RANDOMIZED CONTROLLED TRIAL OF SCREENING FOR DEPRESSION IN CARDIAC OUTPATIENTS

描述(由申请人提供)：本提案是对PA-09-070号计划公告的回应，“AHRQ健康服务研究项目”预防/护理管理组合要求开展旨在“提高循证预防服务和慢性护理管理的质量、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并存的，抑郁症是心脏病患者，特别是急性冠脉综合征(ACS)患者的心理社会发病率、对药物治疗方案的不遵守、身体缺乏活动、身体功能不良以及医疗发病率和死亡率的危险因素。2006年，医疗研究和质量机构(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风险因素，但没有足够的证据支持在心脏病患者中进行抑郁症筛查的效用。自那时以来，一直没有研究确定心脏病患者抑郁筛查的有效性。然而，美国心脏协会和其他组织呼吁对急性冠脉综合征患者进行抑郁症筛查，以改进对这一危险因素的识别和治疗。我们建议对近期有急性冠脉综合征病史的心脏病门诊患者进行一项随机对照试验，比较抑郁筛查和病例管理与常规护理的效果。这项研究将招募因急性冠脉综合征住院后在华盛顿大学高级医学中心进行心脏病门诊预约的患者。符合医学条件的患者将接受患者健康问卷-9(PHQ-9)和贝克抑郁问卷(BDI-II)的筛查。PHQ-9得分在10分或以上的前300名患者将被随机分配到两种情况中的一种：由他们的心脏病专家和初级保健医生提供的常规护理，或协作性抑郁症筛查干预(CDSI)。100名PHQ-9得分在9分或以下的患者也将被招募，以确定PHQ-9和BDI-II在基于访谈诊断严重抑郁症方面的敏感性和特异性。护士病例经理(NCM)将对患者进行为期六个月的跟踪调查，并与精神病学家协商，定期评估患者的抑郁症和治疗需求。治疗建议将向患者的初级保健医生提出，并由NCM进行监测。如有需要，会转介至精神健康专业人员。患者将在基线、3个月和6个月内接受当前抑郁症、抑郁症治疗史、生活质量、身体功能、对药物治疗方案的坚持以及在登记后12个月内发生的不良医疗事件的评估。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.