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

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(2005-2007) 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. 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. 家庭医生Family Doctors 早期、未分類病徵 Undifferentiated Symptoms 情绪疾病 Mood Disorder • 甄别Screening • 诊断Diagnosis 管理/ 治疗转介 Management Referral 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 www.hkcpma.com

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 HKGovernment • 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 HKGovernment • HospitalAuthority - Public Private InterfaceProject -MentalHealthReview

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 -Motivationalinterviewforearlyteenagedrugusers

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 preventionpress conference • Hong Kong Red Cross -mental health workshops

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。 • Participantsincludedexperts/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 2020. Cambridge, Mass.: HarvardUniversity 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.PreventiveTaskForce(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。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 www.preventiveservices.ahrq.gov

21. 进行甄别诊所需有系统确保 • 准确诊断 • 有效治疗 • 覆诊 Theclinicalpractices 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 questionnairesare selected

25. 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. PHQ-9问卷 Sensitivity ~~ 88% Specificity ~~ 88%

27. 我们的研究Our Study 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. 381-390.

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. 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. 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0.793(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 0.793 (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

36. 表二：2Q 灵敏度及特异度Table 2: Sensitivity and Specificity of 2Q 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 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 PHQ-9 及中文版汉米尔顿抑郁表出现正相关结果。 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 0.793. 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

41. PHQ-9 问卷：灵敏度及特异度比较The PHQ-9 Questionnaire: Comparison of Sensitivities & Specificities among Countries

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。 • 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. The EndThank You ～完～ 谢谢