DEPRESSION
Le dépistage est-il possible ?
Dr François DUMEL (Avec son aimbable autorisation)
Médecin généraliste, Audincourt
Texte original faisant partie de " Comment évaluer le risque suicidaire et notamment l’imminence ou la gravité d’un passage à l’acte en médecine générale ? " [Lire ici].

La fréquence des maladies psychiatriques en médecine de premier recours est importante : environ 25 % des patients présentent une altération de l'état psychique, et 4 à 8 % remplissent les critères diagnostic d'une dépression majeure. La dépression est souvent mal diagnostiquée. On qualifie, souvent à tort, tout trouble de la santé mentale d'état dépressif, et les troubles anxieux, les addictions, les phobies, sont des troubles reconnus tardivement. La précocité du diagnostic peut améliorer le pronostic d'une affection psychiatrique, ce qui rend un dépistage en consultation de médecine générale particulièrement utile

Un travail français vient d'être publié. Un test de repérage des patients potentiellement déprimés à 4 questions le MINI ( Mini International Neuropsychiatric Interview) a été proposé à 1100 personnes de la cohorte GAZEL ( cohorte multiprofessionnelle d'agents EDF-GDF).

Le test est positif si un sujet répond oui à l'une des 4 items suivants :
• j'ai des troubles du sommeil
• je me sens fatigué tout le temps
• je me sens nerveux, tendu
• j'ai du mal à faire face aux évènements.

Parmi les personnes déprimées selon les critères du MINI, mais non prises en charge de façon spécifique, 83% pourraient être dépistées par ce test. Dans cette étude de cohorte 77,4% des sujets déprimés n'ont bénéficié d'aucune prise en charge. Ce test a des propriétés similaires au CES-D version française. Il est d'une utilisation plus simple et devrait s'intégrer plus aisément dans une consultation de médecine générale.

POUR LES PERSONNES AGEES
L'échelle " MINI-GDS" paraît être un outil particulièrement adapté au sujet âgé. Il s'agit d'un questionnaire à quatre questions.

Le test est positif si le sujet âgé répond oui à au moins une des questions suivantes :
• Avez-vous le sentiment que votre vie est vide ?
• Etes-vous heureux la plupart du temps ?
• Vous sentez-vous découragé et triste ?
• Avez-vous l'impression que votre situation est désespérée ?
• La sensibilité de ce test est bonne, la spécificité est faible.

Conclusion Ces différents travaux démontrent qu'il est possible de concevoir et d'utiliser des outils de dépistage de la dépression et des idées suicidaires dans le cadre d'une consultation de médecine générale. Il convient d'affiner ces tests et les faire connaître à la profession de façon à ce que le dépistage de la dépression rentre dans l'anamnèse systématique du consultant quel que soit le motif de consultation.

Marquet S. Evolution de la dépression en médecine générale. Exercer, 1999, N° spécial, recherche 11-15.
Bibliomed Pourquoi la dépression est souvent méconnue en médecine générale ? Bibliomed 2000, 172.
Duburq A, Charpak Y, Blin P. Comment diagnostiquer la dépression en médecine générale ? Elaboration d'un test de repérage des patients. Rev Prat MG, 2000, 14 ( 506 ) : 1403-7.
Fuhrer T, Rouillon F. La version française de l'échelle CES-D ( Center for Epidemiologoc studi-Depression Scale). Description et traduction de l'échelle d'auto-évaluation. Psychiatric < Clément JP, Nassif RF & al. Mise au point et contribution à la validation d'une version française bève de la Geriatric Depression Scale de Yesavage. L'encéphale, 1997, XXIII, 2 : 91-99.

Un dépistage systématique des pathologies psychiatriques courantes en cabinet de médecine générale prend souvent trop de temps. Un questionnaire rempli par le patient lui-même serait la solution et permettrait d'améliorer la prise en charge. C'est la thèse que défend le Professeur Robert L. Spitzer, Columbia University, New-York, auteur de deux questionnaires dont il présentait la version la plus récente - PRIME MD for Today - qui est éditée et mise à la disposition du corps médical par les laboratoires Pfizer SA.

STUDY PUBLISHED IN JAMA FINDS FIRST PATIENT-ADMINISTERED QUESTIONNAIRE FOR MENTAL HEALTH DISORDERS 85% EFFECTIVE IN DIAGNOSIS

NEW YORK, November 11, 1999 – A self-administered patient health questionnaire has proven as effective and easier to use than an earlier version administered by physicians, according to a study published this week in the Journal of the American Medical Association (JAMA).

The PRIME-MD TodayTM Patient Health Questionnaire, which is the first diagnostic test that can be entirely self-administered by the patient, is an updated and expanded version of the widely used PRIME-MD® (Primary Care Evaluation of Mental Disorders) program, first developed in 1993. PRIME-MD® was the first standardized test designed by both psychiatrists and primary care physicians to help screen, evaluate and diagnose mental health disorders most commonly seen in primary care settings.

"While the new Patient Health Questionnaire, studied in this multi- center clinical trial, is shorter and more efficient than the original version, it successfully evaluates the severity of mood and somatoform disorders," said Robert L. Spitzer, MD, of the Biometrics Research Department, New York State Psychiatric Institute and Columbia University and lead author of the study. "With an early and accurate diagnosis, such as one obtained through the PHQ, doctors can determine appropriate treatment and take steps to improve patient's quality of life."

Mental disorders in primary care are common, disabling, and costly. Studies show that as many as one in five people who visit a primary care physician may be suffering from a mental disorder as a primary or associated condition, and many of those patients remain undiagnosed and untreated.

Developed through a grant from Pfizer, the new questionnaire evaluates the five most common groups of mental health disorders (mood, anxiety, alcohol, eating disorders and somatoform disorders), as well as women's reproductive health issues and psychosocial stressors affecting both men and women. PHQ diagnoses are based on diagnostic criteria contained in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The Patient Health Questionnaire is available in English and Spanish, and can be read to the patient if necessary.

"Pfizer is committed to an overall health management approach to treatment," said Karen Katen, President, U.S. Pharmaceuticals. "To this end, Pfizer has developed a series of programs to support the management of depression, including LINK®, a workplace depression awareness program, and RHYTHMS®, designed to assist patients with compliance during the treatment process. The new PRIME-MD TodayTM PHQ supports this continuum of care by providing an opportunity for early diagnosis in the primary care setting."

PRIME-MD TodayTM was developed by Robert L. Spitzer, MD, and Janet B.W. Williams, DSW, of the Biometrics Research Department, New York State Psychiatric Institute and Columbia University; and an Advisory Committee of primary care, OB/GYN and psychiatry practitioners. Development of the PHQ was underwritten by an educational grant from Pfizer U.S. Pharmaceuticals Inc. PRIME-MD® is a trademark of Pfizer Inc, and is made available free to physicians and other healthcare providers by the company.

PRIME MD TODAY®

Question about dépression :
---- Not at all
---- Sevral days
---- More than half the days
---- Nearly ever day

Adapted from PRIME-MD TodayTM Tool. PRIME-MD® and PRIME-MD TodayTM are trademarks of Pfizer Inc. Copyright ©2001 Pfizer Inc. All rights reserved.

Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
Over the last 2 weeks, how often have you been bothered by trouble falling or staying asleep, or sleeping
too much? Over the last 2 weeks, how often have you been bothered by feeling tired or having little energy?
Over the last 2 weeks, how often have you been bothered by poor appetite or overeating?
Over the last 2 weeks, how often have you been bothered by feeling bad about yourself, or that you are a failure, or have let yourself or your family down?
Over the last 2 weeks, how often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
Over the last 2 weeks, how often have you been bothered by moving or speaking so slowly that other people could have noticed. Or the opposite--being so fidgety or restless that you have been moving around a lot more than usual?
Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?

If you checked "several days" or higher for (a) or (b) and 4 or more other problems, discuss your answers with a doctor. Only a doctor can make a diagnosis of depression. Also talk to your doctor if you checked "several days" or higher for (i), thinking that you would be better off dead or wanting to hurt yourself. Having repeated thoughts of death or suicide is the most serious symptom of depression. If you are thinking of harming yourself, get help immediately; make your feelings known to someone who can help you — your doctor, family members, friends. Your doctor is an excellent person to tell.

Table 1 - The DSM-IV Criteria For MajorDepression To meet the criteria for major depression, the patient must have at least five of the following symptoms for a period of 2 weeks or longer. At least one of these symptoms must be a depressed mood most of the day, nearly every day, or a markedly diminished interest or pleasure in all or almost all daily activities nearly every day. 1. Depressed mood 2. Markedly diminished interest or pleasure in activities 3. Significant weight loss or loss of appetite 4. Insomnia or hypersomnia 5. Psychomotor retardation or agitation 6. Loss of energy 7. Feelings of worthlessness or guilt 8. Decreased ability to concentrate 9. Recurrent thoughts of death or suicide Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric AssociationWashington, DC, 1994.