The pathways study - A randomized trial of collaborative care in patients with diabetes and depression
The pathways study - A randomized trial of collaborative care in patients with diabetes and depression
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DOI：
10.1001/archpsyc.61.10.1042
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发表时间：
2004-10-01
影响因子：
--
通讯作者：
Bush, T
中科院分区：
文献类型：
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作者：
Katon, WJ;Von Korff, M;Bush, T
背景：糖尿病患者中抑郁症的患病率很高。抑郁症已被证明与糖尿病患者的不良自我管理（坚持饮食、锻炼、检查血糖水平）和高血红蛋白 A(1c) (HbA(1c)) 水平有关。目的：确定提高抑郁症护理质量是否可以改善抑郁症和糖尿病患者的抑郁症和糖尿病结局。设计：随机对照试验，招募时间为 2001 年 3 月 1 日至 2002 年 5 月 31 日。地点：9 个初级保健诊所来自大型健康维护组织。参与者：总共 329 名患有糖尿病并合并重度抑郁症和/或心境恶劣的患者。干预：患者被随机分配到 Pathways 病例管理干预组 (n = 164) 或常规护理组 (n = 165)。该干预措施加强了对初级保健医生开具的抗抑郁药物治疗或初级保健中提供的问题解决疗法的教育和支持。主要结果指标：基线和抑郁症 3、6 和 12 个月的独立盲法评估（霍普金斯症状检查表 90）、整体改善和护理满意度。使用自动化临床数据来评估抗抑郁治疗方案的依从性、接受专业心理健康就诊的百分比以及 HbA(1c) 水平。结果：与常规护理患者相比，干预患者在第一个 6 个月期间（比值比 [OR]，4.15；95% 置信区间 [CI]，2.28-7.55）和第二个 6 个月期间，抗抑郁药物治疗剂量充足性方面表现出更大的改善（OR，2.90；95% CI，1.69-4.98），随时间推移抑郁严重程度减轻（z= 2.84，P= .004），6 个月时患者评价的总体改善评分较高（干预为 69.4%，常规护理为 39.3%；OR，3.50；95% CI，2.16-5.68）和 12 个月（干预71.9% 对比常规护理 42.3%；OR，3.50；95% CI，2.14-5.72），并且 6 个月（OR，2.01；95% CI，1.18-3.43）和 12 个月（OR，2.88；95% CI，1.67-4.97）的护理满意度更高。虽然抑郁结局得到改善，但 HbA(1c) 结局没有观察到差异。 结论：Pathways 协作护理模式改善了共病重度抑郁症和/或心境恶劣和糖尿病患者的抑郁护理和结局，但单独改善抑郁护理并不能改善血糖控制。
Background: There is a high prevalence of depression in patients with diabetes mellitus. Depression has been shown to be associated with poor self-management (adherence to diet, exercise, checking blood glucose levels) and high hemoglobin A(1c) (HbA(1c)) levels in patients with diabetes.Objective: To determine whether enhancing quality of care for depression improves both depression and diabetes outcomes in patients with depression and diabetes.Design: Randomized controlled trial with recruitment from March 1, 2001, to May 31, 2002.Setting: Nine primary care clinics from a large health maintenance organization.Participants: A total of 329 patients with diabetes mellitus and comorbid major depression and/or dysthymia.Intervention: Patients were randomly assigned to the Pathways case management intervention (n = 164) or usual care (n = 165). The intervention provided enhanced education and support of antidepressant medication treatment prescribed by the primary care physician or problem-solving therapy delivered in primary care.Main Outcome Measures: independent blinded assessments at baseline and 3, 6, and 12 months of depression (Hopkins Symptom Checklist 90), global improvement, and satisfaction with care. Automated clinical data were used to evaluate adherence to antidepressant regimens, percentage receiving specialty mental health visits, and HbA(1c) levels.Results: When compared with usual care patients, intervention patients showed greater improvement in adequacy of dosage of antidepressant medication treatment in the first 6-month period (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.28-7.55) and the second 6-month period (OR, 2.90; 95% CI, 1.69-4.98), less depression severity over time (z= 2.84, P= .004), a higher rating of patient-rated global improvement at 6 months (intervention 69.4% vs usual care 39.3%; OR, 3.50; 95% CI, 2.16-5.68) and 12 months (intervention 71.9% vs usual care 42.3%; OR, 3.50; 95% CI, 2.14-5.72), and higher satisfaction with care at 6 months (OR, 2.01; 95% CI, 1.18-3.43) and 12 months (OR, 2.88; 95% CI, 1.67-4.97). Although depressive outcomes were improved, no differences in HbA(1c) outcomes were observed.Conclusion: The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.