"Ecosystem Focused Therapy" in Post Stroke Depression

描述(申请人提供)：我们建议研究“生态系统聚焦疗法”(EFT)对中风后抑郁(PSD)的疗效，这是一种困扰大量中风患者的障碍，并在中风后多年增加死亡率、认知障碍和残疾。EFT是一种新的家庭干预措施，基于我们的PSD综合模型，该模型源于我们对晚年抑郁症的临床生物学和治疗研究。它假定有两条通往PSD的主要途径。首先，中风和中风修复机制有助于代谢变化，介导PSD。其次，由于患者的突然残疾以及患者需求和家庭生活的变化而引发的“心理社会风暴”给这一连串的抑郁事件增加了生物负担。EFT以PSD的“心理社会风暴”为目标，关注患者的能力和他/她的“生态系统”(家庭、专业治疗师)的挑战之间的相互作用。EFT遵循基于“适应功能模型”的结构化个性化方法，在该模型中，行为是个人能力和环境需求的函数。因此，EFT不断地根据PSD患者的能力水平“校准环境”，并通过五个集成组件瞄准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)提供了一种“附着力增强结构”。3)为患者提供了一个关注问题、受患者重视、与日常功能相关的“问题解决结构”。4)它帮助家庭“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工作 目标是增加患者对康复和社会活动的参与度。我们将招募160人 对卒中后3个月内的PSD患者随机分配10次每周一次的EFT和4次(超过一年)的EFT或对照条件(中风和抑郁教育；ESD)，均由训练有素的社会工作者(MSW)实施。我们的主要假设是：在12周的时间里，EFT将在以下方面导致比ESD更大的降低：H1)抑郁症的严重程度；以及H2)残疾。我们的第二个假设假设：SH1)EFT将导致比ESD高12周的缓解率(HAM-DD10)；以及SH2)EFT参与者在26周和52周时的抑郁和残疾得分低于ESD，而生活质量得分高于ESD。探索性分析将考察残疾和抑郁是否相互影响，以及“自我效能感”、“行为激活”和遵守康复建议和/或抗抑郁药物是否调节抑郁和残疾的变化。我们还将探讨PSD和5-羟色胺转运体的临床特征是否影响ESD的疗效。

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.