可降低年长者忧郁和自我伤害的介入方式


  【24drs.com】把年长患者的忧郁与自杀行为之处置及评估的相关信息让家庭医师知悉,可以显著降低此类患者的忧郁和自我伤害。
  
  西澳大利亚大学老年精神科荣誉教授、西澳大利亚医学研究中心主任Osvaldo P. Almeida博士表示,藉由家庭医师进行系统性回馈以及教育如何评估和处置这些状况,可以降低社区年长者的忧郁和自杀想法盛行率。
  
  研究刊载于7/8月版家庭医学志。
  
  Almeida博士表示,之前的研究成功地使用加强护理改善临床显著忧郁症状者的处置,这方法称为特定性预防,我们希望探讨一个更普及的介入方式,不限于呈现明显或次忧郁征候的年长者;这个方法不依赖案例控制或系统性使用心理介入,显著降低了计划费用。
  
  Almeida博士等人进行一个系统性方式审核373名澳大利亚一般开业医师的实务,共有21,762名60岁以上病患的资料。
  
  被随机指派到介入组的医师获得有关忧郁或自杀意念病患的详细回馈信息,包括出现的任何征兆或症状,以及他们是否有辨识这些征兆及症状,他们也被告知他们的审核结果以及其它研究对象的比较。
  
  除了个人化回馈,介入组的医师也接受书面教育资料和6次教育电子报月刊,提供计画进度的回馈,以及提供评估忧郁或自杀意念年长者时「务必记住事项」的提示,这些电子报共提供2年。
  
  被随机指派到对照组的医师们完成实务审核,但是没有接受个别回馈;他们也接受6次电子报月刊,但是未被提供有关年长者忧郁和自杀行为筛检、诊断和处置的教育资料。
  
  在开始时和12个月与24个月之后评估是否出现临床显著忧郁(经Patient Health Questionnaire分数10分以上确认)或自我伤害行为(过去12个月内有自杀想法或试图自杀)。
  
  该研究显示,在追踪期间,和对照组医师治疗的病患相比,被随机指派到介入组给一般开业医师治疗的年长者,忧郁或自我伤害行为的机会降低了10% (95%信心区间[CI],3% - 17%)。
  
  事后分析中,研究者发现介入组对于忧郁的相对效果并未显著(胜算比[OR],0.93;95% CI,0.83 - 1.03),但是介入组对于24个月期间的自我伤害行为的效果则是显著(OR,0.80;95% CI,0.68 - 0.94)。
  
  Almeida博士表示,介入的效益主要是因为降低开始时无症状成年人的自我伤害行为;对于研究一开始即有症状的年长者, 24个月时的忧郁或自我伤害行为盛行率的降低并无明显效果。
  
  他指出,实际上,希望可以看见这个介入方式的相关方面整合到临床实务,以确认是否可实际降低社区的忧郁和自杀行为盛行率。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6881&x_classno=0&x_chkdelpoint=Y
  

Intervention May Reduce Depression, Self-Harm in Seniors

By Fran Lowry
Medscape Medical News

July 16, 2012 — Giving family physicians feedback about their practice as well as relevant information about the assessment and management of depression and suicidal behavior of their older patients has the potential to significantly reduce depression and self-harm in this population.

"It is possible to decrease the prevalence of depression and suicide ideation amongst older adults living in the community by providing family physicians systematic feedback and also educating them about how to assess and manage these conditions," lead author Osvaldo P. Almeida, MD, PhD, professor and Winthrop chair of geriatric psychiatry at the University of Western Australia and director of research at the Western Australian Institute for Medical Research in Perth told Medscape Medical News.

The study is published in the July/August issue of the Annals of Family Medicine.

New Approach

"Previous studies have successfully used stepped care to improve the management of patients with clinically significant depressive symptoms, an approach known as 'indicated prevention,' " Dr. Almeida said. "We wanted to test a more universal approach to intervention that would not be limited to older people who show overt or subsyndromal depressive symptoms."

The approach did not rely on case management or the systematic use of psychological interventions, which significantly reduced the costs of the program, he added.

Dr. Almeida and his group conducted a systematic audit of the practice of 373 Australian general practitioners who had a total of 21,762 patients aged 60 years or older.

Physicians who were randomly assigned to the intervention group received detailed feedback about their patients with depression or suicide ideation, including any signs or symptoms that were present and whether they did or did not identify those signs and symptoms. They were also told how the results of their audit compared with those of the other study participants.

In addition to the personalized feedback, the physicians in the intervention group also received printed educational material and 6 monthly educational newsletters that provided feedback about the progress of the project and offered "hints" about "things to remember" when assessing an older person for depression or suicide ideation. These newsletters were delivered over a period of 2 years.

Real-World Relevance?

Physicians randomly assigned to the control group completed a practice audit but did not receive individualized feedback. They also received 6 monthly newsletters but were not offered access to the educational material about screening, diagnosis, and management of depression and suicide behavior in later life.

The presence of clinically significant depression, as determined by a Patient Health Questionnaire score of 10 or more, or self-harm behavior (thoughts of suicide or a suicide attempt during the previous 12 months) were assessed at baseline and again after 12 and 24 months.

The study showed that older adults who were treated by general practitioners randomly assigned to the feedback intervention had a 10% (95% confidence interval [CI], 3% - 17%) reduction in the odds of depression or self-harm behavior during follow-up compared with those who were treated by the control physicians.

In a post-hoc analysis, the researchers found that the relative effect of the intervention on depression was not significant (odds ratio [OR], 0.93; 95% CI, 0.83 - 1.03) but that the effect of the intervention on self-harm behavior over 24 months was significant (OR, 0.80; 95% CI, 0.68 - 0.94).

"The benefit of the intervention was primarily due to the reduction of self-harm behavior in adults who did not report symptoms at baseline. It had no obvious effect in reducing the 24-month prevalence of depression or self-harm behavior in older adults who had symptoms at study entry," Dr. Almeida said.

"I would like to see the relevant aspects of the intervention integrated into normal clinical practice to determine if, in the real world, this would lead to a decline in the prevalence of depression and suicide behavior in the community," he added.

This study was supported by the National Health and Medical Research Council of Australia. Dr. Almeida has disclosed no relevant financial relationships.

Ann Fam Med. 2012;10:347-356.

    
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