Effect of a Lay Counselor Intervention on Prevention of Major Depression in Older Adults Living in Low- and Middle-Income Countries A Randomized Clinical Trial
Effect of a Lay Counselor Intervention on Prevention of Major Depression in Older Adults Living in Low- and Middle-Income Countries A Randomized Clinical Trial
复制标题
DOI：
10.1001/jamapsychiatry.2018.3048
复制
发表时间：
2019-01-01
期刊：
影响因子：
25.8
通讯作者：
Reynolds, Charles F., III
中科院分区：
文献类型：
--
作者：
Dias, Amit;Azariah, Fredric;Reynolds, Charles F., III
在低收入和中等收入国家的老年人中预防抑郁症的重要性很重要，因为治疗资源的稀缺性和残疾、自杀和痴呆的风险。目的评估由非专业顾问提供的抑郁预防干预对来自低收入和中等收入国家的老年人是否有效。设计、设置和参与者这项平行分组随机临床试验采用掩蔽结局评估，在印度果阿的农村和城市初级保健诊所进行了181名患有亚综合征抑郁症状的老年人(=60岁)。第一名参与者于2015年3月31日进入试验，最后一名参与者于2017年6月2日离开。数据分析采用意向治疗方法。干预措施生活咨询师提供问题解决治疗、失眠的简短行为治疗、糖尿病等常见内科疾病的自我护理教育，以及获得医疗和社会计划的帮助。主要结果和衡量结果是主要抑郁发作的发生率。这项研究还评估了12个月内的症状变化(12个项目的一般健康问卷[GHQ-12]；分数范围为0至12，分数越高，表明抑郁和焦虑症状越严重)、功能状态(世界卫生组织残疾评估计划2.0；分数范围12至60，分数越高，表明残疾程度越大)、认知(印地语迷你精神状态检查；分数范围0至30，分数越高，表明认知功能更好)、血压和体重指数，以提供进一步的临床背景。114名(63.0%)女性)：91名接受干预组(老年抑郁症干预)，90名接受日常护理(CAU)。DIL干预组重度抑郁发生率低于CAU组(4.40%比14.44%；对数等级P=0.04；需要治疗次数9.95；95%可信区间5.12~182.43)。12个月Kaplan-Meier估计的无抑郁参与者百分比DIL组为95.1%(95%CI，90.5%-99.9%)，CAU组为87.4%(95%CI，80.4%-95.1%)。抑郁症状(GHQ-12)的发生率也较低(12个月平均差，-1.18；95%可信区间，-2.03至-0.31；x组交互作用P<；.001)。残疾或认知方面的衡量标准没有变化。DIL干预显著降低了收缩压(12个月平均差，-6.98；95%CI，-11.96至-2.01；x时间交互作用P<；.001)和体重指数的变化(12个月平均差，0.23；95%CI，-0.97至1.43；P=.04)。结论和相关性DIL干预能有效地预防有亚综合征症状的老年人的严重抑郁发作。如果复制，DIL干预可能对生活在低收入和中等收入国家的老年人有效。
IMPORTANCE Preventing depression in older adults living in low- and middle-income countries is important because of the scarcity of treatment resources and the risk of disability, suicide, and dementia.OBJECTIVE To assess whether an intervention for depression prevention provided by lay counselors is effective in older adults from low- and middle-income countries.DESIGN, SETTING, AND PARTICIPANTS This parallel-group randomized clinical trial with masked outcome assessment was performed in 181 older adults (>= 60 years) with subsyndromal depressive symptoms at rural and urban primary care clinics in Goa, India. The first participant entered the trial on March 31, 2015, and the last exited on June 2, 2017. Data analysis used the intention-to-treat approach.INTERVENTIONS Lay counselors provided problem-solving therapy, brief behavioral treatment for insomnia, education in self-care of common medical disorders such as diabetes, and assistance in accessing medical and social programs.MAIN OUTCOMES AND MEASURES The main outcomewas incidence of major depressive episodes. The study also assessed symptom change during 12 months (12-item General Health Questionnaire [GHQ-12]; score range of 0 to 12, with higher scores indicating greater symptoms of depression and anxiety), functional status(World Health Organization Disability Assessment Schedule 2.0; score range of 12 to 60, with higher scores indicating greater disability), cognition (Hindi Mini-Mental State Examination; score range of 0 to 30, with higher scores indicating better cognitive functioning), blood pressure, and body mass index to provide further clinical context.RESULTS The study enrolled 181 participants(mean[SD] age, 69.6[7.2] years; 114[63.0%] female): 91 to the intervention arm(depression in later life[DIL] intervention) and 90 to care as usual(CAU). Incident episodes of major depression were lower in the DIL intervention than in the CAU group(4.40% vs 14.44%; log-rank P = .04; number needed to treat, 9.95; 95% CI, 5.12-182.43). The 12-month Kaplan-Meier estimates of percentage of depression-free participants were 95.1%(95% CI, 90.5%-99.9%) in the DIL group vs 87.4% (95% CI, 80.4%-95.1%) in the CAU group. The incidence of depressive symptoms(GHQ-12) was also less(12-month mean difference,-1.18; 95% CI,-2.03 to -0.31; group x time interaction P < .001). There were no changes in measures of disability or cognition. The DIL intervention was associated with a significantly greater lowering of systolic blood pressure (12-month mean difference, -6.98; 95% CI, -11.96 to -2.01; group x time interaction P < .001) and change in body mass index (12-month mean difference, 0.23; 95% CI, -0.97 to 1.43; P = .04).CONCLUSIONS AND RELEVANCE The DIL intervention is effective for preventing episodes of major depression in older persons with subsyndromal symptoms. If replicated, the DIL intervention may be effective in older adults living in low- and middle-income countries.