Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.
Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.
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DOI：
10.1001/jamapsychiatry.2014.1305
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发表时间：
2015-01
期刊：
影响因子：
25.8
通讯作者：
Alexopoulos GS
中科院分区：
文献类型：
--
作者：
Kiosses DN;Ravdin LD;Gross JJ;Raue P;Kotbi N;Alexopoulos GS
问题适应疗法(PATH)是一种针对患有严重抑郁症、认知障碍(从轻度认知缺陷到中度痴呆)和残疾的老年人的治疗方法。抗抑郁药在这一人群中的疗效有限，心理社会干预也没有得到充分的调查。为测试认知受损患者12周路径与支持疗法(ST-CI)在74名患有严重抑郁、认知障碍和残疾的老年人中减少抑郁和残疾的有效性。2006年4月1日至2011年9月31日的随机对照试验。威尔-康奈尔老年精神病学研究所；干预措施在参与者的家中进行。通过韦尔-康奈尔老年精神病学研究所的协作社区机构招募了74名患有严重抑郁症和认知障碍的老年参与者(年龄65岁，≥)，他们被随机分配到每周12次的Path或ST-CI治疗中(流失率为14.8%)。家庭交付路径与家庭交付ST-CI。PATH将问题解决方法与补偿策略、环境适应和照顾者参与相结合，以改善患者的情绪调节。ST-CI注重情感、理解和移情的表达。纵向数据的混合效应模型比较了PATH和ST-CI在治疗12周期间在减少抑郁(MADRS)和残疾(WHODAS-II)方面的有效性。与ST-CI参与者相比，路径参与者的抑郁(治疗X时间：F[1,179]=8.03，p=0.0051；12周时的Cohen‘s D：0.6)和残疾(治疗X时间：F[1,169]=14.86，p=0.0002；Cohen’s D：0.67)在12周内显著减少(主要结果)。此外，路径参与者的抑郁缓解率显著高于ST-CI参与者(37.84%对13.51%；卡方：5.74df=1，p=0.0174；需要治疗的人数(NNT)=4.11)(次要结果)。探索性分析显示，即使在耐药抑郁症参与者的亚组中，路径也比ST-CI更能减少抑郁(F[1，72.7]=6.01p=0.0166；科恩的d：12周：0.95.在减少抑郁和残疾方面，PATH比ST-CI更有效。PATH可能会为一大群抑郁、认知受损、几乎没有治疗选择的老年人提供缓解。
Problem Adaptation Therapy (PATH) is a treatment for older adults with major depression, cognitive impairment (from mild cognitive deficits to moderate dementia) and disability. Antidepressants have limited efficacy in this population and psychosocial interventions are inadequately investigated. To test the efficacy of 12-week PATH vs. Supportive Therapy for Cognitively Impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment and disability. Randomized Controlled Trial from April 1, 2006 until September 31, 2011. Weill-Cornell Institute of Geriatric Psychiatry; interventions were administered at participants’ homes. Seventy-four older participants (age≥65 years) with major depression and cognitive impairment up to the level of moderate dementia were recruited through collaborating community agencies of Weill-Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate). Home-delivered PATH vs. home-delivered ST-CI. PATH integrates a problem solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients’ emotion regulation. ST-CI focuses on expression of affect, understanding and empathy. Mixed-effects models for longitudinal data compared the efficacy of PATH to that of ST-CI in reducing depression (MADRS) and disability (WHODAS-II) over 12 weeks of treatment. PATH participants had significantly greater reduction in depression (treatment X time: F[1,179]=8.03, p=0.0051; Cohen’s D at 12 weeks: 0.60) and disability (treatment X time: F[1,169]=14.86, p=0.0002; Cohen’s D at 12 weeks: 0.67) than ST-CI participants over the 12-week period (primary outcomes). Further, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs. 13.51%; Chi-square: 5.74, df=1, p=0.0174; Number Needed to Treat (NNT)=4.11) (secondary outcome). Exploratory analysis showed that PATH led to greater reduction in depression than ST-CI even in the subgroup of participants with drug treatment resistant depression (F[1,72.7]=6.01, p=0.0166; Cohen’s d: week 12: 0.95). PATH was more efficacious than ST-CI in reducing depression and disability. PATH may provide relief to a large group of depressed, cognitively impaired older adults with few treatment options.