"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并在卒中后数年内增加死亡率、认知障碍和残疾的疾病。EFT是一种新的，家庭提供的干预，基于我们的综合模型的PSD，这源于我们的临床生物学和治疗研究，在晚年抑郁症。它假定两个主要路径PSD。首先，中风和中风修复机制有助于介导PSD的代谢变化。其次，患者突然残疾以及患者需求和家庭生活的变化引发的“心理社会风暴”给这一系列致抑郁事件增加了生物学负担。EFT的目标是PSD的“心理风暴”，并侧重于患者的能力和他/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，其中行为是个人能力和环境需求的函数。因此，EFT不断地“校准环境”，以PSD患者的能力水平，并通过五个综合组成部分瞄准PSD“心理风暴”：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)它提供了一种“粘附增强结构”。3)它为患者提供了一个“问题解决结构”，专注于患者重视的问题，并与日常功能相关。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”， 目标是增加患者参与康复和社会活动。我们将招募160名 卒中后3个月内的PSD患者，并将他们随机分配到10个每周一次的EFT和4个“助推器”会议（超过1年）或比较条件（卒中和抑郁教育; ESD），两者都由训练有素的社会工作者（MSW）管理。我们的主要假设是：在12周的时间内，EFT将导致比ESD更大的减少：H1）抑郁症的严重程度;和H2）残疾。我们的次要假设假定：SH 1）EFT在12周时的缓解率（HAM-Dd 10）高于ESD; SH 2）EFT参与者在26周和52周时的抑郁和残疾评分低于ESD，生活质量评分高于ESD。探索性分析将检查残疾和抑郁是否介导彼此的影响，以及“自我效能”、“行为激活”和对康复建议和/或抗抑郁药的依从性是否介导抑郁和残疾的变化。我们还将探讨PSD的临床特征和5-羟色胺转运蛋白基因型是否会调节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.