A Structured Protocol Model of Depression Care versus Clinical Acumen: A Cluster Randomized Trial of the Effects on Depression Screening, Diagnostic Evaluation, and Treatment Uptake in Ugandan HIV Clinics.
A Structured Protocol Model of Depression Care versus Clinical Acumen: A Cluster Randomized Trial of the Effects on Depression Screening, Diagnostic Evaluation, and Treatment Uptake in Ugandan HIV Clinics.
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DOI：
10.1371/journal.pone.0153132
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发表时间：
2016
期刊：
影响因子：
3.7
通讯作者：
Akena D
中科院分区：
文献类型：
--
作者：
Wagner GJ;Ngo V;Goutam P;Glick P;Musisi S;Akena D
抑郁症在艾滋病毒感染者中很常见，它对艾滋病毒预防和治疗反应都有影响，但在撒哈拉以南非洲，抑郁症治疗很少被纳入艾滋病毒护理，部分原因是缺乏心理健康专业人员。我们在乌干达的10个艾滋病诊所进行了一项集群随机对照试验，采用两种任务转移模式来促进医疗提供者提供的抑郁症护理：一种使用结构化协议，另一种依赖于临床敏锐性。这两种模式都是从使用2项患者健康问卷（PHQ-2）对所有客户进行常规抑郁症筛查开始的，其中我们招募了1252名客户（640名在结构化协议诊所，612名在临床智慧诊所），他们在12个月内筛查呈阳性。我们比较了两个模型：（1）所有客户参与者的比例，以及那些临床抑郁症（基于调查管理的9项PHQ-9>9），他们接受了使用PHQ-9进行的抑郁症筛选后评估;（2）临床抑郁症患者接受抗抑郁治疗的比例。使用野生聚类自举法进行线性概率回归分析，以控制聚类;患者特征、诊所规模和时间固定效应作为协变量。在所有客户参与者中，结构化协议组的参与者更有可能使用PHQ-9接受医疗提供者的进一步评估（84% vs. 49%; beta = .33; p = .01）。在临床抑郁症患者（n = 369）中，结构化协议模型相对于临床敏锐度的优势在PHQ-9抑郁症评估方面没有统计学显著性（93%对68%; β = 0.21; p = 0.14）或抗抑郁药处方（69%对58%; β = 0.10; p = 0.50），部分原因是只有30%的筛查阳性的客户是临床抑郁症。这些研究结果表明，在这两种模式中，抑郁症护理实践被广泛采用的供应商，抑郁症护理达到大多数抑郁症的客户。结构化的协议模型是有利的，以确保积极筛选的客户端收到抑郁症的评估，但这两种模式同样表现良好，以确保治疗抑郁症的客户端的背景下，强有力的监督支持。试用注册：ClinicalTrials.gov NCT 02056106
Depression is common among people living with HIV, and it has consequences for both HIV prevention and treatment response, yet depression treatment is rarely integrated into HIV care in sub-Saharan Africa, partly due to the paucity of mental health professionals. We conducted a cluster randomized controlled trial of two task-shifting models to facilitating depression care delivered by medical providers: one that utilized a structured protocol, and one that relied on clinical acumen, in 10 HIV clinics in Uganda. Both models started with routine depression screening of all clients at triage using the 2-item Patient Health Questionnaire (PHQ-2), from which we enrolled 1252 clients (640 at structured protocol clinics, 612 at clinical acumen clinics) who had screened positive over 12 months. We compared the two models on (1) proportion of all client participants, and those clinically depressed (based on survey-administered 9-item PHQ-9>9), who received post-screening evaluation for depression using the PHQ-9; and (2) proportion of clinically depressed who were prescribed antidepressant therapy. Linear probability regression analyses were conducted using a wild cluster bootstrap to control for clustering; patient characteristics, clinic size and time fixed effects were included as covariates. Among all client participants, those in the structured protocol arm were far more likely to have received further evaluation by a medical provider using the PHQ-9 (84% vs. 49%; beta = .33; p = .01). Among the clinically depressed clients (n = 369), the advantage of the structured protocol model over clinical acumen was not statistically significant with regard to PHQ-9 depression evaluation (93% vs. 68%; beta = .21; p = .14) or prescription of antidepressants (69% vs. 58%; beta = .10; p = .50), in part because only 30% of clients who screened positive were clinically depressed. These findings reveal that in both models depression care practices were widely adopted by providers, and depression care reached most depressed clients. The structured protocol model is advantageous for ensuring that positively screened clients receive a depression evaluation, but the two models performed equally well in ensuring the treatment of depressed clients in the context of strong supervision support. Trial Registration: ClinicalTrials.gov NCT02056106