美国成人抑郁症常被过度诊断和治疗

美国一项调查研究显示，在美国成人中经常出现抑郁症过度诊断和过度治疗现象。

这项研究旨在了解被临床医生确诊为抑郁症的患者是否也符合DSM-IV对12个月重度抑郁发作(MDE)诊断标准。结果显示，在被诊断为抑郁症的5,639例患者中，仅有38.4%的患者真正符合MDE标准。此外，大部分患者报告正在使用精神类处方药物，无论其是否符合MDE标准。

主要研究者、约翰霍普金斯大学的Ramin Mojtabai博士认为，上述结果突显了美国精神病药物——特别是抗抑郁药物——处方和使用的发展趋势，以及精神疾病诊断方面的不足。

成人受访者样本来自2009年和2010年美国药物使用和健康调查(NSDUH)。通过计算机辅助的现场交谈对受访者进行评估，以确定其是否符合DSM-IV MDE诊断标准。利用美国共病再调查(NCS-R)复合性国际诊断交谈表(CIDI)中的问题，受访者必须符合9项症状标准中的5项以及DSM-Ⅳ临床意义标准(功能性损伤)。此外，还询问了受试者过去12个月住院或门诊治疗或用药情况，以及受教育程度、总体健康情况和就业状况等人口统计学资料。

结果显示，与18~25岁年龄组患者相比，35~49岁和≥65岁年龄组患者符合12个月MDE标准的比例较低。而未就业、离异、受教育程度较高以及自我健康评价较差的患者符合12个月MDE标准的比例较高。

此外，该研究假阳性确诊率与既往研究结果相似。研究者认为，多种因素或与假阳性率较高有关，诸如社区机构抑郁症发病率通常较低、缺少熟悉诊断标准的医生以及对阈下症状的界定不清晰。

研究者承认该研究存在一些局限性。首先，由于许多医生并没有与患者分享其诊断想法，医生实际确诊的抑郁症患病率或许远远高于该研究的估算值。第二，结构式访谈和医生诊断均属敏感性不佳的办法。第三，NSDUH调查没有指定招募受试者的医生类型。第四，被诊断为抑郁症的患者或许实际上患有另外一种精神疾病，如焦虑或适应障碍，而抗抑郁药物也可使之受益。最后，为预防缓解后复发，部分抑郁症成人患者或需长期治疗。

他提到了由Laura Batstra博士和Allen Frances博士最初推荐的一种更为谨慎的精神疾病诊断方法。该方法可避免医生将阈下症状和轻度患者诊断为精神疾病，并鼓励在适当的情况下采取较为温和的干预措施(Psychother. Psychosom. 2012;81:5-10)。

Mojtabai博士表示，这项研究凸显了精神疾病准确诊断所面临的挑战，以及鉴于初级保健医生在精神疾病治疗中的作用愈加重要，应特别优先考虑提高其精神疾病诊治水平。

Mojtabai博士承认收受了灵北制药公司的咨询费用。

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By: MADHU RAJARAMAN, Internal Medicine News Digital Network

Depression is frequently overdiagnosed and overtreated in American adults, according to a national survey study.

The study explored whether patients identified as depressed by their clinicians also met the DSM-IV diagnostic criteria for 12-month major depressive episodes (MDE). Results showed that of the 5,639 participants with clinician-identified depression, only 38.4% actually met the MDE criteria. Additionally, a majority of participants reported using prescribed psychiatric medications, regardless of whether they met MDE conditions.

"This finding highlights the growing trends in prescription and use of psychiatric medications, and especially antidepressants, in the USA, even in the absence of a psychiatric diagnosis," wrote study author Dr. Ramin Mojtabai of the department of mental health at Johns Hopkins Bloomberg School of Public Health, Baltimore.

A sample of adult participants was drawn from the 2009 and 2010 National Survey of Drug Use and Health (NSDUH). Participants completed an assessment in the form of a computer-assisted in-person interview to determine whether they met DSM-IV criteria for major depressive episodes. Using questions derived from the Composite International Diagnostic Interview (CIDI) from the National Comorbidity Survey Replication, participants had to meet 5 of 9 symptom criteria and the DSM-IV clinical significance criteria (distress or impairment in functioning).

In addition to diagnostic criteria for depression, participants also were asked to report any inpatient or outpatient treatment or medications sought and prescribed over the past 12 months. Demographic information, such as education, general health, and employment status, also was collected.

Results showed that adults in the groups aged 35-49 years and ≥65 years and older were less likely to meet the 12-month MDE criteria than were adults aged 18-25 years.

"In contrast, participants who were out of the workforce, those who were divorced or separated, the more educated and those with poorer self-rated health were more likely to meet the 12-month MDE criteria," Dr. Mojtabai wrote.

He added that the rate of false-positive diagnosis found in this study echoes that of prior research, and that numerous factors could contribute to this high rate, such as a generally low incidence of depression in community settings, a lack of clinician knowledge about diagnostic criteria, and "ambiguity regarding subthreshold syndromes."

Dr. Mojtabai noted a few limitations to this study. First, he speculated that the true prevalence of clinician-diagnosed depression is likely much higher than is estimated in this study, as many doctors might not share their diagnostic impressions with patients. Second, he cautioned that structured interviews and clinician diagnoses are measures of "imperfect sensitivity." Third, the type of doctor was not specified in the NSDUH survey used to recruit participants. Fourth, some patients diagnosed with depression might in fact have another disorder, such as anxiety or adjustment disorder, which might benefit from antidepressant medication. And lastly, some adults with depression might require long-term treatment to prevent recurrence after remission.

He mentioned a more vigilant approach to diagnosing mental health disorders, originally suggested by Laura Batstra, Ph.D., and Dr. Allen Frances, "which allows clinicians to avoid labeling subthreshold symptoms and mild conditions with psychiatric diagnoses" and encourages the use of less intense psychological interventions when appropriate (Psychother. Psychosom. 2012;81:5-10).

Dr. Mojtabai explained that this study underscores the challenge of accurately diagnosing mental disorders, and as primary care starts to play a larger role in mental health care, special priority should be given to improved diagnosis and treatment of psychiatric conditions.

Dr. Mojtabai disclosed receiving consulting fees from Lundbeck Pharmaceuticals.