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La dépression dans les populations médicales

Published online by Cambridge University Press:  28 April 2020

T. Lemperière
T. Lemperière*
Affiliation:
Hôpital Louis-Mourier, 178, rue des Renouillers, 92700Colombes, France
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Résumé

La prévalence élevée des états dépressifs dans la clientèle du généraliste (environ 10% des consultants) et chez les patients de médecine interne (15 à 25% des hospitalisés) est maintenant bien établie. Ce fait a été longtemps négligé par les praticiens et les psychiatres; même actuellement son importance reste sous-estimée.

La proportion d’états dépressifs non-identifiés par les praticiens varie de 1/3 à 2/3 selon les études. Les dépressions méconnues sont source de surconsommation médicale (consultations répétées, examens paracliniques, hospitalisations pour bilans) et ont une évolution moins favorable, plus chronique, que les dépressions identifiées et correctement traitées. Des cas sévères de dépression échappent souvent au dépistage, ce qui n’est pas sans conséquences graves: on sait en effet que la majorité des gens qui se suicident ont consulté un médecin dans le mois qui a précédé leur décès.

Parmi les facteurs qui rendent compte de la méconnaissance des états dépressifs par les médecins non-spécialistes, les uns tiennent aux patients qui, dans leur dialogue avec le généraliste, utilisent davantage le langage de la somatisation qu’ils ne verbalisent explicitement un vécu dépressif. D’autres tiennent aux praticiens, à leur intérêt prévalent et parlois exclusif pour les problèmes somatiques, à leur souci légitime de ne pas passer à côté du diagnostic d’une affection médicale, à l’idée qu’ils se font de la dépression et des déprimés, à leur propension à considérer toutes les manifestations dysphoriques comme conséquences légitimes de la maladie physique. Il faut aussi compter avec les conditions d’exercice du généraliste, le temps très court de sa consultation où il n’est pas facile de différencier une réelle pathologie dépressive, généralement liée à des troubles anxieux et moins nette que dans les consultations Psychiatriques, de troubles émotionnels mineurs, situationnels et transitoires.

Les instruments habituellement utilisés pour le dépistage et le diagnostic de la dépression (échelles d’autoévaluation, critères de diagnostic type RDC ou critères du DSM III) n’ont pas été validés pour les populations de patients somatiques. Récemment deux nouveaux instruments viennent d’être mis au point pour la détection de la symptomatologie dépressive chez les patients somatiques: I'échelle HAD (Hospital Anxiety and Depression Scale) de Zigmond et Snaith (1983) et le Questionnaire Abrégé d’Auto-Évaluation de la Symptomatologie Dépressive (QD2A) de Pichot et al. (1984). Ces échelles, de passation rapide et bien acceptées par les patients, peuvent servir d’aide au diagnostic pour le praticien dans la perspective d’un meilleur dépistage de la dépression et d’une prise en charge plus efficace des déprimés.

Summary

Summary

The high incidence of depressive states (approx. 10%) in patients Consulting the general practitioner and amongst hospital admissions (15 —25% of hospitalized patients) is now well eslablished. This situation was long overlooked by practitioners and psychiatrists, and even today the significance of this high incidence is underestimated.

The proportion of depressive states that are unidentified by practitioners varies, depending on the studies from one- to two-thirds. Unrecognized depressions result in overuse of medical services (repeated consultations paraclinical examinations, hospitalisations for health checkups) and are of a more chronic and less favourable evolution than depressions which have been identified and correctly treated. Severe cases of depression often remain undetected, which may have serions consequences: it is a known fact that the majority of persons who commit suicide have seen a doctor in the month prior to their death.

Amongst the factors responsible for non specialist doctors not recognizing depressive states, some are due to the patients tendency to communicate in somatic terms, rather than clearly verbalizing the depressive experience. Other factors are due to the practitioners themselves, and to their main and sometimes exclusive preoccupation with somatic problems, their understandable concern at not correctly diagnosing a medical disease, their attitude towards depression and depressed persons and their tendency to consider all dysphoric manifestations as legitimate symptoms of a physical disease. To this should be added the conditions under which the general practitioner exercises his profession, the extremely short consultations during which it is far from easy to differentiate a depressive pathology, generally connected with a state of anxiety and less clearly defined than in psychiatric consultations, from transitory minor emotional and situational disturbances.

The instruments which are generally used for detecting and diagnosing depression (auto-evaluation scales, criteria for diagnosis such as the RDC or DSM III) have not been validated for the somatic-patient category. Two new instruments have recently been developed for detecting a depressive symptomatology in somatic patients: the HAD scale (Hospital Anxiety and Depression Scale) introduced by Zigmond and Snaith (1983) and the «Questionnaire Abrégé d'Auto-Évaluation de la Symptomatologie Dépressive», a shortened auto-evaluation questionnaire for depressive symptomatology (QD2A), developed by Pichot et al. (1984). These scales, which take little time to complete and are well-accepted by patients, may serve as diagnostic aids for the practitioner, thus enabling him to better recognize the depressive state, and treat depressed patients more effectively.

Keywords

généralistemédecine interneétals dépressifs non-identifiésgeneral practitionerhospital admissionsunidentified depressive states
Type
Research Article
Information
Psychiatry and Psychobiology , Volume 3 , Issue S1: Les Etats Dépressifs: vers une révision des concepts Paris, 20 Novembre 1987 , 1988 , pp. 71s - 83s
Copyright
Copyright © European Psychiatric Association 1998

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