"Ecosystem Focused Therapy" in Post Stroke Depression

描述（由申请人提供）：我们建议研究“生态系统聚焦疗法”（EFT）在卒中后抑郁症（PSD）中的疗效，PSD是一种困扰大量卒中患者的疾病，并在卒中后数年内增加死亡率、认知障碍和残疾。EFT是基于我们的PSD综合模型的一种新的家庭干预方法，该模型起源于我们对老年抑郁症的临床生物学和治疗研究。它假定了通往PSD的两条主要途径。首先，卒中和卒中修复机制有助于代谢变化介导PSD。其次，由于患者突然残疾以及患者需求和家庭生活的变化而产生的“社会心理风暴”，为这一连串致抑郁事件增加了生物学负担。EFT针对PSD的“社会心理风暴”，并关注患者的能力与他/她的“生态系统”（家庭，专业治疗师）的挑战之间的相互作用。EFT遵循一种基于“适应性功能模型”的结构化个性化方法，其中行为是个人能力和环境需求的函数。因此，EFT通过五个组成部分不断地“校准环境”，以适应PSD患者的能力水平，并针对PSD的“心理社会风暴”：1)它提供了一个以行动为导向的、关于患者康复的“新视角”。2)它提供了一个“依从性增强结构”。3)它为患者提供了一个“问题解决结构”，关注问题，受到患者的重视，并与日常功能相关。4)帮助家庭“重新设计其目标、参与和计划”，以适应患者的残疾。5)它“与专业治疗师协调护理”

DESCRIPTION (provided by applicant): We propose to study the efficacy of "Ecosystem Focused Therapy" (EFT) in post-stroke depression (PSD), a disorder that afflicts a large number of stroke victims and increases mortality, cognitive impairment, and disability for years after stroke. EFT is a new, home-delivered intervention based on our integrative model of PSD, which originated from our clinical biology and treatment studies in late-life depression. It postulates two main paths to PSD. First, stroke and stroke-repair mechanisms contribute to metabolic changes mediating PSD. Second, a "psychosocial storm" stemming both from the patient's sudden disability and the change in the patient's needs and family life add a biological burden to this cascade of depressogenic events. EFT targets the "psychosocial storm" of PSD and focuses on the reciprocal interaction between the patient's abilities and the challenges of his/her "ecosystem" (family, specialized therapists). EFT follows a structured personalization approach based on the "model of adaptive functioning", in which behavior is a function of the person's competence and the demands of the environment. Thus, EFT continuously "calibrates the environment" to the PSD patient's competence level and targets the PSD "psychosocial storm" through five integrated components: 1) It offers an action-oriented, "new perspective" about the patient's recovery. 2) It provides an "adherence enhancement structure". 3) It offers a "problem solving structure" to the patient focusing on problems, valued by the patient, and pertinent to daily function. 4) It helps the family "reengineer its goals, involvement, and plans" o accommodate the patient's disability. 5) It "coordinates care with specialized therapists" with the goal to increase patient participation in rehabilitation and social activities. We will recruit 160 PSD patients within 3 months after stroke and randomly assign them to 10 weekly sessions and 4 "booster" sessions (over 1 year) of EFT or a comparison condition (Education on Stroke and Depression; ESD) both administered by trained social workers (MSW). Our Primary Hypotheses state that: Over a period of 12 weeks, EFT will lead to greater reduction than ESD in: H1) severity of depression; and H2) disability. Our Secondary Hypotheses postulate that: SH1) EFT will lead to higher remission (HAM-Dd10) rates than ESD by 12 weeks; and SH2) EFT participants will have lower scores of depression and disability and higher scores in quality of life than ESD at 26 and 52 weeks. Exploratory Analyses will examine whether disability and depression mediate the effect of each other and whether "self-efficacy", "behavioral activation", and adherence to rehabilitation recommendations and/or antidepressants mediate change in depression and disability. We will also explore whether clinical features of PSD and serotonin transporter genotypes moderate the efficacy of ESD. PUBLIC HEALTH RELEVANCE: This study proposes to investigate the efficacy of a novel, home-delivered, psychosocial intervention in reducing depression and disability in depressed stroke survivors. The intervention is designed to enable patients to develop a new perspective and adaptation skills and to change their "ecosystem" (family, specialized therapists) so as to accommodate the patients' new state. This way, the new intervention can offer an optimal chance at adaptation, by promoting the patients' adherence to rehabilitation and by increasing their sense of competence and their engagement in valued activities.