Screening of Screening of Depression in Depression in Primary CarePrimary Care

鄭志文醫生香港大學內外全科醫學士

香港中文大學家庭醫學碩士 英國皇家全科醫學院院士

香港大學社區精神醫學深造文憑

Depression is CommonDepression is Common

The WHO identified depression as the The WHO identified depression as the fourth leading cause of worldwide fourth leading cause of worldwide disease in 1990, and depressive illness disease in 1990, and depressive illness is projected to be the second leading is projected to be the second leading cause of disability worldwide in 2020.cause of disability worldwide in 2020. Murray CJ, Lopez AD. The global burden of disease: a comprehensive Murray CJ, Lopez AD. The global burden of disease: a comprehensive

assessment of mortality and disability from diseases, injuries, and risk assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, Mass.: Harvard factors in 1990 and projected to 2020. Cambridge, Mass.: Harvard University Press, 1996.University Press, 1996.

根據世界衛生組織研根據世界衛生組織研究，抑鬱症將會於究，抑鬱症將會於 20202020 年成為世界第二位年成為世界第二位慢性疾病慢性疾病

A recent study by the Mood A recent study by the Mood Disorder Centre of the Chinese Disorder Centre of the Chinese University of Hong Kong found University of Hong Kong found that about 8.3 per cent of people that about 8.3 per cent of people had symptoms of depression in had symptoms of depression in the previous 12 months.the previous 12 months. SCMP, April 25, 2005SCMP, April 25, 2005

Screening for Depression is Screening for Depression is UsefulUseful

► In 2002, after a large systematic In 2002, after a large systematic review, the USPSTF (United States review, the USPSTF (United States Preventive Service Task Force) Preventive Service Task Force) recommended screening adults for recommended screening adults for depression depression

► in clinical practices that have systems in clinical practices that have systems in place to assure accurate diagnosis, in place to assure accurate diagnosis, effective treatment, and follow-up.effective treatment, and follow-up.

► It found good evidence that screening It found good evidence that screening improved the accurate identification of improved the accurate identification of depressed patients in primary care settings depressed patients in primary care settings

►and that treatment of depressed adults and that treatment of depressed adults identified in primary care settings identified in primary care settings decreases clinical morbidity. decreases clinical morbidity.

► It concluded that the benefits of screening It concluded that the benefits of screening were likely to out-weight any potential were likely to out-weight any potential harmsharms

Screening InstrumentsScreening Instruments

►the Two-question Test (2Q)the Two-question Test (2Q)

►the Patient Health the Patient Health Questionnaire (PHQ-9)Questionnaire (PHQ-9)

The 2 QThe 2 Q

►During the past month, have you During the past month, have you often been bothered by feeling often been bothered by feeling down, depressed, or hopeless?down, depressed, or hopeless?

►During the past month, have you During the past month, have you often been bothered by little often been bothered by little interest or pleasure in doing interest or pleasure in doing things?things?

►The original PRIME-MD study reported The original PRIME-MD study reported that a "yes" answer to one of these that a "yes" answer to one of these two questions was: two questions was:

►86% sensitive, and 86% sensitive, and ►75% specific 75% specific ►compared with a subsequent compared with a subsequent

telephone interview diagnosis of major telephone interview diagnosis of major depressive disorder.depressive disorder.

The PHQ 9The PHQ 9

►The PHQ-9 had been validated in a The PHQ-9 had been validated in a study involving 3000 primary care study involving 3000 primary care patients. patients.

►A PHQ-9 score >9 had A PHQ-9 score >9 had ►a sensitivity of 88% and a sensitivity of 88% and ►a specificity of 88% for major a specificity of 88% for major

depressiondepression

Validation is neededValidation is needed

►Translation and back-translationTranslation and back-translation►Applied against adult patients of 14 HK Applied against adult patients of 14 HK

family doctorsfamily doctors►357 patients took part357 patients took part►Using the Hamilton Depression Scale Using the Hamilton Depression Scale

as gold standard as gold standard

The 2 QThe 2 Q

在在過去的一個月過去的一個月，您曾否經常被以下事情煩，您曾否經常被以下事情煩擾：擾：

幾乎沒有興趣或樂趣去做事

感覺情緒低落、抑鬱或絕望

The PHQ 9The PHQ 9

在在過去的兩個星期過去的兩個星期，您曾否經常被以下問題煩，您曾否經常被以下問題煩擾着擾着 ? ?

1.1. 幾乎沒有興趣或樂趣去做事幾乎沒有興趣或樂趣去做事2.2. 感覺情緒低落，抑鬱或絕望感覺情緒低落，抑鬱或絕望3.3. 入睡或保持睡眠有困難。或者睡得太多入睡或保持睡眠有困難。或者睡得太多4.4. 感到疲倦或缺乏體力感到疲倦或缺乏體力5.5. 胃口不好或吃得過量胃口不好或吃得過量

6.6. 您覺得自卑或自責，或者覺得自己或家人您覺得自卑或自責，或者覺得自己或家人對自己感到失望對自己感到失望

7.7. 對事情的集中力有困難，例如閱報或看電對事情的集中力有困難，例如閱報或看電視視

8.8. 您的活動或說話速度很慢以致別人也留意您的活動或說話速度很慢以致別人也留意到。或者情況相反：您感到心煩意亂或坐到。或者情況相反：您感到心煩意亂或坐立不安以致四處走動的情況多於平時立不安以致四處走動的情況多於平時

9.9. 有否想到傷害自己，自殺傾向或行為有否想到傷害自己，自殺傾向或行為

到目前為止，假如您在這份問卷中檢到目前為止，假如您在這份問卷中檢查出任何問題，您覺得這些問題對查出任何問題，您覺得這些問題對您的工作、料理家中的事務或與其您的工作、料理家中的事務或與其他人相處的事情上遇到多少困難？他人相處的事情上遇到多少困難？

0

5

10

15

20

25

30

35

40

0 5 10 15 20 25 30

phq9 score

CH

DS

sco

re

Correlation between Correlation between CHDS and PHQ-9CHDS and PHQ-9

►The results of the PHQ-9 showed a The results of the PHQ-9 showed a good correlation with that from good correlation with that from the CHDS.the CHDS.

►The Pearson Correlation is 0.793. The Pearson Correlation is 0.793. This is statistically significant to This is statistically significant to the 0.01 level (2-tailed).the 0.01 level (2-tailed).

Sensitivity and specificity Sensitivity and specificity of 2Qof 2Q

CHDS <= 16CHDS <= 16 CHDS > 16CHDS > 16 TotalTotal

2Q = 02Q = 0 240240 11 241241

2Q > 02Q > 0 8787 2929 116116

TotalTotal 327327 3030 357357

►Sensitivity = 96.7%Sensitivity = 96.7%►Specificity = 73.4%Specificity = 73.4%

Sensitivity and specificity Sensitivity and specificity of PHQ-9of PHQ-9

CHDS <= 16CHDS <= 16 CHDS > 16CHDS > 16TotalTotal

PHQ-9 <= 9PHQ-9 <= 9 301301 66 307307

PHQ-9 > 9PHQ-9 > 9 2626 2424 5050

TotalTotal 327327 3030 357357

►Sensitivity = 80%Sensitivity = 80%►Specificity = 92%Specificity = 92%

The EndThe EndThank YouThank You