa of 0. 774, but Kappa for that between the findings by non-psychiatric physicians and CIDI was 0. 439. Effectiveness of treatment for depression by psychiatrists was better than that by non-psychiatric physicians, with higher total score and scores for each item of HAMD four, eight and 12 weeks after treatment, respectively （ P 〈 0. 05 or P 〈 0. 01 ）. Length of professional work of non-psychiatric physicians and annual time for professional training in management of mental disorders associated with their ability of identification for depression （ P 〈 0. 05 ）. Conclusion Ability of non-psychiatric physicians to identify and cope with depression in the psychiatric department of general hospitals was insufficient, suggesting that more importance shoed be attached to the management of service quality at psychiatric department of general hospitals.