Depression care management for adults older than 60 years in primary care clinics in urban China: a cluster-randomised trial
Depression care management for adults older than 60 years in primary care clinics in urban China: a cluster-randomised trial
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DOI：
10.1016/s2215-0366(15)00002-4
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发表时间：
2015-04-01
影响因子：
64.3
通讯作者：
Wu, Jiayan
中科院分区：
文献类型：
--
作者：
Chen, Shulin;Conwell, Yeates;Wu, Jiayan
背景中国的国家卫生政策将抑郁症归类为一种慢性病，应在初级保健机构进行管理。在一些高收入国家，使用慢性病管理原则和基于初级保健的协作护理模式改善了老年抑郁症的结局;然而，这种方法尚未在中国进行测试。我们的目的是评估是否使用协作护理抑郁症护理管理（DCM）干预可以改善结果为中国成年人与抑郁症60岁及以上，2011年1月11日和2013年11月30日之间，我们做了一个集群随机试验的患者从初级保健中心诊所在杭州市上城区在中国东部。我们随机分配（1：1）DCM诊所（包括培训医生使用治疗指南，培训初级保健护士担任护理经理，并咨询精神科医生作为支持）或向所有符合条件的60岁及以上重度抑郁症患者提供增强护理。通过计算机算法从该地区的所有初级保健诊所中随机选择诊所，然后通过计算机算法远程随机分配抑郁症护理干预措施。医生、研究人员和患者均未对诊所分配设盲。我们的主要结果是在意向治疗人群的混合效应模型中，使用基线和3、6和12个月随访时的聚类数据进行汉密尔顿抑郁评定量表（HAMD）评分的差异。我们最初的目标是分析24个月时的结局，但是12个月时组间差异很大，资金不足以继续到24个月，因此我们决定在12个月时结束试验。本试验在ClinicalTrials.gov注册，注册号为NCT 01287494。结果在上城区34家初级保健诊所中，随机选择16家。我们随机分配了8个诊所进行DCM干预（164例患者入组），8个初级保健诊所照常进行加强护理（162例患者）。对于每种干预，患者组之间的基线人口统计学和临床变量没有重大差异。在12个月的时间里，在诊所中被分配到DCM的患者比在实践中被分配到常规加强护理的患者HAMD评分有显著更大的降低（估计组间差异-6.5 [95%CI-7.1至-5.9]; Cohen's d 0.8 [95%CI 0.8-0.9]; p
Background China's national health policy classifies depression as a chronic disease that should be managed in primary care settings. In some high-income countries use of chronic disease management principles and primary care-based collaborative-care models have improved outcomes for late-life depression; however, this approach has not yet been tested in China. We aimed to assess whether use of a collaborative-care depression care management (DCM) intervention could improve outcomes for Chinese adults with depression aged 60 years and older.Methods Between Jan 11, 2011, and Nov 30, 2013, we did a cluster-randomised trial in patients from primary care centre clinics in Shangcheng district of Hangzhou city in eastern China. We randomly assigned (1: 1) clinics to either DCM (involving training for physicians in use of treatment guidelines, training for primary care nurses to function as care managers, and consultation with psychiatrists as support) or to give enhanced care as usual to all eligible patients aged 60 years and older with major depressive disorder. Clinics were chosen randomly for inclusion from all primary care clinics in the district by computer algorithm and then randomly allocated depression care interventions remotely by computer algorithm. Physicians, study personnel, and patients were not masked to clinic assignment. Our primary outcome was difference in Hamilton Depression Rating Scale (HAMD) score using data for clusters at baseline and 3, 6, and 12 month follow-up in a mixed-effects model of the intention-to-treat population. We originally aimed to analyse outcomes at 24 months, however the difference between groups at 12 months was large and funding was insufficient to continue to 24 months, therefore we decided to end the trial at 12 months. This trial is registered with ClinicalTrials.gov,number NCT01287494.Findings Of 34 primary care clinics in Shangcheng district, 16 were randomly chosen. We randomly assigned eight clinics to the DCM intervention (164 patients enrolled) and eight primary care clinics to enhanced care as usual (162 patients). There were no major differences in baseline demographic and clinical variables between the groups of patients for each intervention. Over the 12 months, patients in clinics assigned to DCM had a significantly greater reduction in HAMD score than did those in practices assigned to enhanced care as usual (estimated between group diff erence-6.5 [95% CI -7.1 to -5.9]; Cohen's d 0.8 [95% CI 0.8-0.9]; p