Cognitive Behavior Therapy for Depression and Self-Care in Heart Failure Patients: A Randomized Clinical Trial.
Cognitive Behavior Therapy for Depression and Self-Care in Heart Failure Patients: A Randomized Clinical Trial.
复制标题
DOI：
10.1001/jamainternmed.2015.5220
复制
发表时间：
2015-11
影响因子：
39
通讯作者：
Rubin EH
中科院分区：
文献类型：
--
作者：
Freedland KE;Carney RM;Rich MW;Steinmeyer BC;Rubin EH
抑郁和自我护理不足是常见且相互关联的问题，增加了心力衰竭（HF）患者的住院和死亡风险。确定综合认知行为疗法（CBT）干预对抑郁症和HF自我护理的疗效。单盲结局评估的随机临床试验。合格患者于2010年1月4日至2013年6月28日在圣路易斯的华盛顿大学医学中心入组。参与者是158名纽约心脏协会I、II和III级心力衰竭伴重度抑郁症的门诊患者。由经验丰富的治疗师提供的认知行为治疗加常规护理（UC），或仅常规护理。两组的心脏护理都得到了加强，由心脏科护士提供结构化的HF教育计划。主要结局是6个月时由贝克抑郁量表测量的抑郁严重程度。心力衰竭自我护理指数信心和维持子量表是共同主要结局。次要结果包括焦虑、抑郁、身体功能、疲劳、社会角色和活动以及生活质量的测量。住院和死亡是探索性结局。158例患者被随机分配至UC组（n=79）或CBT组（n=79）。在每组中，26例（33%）患者在基线时服用抗抑郁药。132名（84%）参与者完成了6个月的治疗后评估; 60名（76%）UC和58名（73%）CBT参与者完成了每次随访评估（P-.88）。在贝克抑郁量表（BDI-II）上，CBT组的6个月抑郁评分低于UC组（12.8 [10.6] vs 17.3 [10.7]; P-0.008）。BDI-II（46% vs 19%;需要治疗的人数[NNT] = 3.76; 95%CI，3.62-3.90; P<.001）和汉密尔顿抑郁量表（51% vs 20%; NNT=3.29; 95%CI，3.15-3.43; P<.001）的缓解率存在差异。两组在自我护理维持或信心分量表上没有差异。随机化后6个月，CBT组的平均（SD）贝克抑郁量表评分（12.8[10.6]）低于UC组（17.3 [10.7]），P= 0.008。两组在自我护理维持或信心子量表评分或身体功能测量方面无统计学显著差异。焦虑和疲劳评分较低，精神和HF相关的生活质量和社会功能评分较高，在6个月的CBT比UC手臂，有较少的住院治疗的干预比UC arm.A CBT干预，针对抑郁症和心力衰竭自我护理是有效的抑郁症，但不是HF自我护理或身体功能相对于增强常规护理。其他好处包括减少焦虑和疲劳，改善社会功能，以及更好的健康相关生活质量。试用注册clinicaltrials.gov标识符：NCT 01028625
Depression and inadequate self-care are common and interrelated problems that increase the risks of hospitalization and mortality in patients with heart failure (HF). To determine the efficacy of an integrative cognitive behavior therapy (CBT) intervention for depression and HF self-care. Randomized clinical trial with single-blind outcome assessments. Eligible patients were enrolled at Washington University Medical Center in St. Louis between January 4, 2010 and June 28, 2013. The participants were 158 outpatients in New York Heart Association Class I, II, and III heart failure with comorbid major depression. Cognitive behavior therapy delivered by experienced therapists plus usual care (UC), or usual care alone. Usual care was enhanced in both groups with a structured HF education program delivered by a cardiac nurse. The primary outcome was severity of depression at 6 months as measured by the Beck Depression Inventory. The Self-Care of Heart Failure Index Confidence and Maintenance subscales were co-primary outcomes. Secondary outcomes included measures of anxiety, depression, physical functioning, fatigue, social roles and activities, and quality of life. Hospitalizations and deaths were exploratory outcomes. One hundred fifty-eight patients were randomized to UC (n=79) or CBT (n=79). Within each arm, 26 (33%) of the patients were taking an antidepressant at baseline. One hundred thirty-two (84%) of the participants completed the 6-month posttreatment assessments; 60 (76%) of the UC and 58 (73%) of the CBT participants completed every follow-up assessment (P−.88). Six-month depression scores were lower in the CBT than the UC arm on the Beck Depression Inventory (BDI-II) (12.8 [10.6] vs 17.3 [10.7]; P−.008). Remission rates differed on the BDI-II (46% vs 19%; number needed to treat [NNT] = 3.76; 95% CI, 3.62-3.90; P<.001) and the Hamilton Depression Scale (51% vs 20%; NNT=3.29; 95% CI, 3.15-3.43; P<.001). The groups did not differ on the Self-Care Maintenance or Confidence subscales. The mean (SD) Beck Depression Inventory scores 6 months after randomization were lower in the CBT (12.8[10.6]) than the UC arm (17.3 [10.7]), P=.008. There were no statistically significant differences between the groups on the Self-Care Maintenance or Confidence subscales scores or on physical functioning measures. Anxiety and fatigue scores were lower and mental- and HF-related quality of life and social functioning scores were higher at 6 months in the CBT than the UC arm, and there were fewer hospitalizations in the intervention than the UC arm. A CBT intervention that targets both depression and heart failure self-care is efficacious for depression but not for HF self-care or physical functioning relative to enhanced usual care. Additional benefits include reduced anxiety and fatigue, improved social functioning, and better health-related quality of life. Trial Registration clinicaltrials.gov Identifier: NCT01028625