关于抑郁症管理的指南建议从业者使用患者报告的结果测量来对症状进行后续监测,但在患者预后方面缺乏获益的证据.
■使用患者健康问卷-9问卷作为监测抑郁症的患者报告结果指标进行测试,培训从业者解释分数和给患者反馈。
■并行组,集群随机优势试验;干预和对照1:1分配。
■英国初级保健(英格兰和威尔士的141组一般做法)。
■年龄≥18岁的患者出现新的抑郁症或症状,主要通过病历搜索招募,加上协商中的机会主义。
■目前的抑郁症治疗,痴呆症,精神病,药物滥用和自杀风险。
■患者健康问卷-9问卷的管理,患者反馈诊断后不久,在10-35天后的随访中,与平时的护理相比。
■贝克抑郁量表,第二版,12周时的症状评分。
■贝克抑郁量表,第二版,26周得分;抗抑郁药物治疗和精神卫生服务接触;社会功能(工作和社会适应量表)和生活质量(EuroQol5维,5级)12周和26周;26周以上的服务使用来计算NHS费用;26周时的患者满意度(医疗信息满意度量表);和不良事件。
■招募的676名患者的原始目标样本减少到554,因为发现基线和主要结局指标的随访值之间存在显着相关性。
■通过招募大学将远程计算机随机化最小化,小型/大型实践和城市/农村位置。
■鉴于开放集群设计,不可能使参与者失明,但是自我报告结果测量可以防止观察者偏见。分析对分配是盲目的。
■使用线性混合模型,调整基线抑郁,基线焦虑,社会人口因素,和聚类,包括实践作为随机效应。对26周的生活质量和费用进行了分析。
■采用标准化过程理论框架,对患者健康问卷-9的试验过程和使用进行了医师和患者访谈。
■在干预手臂实践中招募了三百零两名患者,在对照实践中招募了227名患者。主要结果数据收集为252(83.4%)和195(85.9%),分别。贝克抑郁量表无显著差异,第二版,12周时评分(校正平均差-0.46,95%置信区间-2.16~1.26).贝克抑郁量表也没有显著差异,第2版,26周得分,社会功能,患者满意度或不良事件。EuroQol-5尺寸,五级版本,26周时的生活质量评分有利于干预组(校正平均差0.053,95%置信区间0.013~0.093).然而,超过26周的质量调整生命年没有显著增加(差异0.0013,95%置信区间-0.0157~0.0182).干预部门的成本较低,但是,再次,不显著(-163英镑,95%置信区间-349英镑至28英镑)。成本效益和成本效用分析,因此,表明干预措施比常规护理占优势,但点估计有相当大的不确定性。使用患者健康问卷-9对患者进行评估,以比较基线和随访时的得分,而从业者的观点更加复杂,有些人认为它太耗时。
使用患者健康问卷-9后12周,我们没有发现抑郁症管理或预后改善的证据,但26周时患者的生活质量更好,也许是因为患者健康问卷-9评分的反馈增加了他们对抑郁改善的意识,并减少了他们的焦虑。初级保健的进一步研究应评估患者报告的结果指标,包括焦虑症状,远程管理,算法为治疗变化提供明确的建议。
■本研究注册为IRAS250225和ISRCTN17299295。
■该奖项由美国国家卫生与护理研究所(NIHR)卫生技术评估计划(NIHR奖参考:17/42/02)资助,并在《卫生技术评估》中全文发布。28号17.有关更多奖项信息,请参阅NIHR资助和奖励网站。
抑郁症很常见,可能会导致残疾,并给国家带来数十亿美元的损失。国家卫生服务建议治疗抑郁症患者的全科医生使用症状问卷来帮助评估这些人是否随着时间的推移而变得更好。症状问卷是一种类型的患者报告的结果测量。患者报告的结果指标似乎使接受治疗和精神保健的人受益,但是这种方法还没有在一般实践中得到彻底的检验。大多数抑郁症患者在一般实践中接受治疗,所以在那里测试病人报告的结果指标是很重要的,也是。在这项研究中,我们测试了使用患者报告的结局指标是否有助于抑郁症患者更快地好转.该研究是一般实践中的“随机对照试验”,分成两组。在一组中,抑郁症患者完成了患者健康问卷,或“PHQ-9”,患者报告的结果测量,衡量抑郁症的九种症状。在另一组中,抑郁症患者照常接受治疗,不使用患者健康问卷-9.我们将患者健康问卷-9的结果反馈给抑郁症患者,向他们展示他们的抑郁症有多严重,并要求他们与照顾他们的从业者讨论结果。我们发现患者报告的结果测量组和对照组在抑郁水平上没有差异;他们的工作或社交生活;他们对实践中的护理满意度;或他们对药物的使用,抑郁症的治疗或专科护理。然而,我们确实发现他们的生活质量在6个月时得到了改善,他们使用的国家卫生服务服务的成本较低。使用患者健康问卷-9可以提高患者的生活质量,也许是通过让他们更加意识到抑郁症状的改善,因此也不那么焦虑了.未来的研究应该使用患者报告的结果指标进行测试,包括焦虑和通过计算机处理答案,以便为从业者提供更清晰的建议,以治疗抑郁症。
UNASSIGNED: Guidelines on the management of depression recommend that practitioners use patient-reported outcome measures for the follow-up monitoring of symptoms, but there is a lack of evidence of benefit in terms of patient outcomes.
UNASSIGNED: To test using the Patient Health Questionnaire-9 questionnaire as a patient-reported outcome measure for monitoring depression, training practitioners in interpreting scores and giving patients feedback.
UNASSIGNED: Parallel-group, cluster-randomised superiority trial; 1 : 1 allocation to intervention and control.
UNASSIGNED: UK primary care (141 group general practices in England and Wales).
UNASSIGNED: Patients aged ≥ 18 years with a new episode of depressive disorder or symptoms, recruited mainly through medical record searches, plus opportunistically in consultations.
UNASSIGNED: Current depression treatment, dementia, psychosis, substance misuse and risk of suicide.
UNASSIGNED: Administration of the Patient Health Questionnaire-9 questionnaire with patient feedback soon after diagnosis, and at follow-up 10-35 days later, compared with usual care.
UNASSIGNED: Beck Depression Inventory, 2nd edition, symptom scores at 12 weeks.
UNASSIGNED: Beck Depression Inventory, 2nd edition, scores at 26 weeks; antidepressant drug treatment and mental health service contacts; social functioning (Work and Social Adjustment Scale) and quality of life (EuroQol 5-Dimension, five-level) at 12 and 26 weeks; service use over 26 weeks to calculate NHS costs; patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale); and adverse events.
UNASSIGNED: The original target sample of 676 patients recruited was reduced to 554 due to finding a significant correlation between baseline and follow-up values for the primary outcome measure.
UNASSIGNED: Remote computerised randomisation with minimisation by recruiting university, small/large practice and urban/rural location.
UNASSIGNED: Blinding of participants was impossible given the open cluster design, but self-report outcome measures prevented observer bias. Analysis was blind to allocation.
UNASSIGNED: Linear mixed models were used, adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering including practice as random effect. Quality of life and costs were analysed over 26 weeks.
UNASSIGNED: Practitioner and patient interviews were conducted to reflect on trial processes and use of the Patient Health Questionnaire-9 using the Normalization Process Theory framework.
UNASSIGNED: Three hundred and two patients were recruited in intervention arm practices and 227 patients were recruited in control practices. Primary outcome data were collected for 252 (83.4%) and 195 (85.9%), respectively. No significant difference in Beck Depression Inventory, 2nd edition, score was found at 12 weeks (adjusted mean difference -0.46, 95% confidence interval -2.16 to 1.26). Nor were significant differences found in Beck Depression Inventory, 2nd Edition, score at 26 weeks, social functioning, patient satisfaction or adverse events. EuroQol-5 Dimensions, five-level version, quality-of-life scores favoured the intervention arm at 26 weeks (adjusted mean difference 0.053, 95% confidence interval 0.013 to 0.093). However, quality-adjusted life-years over 26 weeks were not significantly greater (difference 0.0013, 95% confidence interval -0.0157 to 0.0182). Costs were lower in the intervention arm but, again, not significantly (-£163, 95% confidence interval -£349 to £28). Cost-effectiveness and cost-utility analyses, therefore, suggested that the intervention was dominant over usual care, but with considerable uncertainty around the point estimates. Patients valued using the Patient Health Questionnaire-9 to compare scores at baseline and follow-up, whereas practitioner views were more mixed, with some considering it too time-consuming.
UNASSIGNED: We found no evidence of improved depression management or outcome at 12 weeks from using the Patient Health Questionnaire-9, but patients\' quality of life was better at 26 weeks, perhaps because feedback of Patient Health Questionnaire-9 scores increased their awareness of improvement in their depression and reduced their anxiety. Further research in primary care should evaluate patient-reported outcome measures including anxiety symptoms, administered remotely, with algorithms delivering clear recommendations for changes in treatment.
UNASSIGNED: This study is registered as IRAS250225 and ISRCTN17299295.
UNASSIGNED: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 17. See the NIHR Funding and Awards website for further award information.
Depression is common, can be disabling and costs the nation billions. The National Health Service recommends general practitioners who treat people with depression use symptom questionnaires to help assess whether those people are getting better over time. A symptom questionnaire is one type of patient-reported outcome measure. Patient-reported outcome measures appear to benefit people having therapy and mental health care, but this approach has not been tested thoroughly in general practice. Most people with depression are treated in general practice, so it is important to test patient-reported outcome measures there, too. In this study, we tested whether using a patient-reported outcome measure helps people with depression get better more quickly. The study was a ‘randomised controlled trial’ in general practices, split into two groups. In one group, people with depression completed the Patient Health Questionnaire, or ‘PHQ-9’, patient-reported outcome measure, which measures nine symptoms of depression. In the other group, people with depression were treated as usual without the Patient Health Questionnaire-9. We fed the results of the Patient Health Questionnaire-9 back to the people with depression themselves to show them how severe their depression was and asked them to discuss the results with the practitioners looking after them. We found no differences between the patient-reported outcome measure group and the control group in their level of depression; their work or social life; their satisfaction with care from their practice; or their use of medicines, therapy or specialist care for depression. However, we did find that their quality of life was improved at 6 months, and the costs of the National Health Service services they used were lower. Using the Patient Health Questionnaire-9 can improve patients’ quality of life, perhaps by making them more aware of improvement in their depression symptoms, and less anxious as a result. Future research should test using a patient-reported outcome measure that includes anxiety and processing the answers through a computer to give practitioners clearer advice on possible changes to treatment for depression.