RANDOMIZED CONTROLLED TRIAL OF SCREENING FOR DEPRESSION IN CARDIAC OUTPATIENTS

描述（由申请人提供）：本提案是对计划公告PA-09-070“AHRQ卫生服务研究项目”预防/护理管理组合的回应，该项目要求开展旨在“提高循证预防服务和慢性病护理管理的质量、安全性、效率和有效性”以及“改善预防服务循证建议的实施”的研究。“抑郁症和心血管疾病是高度共病的，抑郁症是心脏病患者心理社会发病率、药物治疗依从性差、身体活动不足、身体功能差以及医学发病率和死亡率的危险因素，特别是在急性冠状动脉综合征（ACS）之后。2006年，美国医疗保健研究和质量机构（AHRQ）的一份证据报告得出结论，尽管有强有力的证据表明抑郁症是心脏事件的危险因素，但没有足够的证据支持心脏病患者抑郁症筛查的实用性。从那时起，没有研究确定心脏病患者抑郁症筛查的有效性。然而，美国心脏协会和其他组织呼吁对ACS患者进行抑郁筛查，以改善对这种危险因素的识别和治疗。我们建议进行一项随机对照试验，比较抑郁症筛查和病例管理对近期有ACS病史的心脏科门诊患者的常规护理的影响。本研究将招募因ACS住院后在华盛顿大学高级医学中心接受门诊心脏病学预约的患者。医学合格的患者将接受患者健康问卷-9（PHQ-9）和贝克抑郁量表（BDI-II）筛查抑郁症。PHQ-9评分为10分或以上的前300名患者将被随机分配到两种情况之一：由心脏病专家和初级保健医生提供的家庭护理，或协作抑郁症筛查干预（CDSI）。还将招募100名PHQ-9评分为9或以下的患者，以确定PHQ-9和BDI-II与基于访谈的抑郁症诊断相关的敏感性和特异性。患者将由一名护士病例管理员（NCM）随访六个月，他将定期评估患者的抑郁症和与精神科医生协商的治疗需求。将向患者的初级保健医生提出治疗建议，并由NCM进行监测。必要时将转介给心理健康专业人员。将在基线、3个月和6个月时评估患者的当前抑郁、抑郁治疗史、生活质量、身体功能、对药物治疗方案的依从性以及入组后12个月内不良医学事件的发生率。将对干预措施进行成本效益分析。

DESCRIPTION (provided by applicant): This proposal is in response to Program Announcement PA-09-070, "AHRQ Health Services Research Projects" Prevention/Care Management Portfolio requesting studies designed to "improve the quality, safety, efficiency, and effectiveness of evidence-based preventive services and chronic care management," and "improving the implementation of evidence-based recommendations on preventive services." Depression and cardiovascular disease are highly comorbid, and depression is a risk factor for psychosocial morbidity, poor adherence to medical treatment regimens, physical inactivity, poor physical functioning, and medical morbidity and mortality in cardiac patients, especially following an acute coronary syndrome (ACS). In 2006, an Evidence Report from the Agency for Healthcare Research and Quality (AHRQ) concluded that, despite strong evidence that depression is a risk factor for cardiac events, there was insufficient evidence to support the utility of depression screening in cardiac patients. There have been no studies since that time to determine the effectiveness of depression screening in cardiac patients. Nevertheless, the American Heart Association and other organizations have called for depression screening for ACS patients to improve identification and treatment of this risk factor. We propose to conduct a randomized, controlled trial comparing the effects of depression screening and case management to usual care in cardiology outpatients with a recent history of ACS. Patients being seen for an outpatient cardiology appointment at the Washington University Center for Advanced Medicine following hospitalization for ACS will be recruited for this study. Medically eligible patients will be administered the Patient Health Questionnaire-9 (PHQ-9) and the Beck Depression Inventory (BDI-II) to screen for depression. The first 300 patients who score 10 or above on the PHQ-9 will be randomly assigned to one of two conditions: Usual care, as provided by their cardiologist and primary care physician, or a collaborative depression screening intervention (CDSI). One hundred patients who score 9 or below on the PHQ-9 will also be recruited to determine the sensitivity and specificity of the PHQ-9 and BDI-II in relation to interview-based diagnosis of major depression. Patients will be followed for six months by a nurse case manager (NCM) who will periodically assess the patient's depression and treatment needs in consultation with a psychiatrist. Treatment recommendations will be made to the patient's primary care physician and monitored by the NCM. Referral to mental health professionals will be made as needed. Patients will be assessed at baseline, 3 and 6 months for current depression, depression treatment history, quality of life, physical functioning, adherence to medical treatment regimens, and the occurrence of adverse medical events in the 12 months following enrollment. Cost effectiveness analysis of the intervention will be conducted.