プライマリ・ケアにおける気分障害の認識と診断について(シンポジウム:うつ病の診断・治療上の問題点とコツ,2008年,第49回日本心身医学会総会(札幌))  [in Japanese] Mood Disorders in Primary Care(Symposium/Depression-Its Diagnostic Issues and the Knack of Treatment)  [in Japanese]

Goldberg&Huxleyモデルは,うつ病患者の受診経路を想定するためのフレームワークとして有用である.プライマリ・ケア領域においては,レベル2(プライマリ・ケア医療機関への受診者)からレベル3(プライマリ・ケア医が確認したうつ病患者)に円滑に通過させる第2フィルターが重要な要因となり,「プライマリ・ケア医のうつ病の認識および診断能力の向上」が鍵となる.さらに第3フィルター「プライマリ・ケア医療機関から精神医療サービスへの連携」が重要である.うつ病スクリーニングツールは,多忙なプライマリ・ケア医にとっては有用であるが,過剰診断傾向につながる危険性をはらんでいる.スクリーニングツールが内包している有用性と限界を十分踏まえたうえで使用することが望ましい.PRIME-MD(Patient Health Questionnaire)PHQ-9は,高い精度をもつため適切な患者情報を共有するためのツールとしては大変有用である.しかしスクリーニングされた症例について,気分障害の適切な診断と治療戦略のためには,十分な診断弁別能力および臨床能力が要請される.

Goldberg P and Huxley described the key features of the model of the pathways to psychiatric care. There are 5 levels from the community to the psychiatric hospital and 4 filters. This framework serves to draw our attention to the "filters" through which depressive patients must pass in order to receive mental health care providers. The 2^<nd> filter is the most important belong to primary care, which includes levels 2 (total depressive patients) and 3 (detected mood disorders). The ability to pass 2^<nd> filter smoothly, depends on detection of mood disorders by primary care physician and makes second prevention for depression. The 3^<rd> filter is also important belong to level 3 and level 4 (all patients treated by mental health services). Screening tests and diagnostic aids for depressive symptoms aim to improve the accuracy with which the primary care physician detects mood disorders. Brief measures are more useful in the busy clinical practice. But they have benefits and limitations. When screening for depression, the cutt-off scores of test should be cautious, and would be connected in a tendency to overdiagnosis. The PRIME-MD PHQ depression scale (PHQ-9) is dual-purpose instrument for making provisional depressive disorder diagnoses and assessing severity for depressive disorders. The PHQ-9 can be administered by the co-medical staffs, and it can be useful clinical tool for screening depression in primary care settings. However, about a screened patient, enough ability for diagnosis and clinical competence are requested for an appropriate diagnosis and treatment strategy of mood disorders.