| Sažetak | Cilj: Utvrditi prevalenciju i komorbiditet depresije odrasle populacije grada Zagreba
te posebice psihosocijalne parametre i njihovo poznavanje od strane liječnika,
postojeću skrb depresivnih pacijenata i primjenjivost upitnika SZO (Mastering
Depression in Primary Care).
Ispitanici i metoda. Reprezentativni uzorak za grad Zagreb je činilo 10 ordinacija
obiteljske medicine sa 17 290 pacijenata. Za podudarnost psihosocijalnih parametara i
valjanost upitnika za depresiju SZO izdvojen je uzorak 76 depresivnih pacijenata iz 3
ordinacije obiteljske medicine te slučajni uzorak od 5% ispitanika tih ordinacija tj.
168 ispitanika. Iz standardizirane zdravstvene dokumentacije obiteljskih liječnika
izdvojeni su podaci o depresijama i njihovoj skrbi. Za procjenu psihosocijalnih
parametara korištena su pitanja preporučena u Evropskim smjernicama za prevenciju
kardiovaskularnih bolesti. Primjenjivost upitnika SZO za depresiju je utvrñena
testiranjem sa Beck Depression Inventory II (BDI II).
Rezultati. Prevalencija depresije je bila 2,2%, a testiranjem BDI II slučajnog uzorka
pronañeno je 29 (18,84%) ispitanika sa simptomima depresivnosti i to 7 (4,54%) teške
depresivnosti. Komorbiditetnu bolest je imalo 301 (78,6%) depresivnih pacijenta, a
najčešće su bile iz skupina MKB 10: IX. Bolesti cirkulacijskog sustava, XIII. Bolesti
mišićno-koštanog sustava i vezivnog tkiva, IV. Endokrine bolesti, bolesti prehrane i
bolesti metabolizma, XI. Bolesti probavnog sustava te V. Duševni poremećaji i
poremećaji ponašanja.
Prepoznate socioekonomske karakteristike su bile: ženski spol (74,7%), srednja
životna dob od 45-65 godina (40,7%), udati/oženjeni (55,3%), srednjoškolsko
obrazovanje (59,2%), umirovljenici (54,5%), prosječnog ekonomskog stanja. Prema
kriterijima socijalne izoliranosti: uglavnom nisu živjeli sami (71,5%), imali su blisku
osobu (66,4%) i pomoć u bolesti (80,9%) te oko trećine nije imalo problema s
partnerom (36,8%). Parametri poslovnog stresa su procjenjeni izmeñu 5 i 6.
Zadovoljstvo životom je procjenjeno x = 4,57±1,72. Logistička regresija je pokazala
značajnu povezanost pacijenata sa dijagnozom Povratnog depresivnog poremećaja
(F33) u odnosu na pacijente sa dijagnozom Depresivne epizode (F32) sa višim
obrazovanjem te sa procjenom liječnika kao potištenije i teške pacijente. Liječnici su poznavali genealoško breme za 55% pacijenata. Od parametara socijalne izoliranosti
najbolje su procjenjeni da li pacijenti žive sami (93,7%), lošije imaju li pomoć u
slučaju bolesti (86,7%) i imaju li blisku osobu (78,1%). Porodični stres je bio
najlošije procjenjen parametar (69,1%). Pokušaj suicida liječnici nisu znali procjeniti
za 10% pacijenata, a parametre poslovnog stresa za oko 13% pacijenata. Razlikovala
se procijena psihosocijalnih parametara od strane depresivnih i ne depresivnih
pacijenata, a i LOM-ovi su ih različito procijenili. Bolja je podudarnost procjene bila
izmeñu LOM-ova i ne depresivnih pacijenata. Farmakoterapiju je koristilo 63%
pacijenta. Najčešće korišteni psihofarmaci su bili: benzodiazepini (63%) i SSRI
(62%), zatim NIMAO (12%), ostale antidepresive (8%) i ostale psihofarmaci (15%).
SSRI su u 90% uzimani kontinuirano, NIMAO u 70%, a benzodiazepini u svega
trećini. Najčešća kombinacija lijekova depresivnih pacijenata je bila: kombinacija
SSRI i benzodiazepina (33,8%) i najviše ih (34%) je koristilo kombinaciju
farmakoterapije i psihoterapije. Polovica pacijenata (47,78%) se nalazilo u stabilnoj
remisiji uz terapiju, četvrtina (24,54%) je bilo u stabilnoj remisiji bez terapije i
četvrtina (27,68%) su imali simptome uz terapiju po procjeni LOM-e čija je pozitivna
prediktivna vrijednost procjene bila 88% u usporedbi s BDI II. Za oko polovicu
(51,44%) depresivnih pacijenata je skrbio samo LOM. Najbolja procjena depresije se
dobila testiranjem sa sva tri upitnika SZO za depresiju ili istovremeno testiranjem sa
MKB 10 upitnikom i Intervjuom liječnika. WHO -5 upitnik je imao pozitivnu
prediktivnu vrijednost 51% i negativnu prediktivnu vrijednosti 90%.
Zaključak. Slabo je prepoznavanje depresije s prevalencijom 2,2 %, loše poznavanje
pojedinih psihosocijalnih parametara sa lošijom procjenom za depresivne pacijente. U
biopsihosocijalnom pristupu specifičnom za depresivne pacijente trebalo bi obratiti
pažnju na prepoznate psihosocijalne parametre. Neprihvatljivo je visoka primjena
benzodiazepina u terapiji premda diskontinuirano. Dobra procjena zdravstvenog
stanja depresivnih pacijenata od strane LOM-ova potvrñena procjenom na BDI II i
trećina liječnika koji uz farmakoterapiju pružaju i suport svojim depresivnim
pacijentima te stav samih liječnika o najvećoj učinkovitosti kombinacije psihoterapije
i farmakoterapije u skladu su sa postojećim smjernicama. Najbolja procjena depresije
bi se dobila testiranjem sa sva tri upitnika SZO za depresiju ili istovremeno testiranjem sa MKB 10 upitnikom i Intervjuom liječnika. WHO -5 upitnik sa dobrom
pozitivnom prediktivnom vrijednosti te visokom negativnom prediktivnom vrijednosti
je dobar instrument sa samo pet pitanja. |
| Sažetak (engleski) | Aim: To establish prevalence and co morbidity of depression in adult population of
Croatian capital Zagreb, particularly the risk factors and their identification by GPs.
To establish the present situation in health care for depressive patients, and
applicability of WHO questionnaire „Mastering Depression in Primary Care“.
Subjects and Methods. Patients (17.290) from ten GPs' offices in the city of Zagreb
formed the representative sample for this study. The sample of 76 depressive patients
from three GPs offices as well as the random sample of 5% of examinees (168) was
picked out in order to estimate the compatibility of risk factors and applicability of
WHO's questionnaire Mastering Depression in Primary. Data were collected from
GPs standardized medical records. Questions recommended by the European
guidelines for cardiovascular diseases were used for the evaluation of psychosocial
factors. Appropriateness of Mastering Depression in Primary Care was estimated with
Beck Depression Inventory II (BDI II).
Results: Prevalence of depression was 2.2%. Testing of examinees from the random
sample with BDI II revealed 29 (18.84%) examinees with depressive symptoms and
7(4.54%) with severe depressive symptoms. Co morbidity was found in 301 (78.6%)
depressive patients. According to ICD10, the most frequent co morbidity diseases
were: IX. Diseases of the circulatory system (I00-I99), XIII. Diseases of the
musculoskeletal system and connective tissue (M00-M99), IV. Endocrine, nutritional
and metabolic diseases (E00-E90), XI. Diseases of the digestive system (K00-K93),
and V. Mental and behavioral disorders (F00-F99).
Socioeconomic characteristics of the patients were: 74.7% were women, middle aged
(45-65 yrs), 55.3% were married, 59.2% with secondary schooling, 54.5% were
retired, and 73.6% with average economic status. According to social isolation they
were: not living alone (71.5%), with close confident (66.4%), with help in case of
illness (80.9%), and with no problems with partner (36.8%). Parameters of job stress
were estimated between 5 and 6, and life satisfaction was x = 4.57±1.72. Logistic
regression showed significant connection of patients with diagnosis of recurrent
depressive disorder (F33) with higher education in relation to the patient with
Depressive episode (F32). GPs were familiar with genealogical burden of diseases of
55% patients. The best estimation among parameters of social isolation was whether
the patients lived alone (93.7%), whether they had help in case of illness (86.7%), and whether they had close confident (78.1%). Problems with partner (69.1%) were the
worst assessed parameter. GPs had no information of suicide attempt for 10% of
patients and of job stress for 13% of patients. Psychosocial factors for depressive and
non depressive patients were assessed differently by GPs as well as by the patients
themselves. Compatibility of assessed factors was better with GPs and non depressive
patients than with GPs and depressive patients. Pharmacotherapy was applied in 63%
of depressive patients. Benzodiazepines (63%) and SSRI (62%) were used most
frequently, then NIMAO (12%), other antidepressives (8%) and other
psychopharmacs (15%). SSRI was used in 90% of the patients regularly, NIMAO in
70% and benzodiazepines in one third (38.3%). The most frequent combination of
antidepressives was SSRI and benzodiazepines (33.8%) while combination of
pharmacotherapy and psychotherapy was applied in 64% of patients. According to
GPs' estimation, about one half of depressive patients (47.78%) were stabile with
therapy, one quarter was stabile without therapy (47.78%), and one quarter (27.68%)
had depressive symptoms in spite of the therapy. GPs took care of half of depressive
patients (51.44%). GPs' clinical identification of depression had good positive
predictive value 88% compared with BDI II. The best prediction of depression was
found when testing of the whole sample with WHO (five) Well-being Index, ICD-10
Depression Inventory and Physician's Interview or with WHO (five) Well-being Index
and Physician's Interview. WHO-5 Well-being Index showed positive predictive value
51%, and negative predictive value 90%.
Conclusion. Depression with prevalence of 2.2% was poorly recognized as some
psychosocial factors especially for depressive patients. In biopsychosocial approach to
depressive patients particular attention has to be focused on those parameters. Use of
benzodiazepines was unacceptably high. GPs identification of depressiveness
compared with BDI II was quite good. One third of GPs giving support to depressive
patients together with pharmacotherapy and their opinion of combination of
psychotherapy and pharmacotherapy as the most effective were in concordance with
accurate recommendations. The best identification of depression was found in testing
the whole sample all together with WHO-5, ICD 10 Inventory and Physician's
Interview or with ICD 10 Inventory and Physician's Interview. WHO -5 has better
characteristics than widely used screening for depression with 2 questions |
