家庭医生甄别抑郁症Screening of Depression by Family Doctors

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1 家庭医生甄别抑郁症Screening of Depression by Family Doctors
郑志文医生 香港社区精神医学会前任会长( ) 香港大学内外全科医学士 香港中文大学家庭医学硕士 英国皇家全科医学院院士 香港大学社区精神医学深造文凭

2 香港社区精神医学会简介 家庭医生甄别抑郁症 验证抑郁甄别工具
An introduction to Hong Kong Community Psychological Medicine Association Screening for depression by family doctors Validation of instruments for screening

3 香港社区精神医学会 Hong Kong Community Psychological Medicine Association (HKCPMA)

4 对社区精神医学有兴趣及曾接受 基本训练的香港家庭医生
香港社区精神医学会 HKCPMA 成员 对社区精神医学有兴趣及曾接受 基本训练的香港家庭医生 Composition Family doctors in Hong Kong with interest and basic training in community psychological medicine

5 Undifferentiated Symptoms
家庭医生 Family Doctors 早期、未分類病徵 Undifferentiated Symptoms 甄别 Screening 诊断 Diagnosis 管理/ 治疗 转介 Management Referral 情绪疾病 Mood Disorder 精神疾病 Psychiatric Disorder

6 家庭医生的特点 Characteristics of Family Doctors
与病人建立长期关系 全人治疗 信任 病人与医疗体系的联系 Long term relation with patients Total patient care Trust Serves as the link between patients & the medical healthcare system

7 香港社区精神医学会 HKCPMA

8 香港社区精神医学会网址 HKCPMA Website

9 香港社区精神医学会 HKCPMA 会旨 推广社区精神医学 与香港政府合作 与非政府组织合作 公民教育 持续医学进修 Objectives
To promote community psychological medicine Collaboration with HK Government Collaboration with NGOs Public Education Doctors Continual Medical Education

10 香港社区精神医学会 HKCPMA 与香港政府合作 医院管理局 - 公私营医疗合作计划 - 精神健康检讨
Collaboration with HK Government Hospital Authority - Public Private Interface Project - Mental Health Review

11 香港社区精神医学会 HKCPMA 禁毒委员会 -利用动机式晤谈法帮助早期滥 药青少年
Action Committee Against Narcotics - Motivational interview for early teenage drug users

12 香港社区精神医学会 HKCPMA 与非政府组织合作 香港医学会 - 抑郁甄别 - 防止滥用药物研讨会 -预防自殺记者招待会 香港红十字会
-精神健康工作坊 Collaboration with NGOs The Hong Kong Medical Association - screening for depression by family doctors - beat drug seminars - suicide prevention press conference Hong Kong Red Cross - mental health workshops

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14 香港社区精神医学会 HKCPMA 公民教育 公众讲座、电台节目 持续医学进修 第一届社区精神医学国际论坛 Public Education
Public talks, radio programmes Continual Medical Education (CME) The 1st International Forum on Community Psychological Medicine (2006)

15 第一届社区精神医学国际论坛 2006 International Forum on Community Psychological Medicine

16 第一届社区精神医学国际论坛 2006 International Forum on Community Psychological Medicine
来自世界各地 (澳洲、英国、意大利、中国等) 的专 家及学者。 四天学术活动中，本地及外地专业医护人员在社区 情绪疾病处理方法进行了深入的探讨、研究及分享。 促使社区精神医学在国际认可跃进一大步。 Participants included experts/professionals from all over the world (e.g. Australia, United Kingdom, Italy, China etc.) This four-day forum enabled exchanges and sharing of experiences between overseas and local mental healthcare professionals in managing psychological problems in the community. It also took a big step forward in the recognition of Community Psychological Medicine internationally.

17 家庭医生甄别抑郁症 Screening for Depression by Family Doctors
抑郁症十分普遍。 根据世界卫生组织，抑郁症于一九九零 年全球致病原因排行第四；预计抑郁症 将会于二零二零年跃升为第二位。 Depression is common. The WHO identified depression as the forth leading cause of worldwide disease in 1990, and depressive illness is projected to be the second leading cause of disability worldwide in 2020.i i Murray CJ, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and projected to Cambridge, Mass.: Harvard University Press, 1996.

18 抑郁症甄别可行及有用。 二零零二年，美国预防服务工作队进 行了一项系统性文献回顾，建议应对 成年病人进入抑郁症甄别(进行甄别 诊所需有系统确保准确诊断、有效治 疗及覆诊)。 Screening is useful. In 2002, after a large systematic reviewii, the U.S. Preventive Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. ii Screening for Depression for Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force. Michael P. Pignone, Bradley N. Gaynes, Jerry L. Rushton et al. Annals of Internal Medicine, 136:10

19 工作队证实甄别可改善基层医疗架 构中对抑郁症的准确辨证，同时对 患者进行治疗，有助减少临床发病 率。
The USPSTF found good evidence that screening improved the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity.

20 工作队总结： 甄别抑郁症的好处大于对病人的潜 在伤害。
The USPSTF concluded that the benefits of screening were likely to outweigh any potential harms.iii iii

21 进行甄别诊所需有系统确保 准确诊断 有效治疗 覆诊
The clinical practices should have systems in place to ensure Accurate Diagnosis Effective Treatment Follow-up

22 甄别工具 简单；方便使用 病人自行填写 中文语言 灵敏度高 特异度高 Screening Instrument
Simple; Easy to use Self-administered In Chinese language Sensitive Specific

23 工欲善其事， 必先利其器。

24 抑郁甄别问卷验证 Validation of Instrument for Screening
没有甄别工具符合五项要点 2Q 及PHQ-9 问卷被拣选 No instrument fulfills all the 5 criteria The 2Q and the PHQ-9 questionnaires are selected

25 Sensitivity ~~ 86% Specificity ~~ 75%
2Q 问卷 1 “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” 2 “During the past month, have you often been bothered by little interest or pleasure in doing things?” Sensitivity ~~ 86% Specificity ~~ 75%

26 Sensitivity ~~ 88% Specificity ~~ 88%
PHQ-9问卷 Sensitivity ~~ 88% Specificity ~~ 88%

27 我们的研究 Our Study 郑志文医生 郑子诚医生 验证中文版2Q与PHQ-9 问卷
郑志文医生 郑子诚医生 To validate the Chinese Version of the 2Q and PHQ-9 Questionnaires in Hong Kong Chinese Patients. Dr. CM CHENG & Dr. Michael CHENG The Hong Kong Practitioner (Oct 2007), Vol. 29, pp

28 研究摘要 Study Summary 目的 --- 验证以中文版2Q问卷及 PHQ-9 问卷在香港基层医疗进行甄别 抑郁症的标准正确度。
Objective --- To study the criterion validity of the Chinese version of the 2Q & the PHQ-9 questionnaires of depression in primary care in Hong Kong.

29 设计 --- 将《基层医疗精神疾病评估 工具(PRIME-MD)》中2Q及PHQ-9 翻 译成中文。
在 14 所普通科医务所，由357位候诊 病人填写问卷。 Design --- The 2Q and the PHQ-9 questionnaires from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) were translated into Chinese. 357 Patients from 14 general practice clinic in Hong Kong were asked to fill in the questionnaires before they saw their doctors.

30 另外医生在不知结果的情况下，对病 人采用 17 项问题中文版汉米尔顿抑郁 表(CHDS) 评估，以此作为诊断抑郁症 的标准，再为2Q及PHQ-9结果验证其 有效性。
The general practitioners, blind to the results, then applied the 17 items Chinese Hamilton Depression Rating Scale (CHDS) for the patients. The 2Q and the PHQ-9 were then validated against the CHDS, which served as the gold standard for depression detection.

31 PHQ-9及CHDS之间的皮尔逊相 关性(Pearson Correlation)。
主要测量内容 2Q及PHQ-9 的灵敏度及特异度 PHQ-9及CHDS之间的皮尔逊相 关性(Pearson Correlation)。 Main outcome measures Sensitivity and specificity of the 2Q and PHQ-9 Pearson Correlation between the PHQ-9 and CHDS

32 PHQ-9 (当分界点为9) 灵敏度为 80%， 特异度为92%。
结果 2Q灵敏度为96.7%，特异度为73.4%。 PHQ-9 (当分界点为9) 灵敏度为 80%， 特异度为92%。 PHQ-9及CHDS 之间皮尔逊相关性为 (p<0.01)。 Results Sensitivity and specificity of the 2Q were 96.7% and 73.4% respectively. Sensitivity and specificity of the PHQ-9 at cut-off point of 9 were 80% and 92% respectively. Pearson Correlation between the PHQ-9 and the CHDS was (p<0.01).

33 2Q问卷 在过去的一个月，您曾否经常被以下 事情烦扰： 　　是 否 几乎没有兴趣去做事 □ □ 感觉情绪低落、抑郁或绝望 □ □

34 PHQ-9 问卷

35 表一：填写问卷病人性别与年龄 Table 1: Subject Characteristics: Sex & Age
Male Female Total Age Mean SD N 40.96 13.100 134 40.57 13.451 212 40.89 13.294 357

36 表二：2Q 灵敏度及特异度 Table 2: Sensitivity and Specificity of 2Q
CHDS ≦ 16 CHDS > 16 Total 2Q = 0 240 1 241 2Q > 0 87 29 116 327 30 357 灵敏度＝96.7% 特异度＝73.4% Sensibility=96.7% Specificity=73.4%

37 表三： PHQ-9 灵敏度及特异度 Table 3: Sensitivity and Specificity of PHQ-9
CHDS ≦ 16 CHDS > 16 Total PHQ-9≦9 301 6 307 PHQ-9 > 9 26 24 50 327 30 357 灵敏度(当分界点为9)＝80% 特异度＝92% Sensibility (cut-off point=9)=80% Specificity=92%

38 图一：CHDS及 PHQ-9 相互关系 Graph 1: Correlation between CHDS and PHQ-9

39 CHDS 及 PHQ-9 相互关系 Correlation between CHDS and PHQ-9
皮尔逊相关性是0.793，统计数据达到 0.01水平(双尾检定)。 The results of the PHQ-9 showed a good correlation with that from the CHDS. The Pearson Correlation is This is statistically significant to the 0.01 level (2-tailed).

40 2Q 问卷：灵敏度及特异度比较 The 2Q Questionnaire: Comparison of Sensitivities & Specificities among Countries
Sensitivity Specificity Our Study (HK) 96.7% 73.4% Spitzer et al. (Columbia) 86% 75% Arroll et al. (Auckland) 97% 67% Whooley et al. (San Francisco) 96% 57%

41 PHQ-9 问卷：灵敏度及特异度比较 The PHQ-9 Questionnaire: Comparison of Sensitivities & Specificities among Countries Sensitivity Specificity Our Study (HK) 80% 92% Kroenke et al. (US) 88% Wulsin et al. (Spain) 77% 100% Rizzo et al. (Italy) 78% 83% William et al. (Indiana) 91% 89%

42 总结 Conclusion 抑郁症十分普遍。它可对病人健 康造成重大影响。 抑郁症甄别是有效的。
抑郁症十分普遍。它可对病人健 康造成重大影响。 抑郁症甄别是有效的。 只需要问两条简单的问题，家庭医 生就可以帮助病人。 Depression is common. Screening is useful. Family doctors can help patients simply by asking two simple questions.

43 ～完～ 谢谢 The End Thank You