可降低年長者憂鬱和自我傷害的介入方式


  【24drs.com】把年長患者的憂鬱與自殺行為之處置及評估的相關資訊讓家庭醫師知悉,可以顯著降低此類患者的憂鬱和自我傷害。
  
  西澳大利亞大學老年精神科榮譽教授、西澳大利亞醫學研究中心主任Osvaldo P. Almeida博士表示,藉由家庭醫師進行系統性回饋以及教育如何評估和處置這些狀況,可以降低社區年長者的憂鬱和自殺想法盛行率。
  
  研究刊載於7/8月版家庭醫學誌。
  
  Almeida博士表示,之前的研究成功地使用加強護理改善臨床顯著憂鬱症狀者的處置,這方法稱為特定性預防,我們希望探討一個更普及的介入方式,不限於呈現明顯或次憂鬱徵候的年長者;這個方法不依賴案例控制或系統性使用心理介入,顯著降低了計劃費用。
  
  Almeida博士等人進行一個系統性方式審核373名澳大利亞一般開業醫師的實務,共有21,762名60歲以上病患的資料。
  
  被隨機指派到介入組的醫師獲得有關憂鬱或自殺意念病患的詳細回饋資訊,包括出現的任何徵兆或症狀,以及他們是否有辨識這些徵兆及症狀,他們也被告知他們的審核結果以及其他研究對象的比較。
  
  除了個人化回饋,介入組的醫師也接受書面教育資料和6次教育電子報月刊,提供計畫進度的回饋,以及提供評估憂鬱或自殺意念年長者時「務必記住事項」的提示,這些電子報共提供2年。
  
  被隨機指派到對照組的醫師們完成實務審核,但是沒有接受個別回饋;他們也接受6次電子報月刊,但是未被提供有關年長者憂鬱和自殺行為篩檢、診斷和處置的教育資料。
  
  在開始時和12個月與24個月之後評估是否出現臨床顯著憂鬱(經Patient Health Questionnaire分數10分以上確認)或自我傷害行為(過去12個月內有自殺想法或試圖自殺)。
  
  該研究顯示,在追蹤期間,和對照組醫師治療的病患相比,被隨機指派到介入組給一般開業醫師治療的年長者,憂鬱或自我傷害行為的機會降低了10% (95%信心區間[CI],3% - 17%)。
  
  事後分析中,研究者發現介入組對於憂鬱的相對效果並未顯著(勝算比[OR],0.93;95% CI,0.83 - 1.03),但是介入組對於24個月期間的自我傷害行為的效果則是顯著(OR,0.80;95% CI,0.68 - 0.94)。
  
  Almeida博士表示,介入的效益主要是因為降低開始時無症狀成年人的自我傷害行為;對於研究一開始即有症狀的年長者, 24個月時的憂鬱或自我傷害行為盛行率的降低並無明顯效果。
  
  他指出,實際上,希望可以看見這個介入方式的相關方面整合到臨床實務,以確認是否可實際降低社區的憂鬱和自殺行為盛行率。
  
  資料來源: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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