Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure.
Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure.
复制标题
初级保健医生治疗抑郁症的方法。
DOI：
10.1001/archfami.8.1.58
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发表时间：
1999
期刊：
影响因子：
--
通讯作者：
J. Cornell
中科院分区：
文献类型：
--
作者：
John W. Williams;K. Rost;A. Dietrich;M. Ciotti;S. Zyzanski;J. Cornell
背景
由于初级保健医生(PCP)是大多数抑郁症患者的初始保健接触者，他们在为抑郁症患者和合并内科疾病患者提供早期发现和综合护理方面具有独特的地位。尽管有这样的机会，但对抑郁症的护理往往不是最理想的。
客观化
为了更好地了解如何设计干预措施来改善护理，我们研究了PCP对识别和管理的方法，以及医生专业和上限程度对3种常见抑郁障碍护理障碍的影响。
方法
一份包含53个项目的问卷被邮寄给3375名随机选择的受试者，被平均分配给家庭医生、普通内科医生和妇产科医生。该问卷评估了每个受试者最近报告的诊断和治疗实践，这些患者被认为患有严重或轻微的抑郁症或恶劣心境，并阻碍了对抑郁症的认识和治疗。符合条件的医生是至少有一半时间看门诊病人进行纵向护理的医生。
结果
在2316名已知资格的医生中，有1350名(58.3%)回复了问卷。受访者为家庭医生(n=621)、普通内科医生(n=474)和妇产科医生(n=255)。初级保健医生报告了与他们最近的案例有关的识别和评估做法如下：通过常规询问或筛查确认抑郁症(9%)、根据正式标准诊断(33.7%)、直接询问自杀(58%)以及评估药物滥用(68.1%)或抑郁症的医学原因(84.1%)。报告的治疗做法是只观察等待(6.1%)、PCP咨询超过5分钟(39.7%)、抗抑郁药物处方(72.5%)和精神健康转诊(38.4%)。诊断评估和治疗方法因专科而异，但不受抑郁类型或头痛程度的影响。医生的障碍因专业的不同而不同，而不是受限制的程度。相比之下，组织障碍，如足够的病史时间和心理健康专业人员的负担能力，更大程度上是由强制程度决定的，而不是由医生专业决定的。患者的障碍很常见，但并不因医生的专业或头衔的不同而不同。
结论
相当大比例的初级保健医生报告了与高质量护理相一致的诊断和治疗方法。治疗方法上的差异更多地与专业有关，而不是与抑郁障碍的类型或头晕程度有关。质量改进工作需要(1)为不同的医生专业量身定做，(2)强调将严重抑郁症与其他抑郁障碍区分开来并相应地调整治疗方法的重要性，(3)解决最佳实践的组织障碍和关于抑郁症治疗的知识差距。
BACKGROUND
Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal.
OBJECTIVE
To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders.
METHODS
A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care.
RESULTS
Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation.
CONCLUSIONS
A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.