Social Inequalities in Outcomes for Treatment of Late-Life Depression

晚年抑郁症治疗结果的社会不平等

• 批准号: 7575769
• 负责人: Stephen E Gilman
• 金额: $ 7.98万
• 依托单位: HARVARD SCHOOL OF PUBLIC HEALTH
• 依托单位国家: 美国
• 财政年份: 2008
• 资助国家: 美国
• 起止时间: 2008-04-01 至 2010-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7575769
• 关键词: Adult; African American; Age; Antidepressive Agents; Case Management; Censuses; Characteristics; Clinical; Clinical Trials; Cognitive; Data; Data Analyses; Databases; Diagnosis; Disadvantaged; Disease; Distress; Education; Effectiveness; Effectiveness of Interventions; Elderly; Epidemiology; Equilibrium; Ethnic Origin; Feeling hopeless; Feeling suicidal; Future; Gender; Grant; Health; Health Services Accessibility; Health Status; Hispanics; Household; Impairment; Income; Individual; Inequality; Intervention; Investigation; Life; Measures; Medical; Minority; Neighborhoods; Occupations; Outcome; Participant; Patients; Pattern; Persons; Pharmacotherapy; Phase; Population; Primary Health Care; Psychotherapy; Public Health; Quality of Care; Race; Randomized Clinical Trials; Randomized Controlled Trials; Relative (related person); Reporting; Research; Research Project Grants; Risk; Risk-Taking; Sampling; Severities; Site; Social status; Social support; Socioeconomic Status; Subgroup; Suggestion; Suicide; Suicide prevention; Symptoms; Syndrome; Treatment Effectiveness; Treatment outcome; Upper arm; Variant; Work; base; caucasian American; chronic depression; collaborative trial; depressed; depression; depressive symptoms; disability; ethnic difference; experience; functional disability; functional status; geriatric depression; health disparity; high risk; improved; insight; low socioeconomic status; male; mortality; open label; primary care setting; racial and ethnic; social; social inequality; treatment effect

DESCRIPTION (provided by applicant): Late-life depression (LLD) is a major public health concern. It is associated with substantial impairment and disability in social and cognitive domains, increases risk for and exacerbates the severity of comorbid medical conditions [4-6], elevates risk for suicidality, and is a significant contributor to mortality. These associations and risks take on greater significance because LLD is commonly under-diagnosed and inadequately treated. Epidemiological research also suggests the presence of social inequalities in LLD. Socioeconomic status (SES), usually assessed by measures of education, income, wealth, occupation, and/or neighborhood characteristics, is associated with risk of depression in older adults (=60 years). Indeed, these risks appear to widen with age, with older adults of lower SES having markedly elevated risk for depression. Evidence is mixed about racial/ethnic inequalities. Whereas rates of LLD are higher among White males than among African-American and Hispanic males, older White males appear to have lower levels of depressive symptoms than older African American males. Furthermore, there is evidence that African Americans and Hispanics, in general, experience higher rates of chronic depression. The relationship between race/ethnicity and depression is itself, influenced by gender, income, and education. This application is for a small research grant (R03) to conduct secondary data analyses to investigate social and racial/ethnic inequalities in outcomes of antidepressant treatments in older adults. These analyses emerge from an initial study in which Cohen et al., (2006) reported SES (as measured by census tract median household income) was a significant moderator of antidepressant treatment in two clinical trials in which all subjects received high quality care. The proposed research will expand on this work by conducting an investigation of possible social inequalities in the effectiveness of PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), a multi-site randomized clinical trial of an intervention (pharmacotherapy, interpersonal psychotherapy, and case management) for the treatment of LLD. We will also investigate whether the relative effectiveness of the intervention depended social inequalities in positive changes in social support during treatment and/or the extent to which patients took advantage of various components of the intervention. The proposed research will benefit from its use of data from a randomized clinical trial that was conducted in "real-world" primary care settings and included a heterogeneous sample of depressed older adults, as well as the availability of multiple measures SES and race/ethnicity at the level of individuals and the neighborhoods in which they lived. Results of this research may yield insights about: 1) the social factors that influence the effectiveness of treatments, even when controlling for access and the quality of treatment; 2) the clinical and public health needs of population subgroups; and, 3) the need for methodological changes in future clinical trials. More generally, we expect this research will make an important contribution to our understanding of health disparities. Late-life depression is a major public health concern in that it is associated with increased risk for functional disability, suicidality, and mortality. Expanding on preliminary research, which suggested social inequalities in the effectiveness of antidepressant treatments, the proposed research will investigate social inequalities (as measured by socioeconomic status and race/ethnicity) in the effectiveness of a primary care intervention for reducing depressive symptoms, hopelessness, and suicidality, and improving functional status in older adults. Results of this research may yield new insights about: 1) the social factors that influence the effectiveness of treatments, even when controlling for access and the quality of treatment; 2) the clinical and public health needs of population subgroups; and, 3) the need for methodological changes in future clinical trials.

描述（由申请人提供）：晚年抑郁症 (LLD) 是一个主要的公共卫生问题。它与社交和认知领域的严重损害和残疾有关，增加了合并症的风险并加剧了其严重程度[4-6]，增加了自杀风险，并且是死亡率的一个重要因素。这些关联和风险变得更加重要，因为 LLD 通常诊断不足且治疗不充分。流行病学研究还表明，LLD 中存在社会不平等。社会经济地位 (SES) 通常通过教育、收入、财富、职业和/或社区特征来评估，与老年人（= 60 岁）患抑郁症的风险相关。事实上，这些风险似乎随着年龄的增长而增加，社会经济地位较低的老年人患抑郁症的风险显着升高。关于种族/民族不平等的证据好坏参半。虽然白人男性的 LLD 比率高于非裔美国人和西班牙裔男性，但老年白人男性的抑郁症状似乎比老年非裔美国男性低。此外，有证据表明，非洲裔美国人和西班牙裔美国人总体上患有慢性抑郁症的比例较高。种族/民族与抑郁症之间的关系本身就受到性别、收入和教育的影响。该申请旨在获得一笔小额研究拨款 (R03)，用于进行二次数据分析，以调查老年人抗抑郁治疗结果中的社会和种族/民族不平等。这些分析源自一项初步研究，其中 Cohen 等人 (2006) 报道，在两项临床试验中，SES（以人口普查区家庭收入中位数衡量）是抗抑郁治疗的重要调节因素，在这两项临床试验中，所有受试者都接受了高质量的护理。拟议的研究将通过调查 PROSPECT（初级护理老年人自杀预防：协作试验）的有效性可能存在的社会不平等来扩展这项工作，这是一项针对 LLD 治疗的干预措施（药物治疗、人际心理治疗和病例管理）的多中心随机临床试验。我们还将调查干预措施的相对有效性是否取决于治疗期间社会支持积极变化的社会不平等和/或患者利用干预措施各个组成部分的程度。拟议的研究将受益于其使用在“现实世界”初级保健环境中进行的随机临床试验的数据，其中包括抑郁老年人的异质样本，以及个人及其居住社区层面的多种社会经济地位和种族/民族衡量指标的可用性。这项研究的结果可能会产生以下方面的见解：1）影响治疗效果的社会因素，即使在控制治疗的可及性和质量的情况下； 2）人群亚群的临床和公共卫生需求； 3）未来临床试验中方法学改变的需要。更一般地说，我们预计这项研究将为我们理解健康差异做出重要贡献。晚年抑郁症是一个主要的公共卫生问题，因为它与功能障碍、自杀和死亡的风险增加有关。初步研究表明抗抑郁治疗的有效性存在社会不平等，拟议的研究将进一步调查初级保健干预措施在减少抑郁症状、绝望和自杀以及改善老年人功能状态方面的有效性方面的社会不平等（通过社会经济地位和种族/族裔来衡量）。这项研究的结果可能会产生以下方面的新见解：1）影响治疗效果的社会因素，即使在控制治疗的可及性和质量的情况下； 2）人群亚群的临床和公共卫生需求； 3）未来临床试验中方法学改变的需要。