Treating Older Patients with Major Depression and Severe COPD

描述（由申请人提供）：COPD影响15%的老年人，是美国第四大死亡原因。超过20%的慢性阻塞性肺病患者患有重度抑郁症。严重慢性阻塞性肺病患者每天都生活在身体不适中，被迫采取妥协的生活方式，并且必须应对因知道自己不可避免的病情恶化和死亡而造成的士气低落。抑郁带来的悲观、无助和无价值，会导致他们放弃，并加剧他们的士气低落。大约一半的COPD抑郁症患者会出现执行功能障碍，这降低了他们制定行为策略来解决治疗需求和生活问题的能力。这些问题因需要患者积极参与的苛刻的COPD治疗而复杂化。一个抑郁、意志消沉、认知受损、身体虚弱的病人最不想做的就是坚持锻炼计划，去看医生和治疗中心，重新设计他/她生活的社会方面。因此，他们放弃治疗和其他活动，经历痛苦的生命结束。我们开发了一种干预（PST-AE），将治疗依从性增强程序（AE）与问题解决疗法（PST）相结合。PST-AE为提高治疗依从性提供教育和直接建议，并为满足患者复杂的治疗需求、抑郁症状和残疾提供行为策略。我们假设，与AE相比，post -AE能减少抑郁和残疾，提高生活质量和COPD治疗的依从性。我们建议从一家康复医院连续招募160名重度抑郁症和严重COPD患者，随机分配接受14次PST-AE （N=80）或AE (N=80)，并在26周内进行系统评分，以验证这些假设。我们的目标是人口中残疾最严重和最痛苦的部分之一。在我们的设计中，我们使用了我们对抑郁症COPD患者的研究经验，对初级保健老年患者的PROSPECT多中心研究，以及我们ACISR的老年抑郁症研究。如果发现有效，PST-AE可以广泛实施，因为它可以被再培训后的来访护士专业人员使用。除COPD外，PST- AE可能是各种慢性衰弱性疾病患者的一种护理模式，这些患者经常发展为抑郁症，放弃治疗，预后不佳，往往是致命的。由于PST-AE的主要重点是提高治疗依从性，这种治疗抑郁症和疾病患者的方法可以产生一种实践模式，该模式具有快速结合临床科学进展的能力。

DESCRIPTION (provided by applicant): COPD affects 15% of older adults and is the fourth leading cause of death in the US. More than 20% of COPD patients have major depression. Patients with severe COPD live with daily physical discomfort, are forced to a compromised life style, and have to cope with demoralization caused by the knowledge of their inescapable deterioration and death. The pessimism, helplessness, and worthlessness of depression, lead to resignation and worsen their demoralization. Executive dysfunction occurs in about half of depressed COPD patients and reduces their ability to develop behavioral strategies to address their treatment needs and their life problems. These problems are compounded by the demanding treatment of COPD that requires active patient participation. The last thing that a depressed, demoralized, cognitively compromised, and physically weak patient wants to do is to pursue a consistent exercise program, go to doctors and treatment centers, and reengineer the social aspects of his/her life. As a consequence, they give up on treatment and other activities and experience a painful end of life. We developed an intervention (PST-AE) that integrates treatment adherence enhancement procedures (AE) with problem solving therapy (PST). PST-AE offers education and direct suggestions for improving treatment adherence and imparts behavioral strategies for meeting the patients' complex treatment needs, depressive symptoms, and disability. We hypothesize that PST-AE will reduce depression and disability and improve quality of life and adherence to treatment of COPD more than AE. We propose to test these hypotheses in 160 patients with major depression and severe COPD consecutively recruited from an inpatient Rehabilitation Hospital who will be randomly assigned to receive 14 sessions of PST-AE (N=80) or AE (N=80) and be systematically rated over 26 weeks. We target one of the most disabled and suffering segments of the population. We used, in our design, our research experience with depressed COPD patients, the PROSPECT multicenter study of primary care elderly patients, and the geriatric depression studies of our ACISR. If found effective, PST-AE can be broadly implemented, as it can be used by visiting nurse professionals after retraining. Beyond COPD, PST- AE may be a model of care for patients with a variety of chronic, debilitating disorders, who often develop depression, give up, and have a poor and often fatal outcome. As a major focus of PST-AE is improvement of treatment adherence, this approach to the care of depressed, medically ill patients can generate a practice model that has the ability to rapidly incorporate advances made in clinical science.