Course and risk factors for depression in late life

描述（申请人提供）：本申请基于在初级保健中进行的随机临床试验，旨在研究抑郁症状和医学合并症的轨迹与2年时重度抑郁症和自杀意念的结局的关系，符合NIMH战略计划，并提交以回应PA-07-082，“使用现有数据集的精神病理学风险因素，2007年5月11日被释放。最近的研究表明，各种初级保健干预措施可以改善晚年抑郁症的结果。然而，这些干预措施尚未被发现对轻度抑郁症有效。虽然一些研究以前已经确定了抑郁症的亚型，但很少有工作集中在晚年抑郁症的亚型上，而且这项工作是在横断面数据中进行的，而不是在干预试验的背景下进行的。本研究的具体目的是：（1）根据基线特征和两种不同类型的纵向特征（1）抑郁症状和2）总体医学合并症，以及2年时基于标准的重度抑郁和/或自杀意念的亚组的相关性，确定初级保健老年患者的亚组;（2）评估目标1中基于抑郁症状或总体医学合并症确定的不同亚组是否改变了协作护理干预对2年时基于标准的重度抑郁和/或自杀意念的影响，以使干预在某些亚组中显示出显著效果;以及（3）评估目标1中2年时对基于标准的重度抑郁症或自杀意念的干预效果的效果修改如何通过不同强度的抗抑郁药物或心理治疗来介导。为了实现这些目标，我们将利用前景（“预防初级保健老年人自杀：合作试验”）中长达2年的筛查、临床评估、治疗和随访评估。总共有1,226名患者，包括所有抑郁症筛查阳性的患者和筛查阴性的随机样本，参加了为期2年的纵向研究。初级保健实践被随机分为：（1）由初级保健实践照常治疗（n = 617例患者）;（2）指南管理干预，包括根据AHCPR指南（针对老年人修订）进行的抑郁症抗抑郁药或心理治疗，由初级保健医生负责，并由硕士级专家协助（干预条件; n = 609例患者）。在1226例初级保健老年患者的样本中，我们要强调的是，我们的分析将基于抑郁症状的过程，而不是DSM-IV诊断。我们建议用药物记录补充前景数据，以在2年随访期间对医学合并症进行分类和量化。一般增长曲线混合模型（GGCMM）是分析抑郁症病程与合并症动态关系的基础。这个项目可以有一个显着的公共卫生的影响，因为进一步了解的协会的过程中的抑郁症状和发病和病程的医疗comormalities老年初级保健患者将是一个关键步骤，在干预，以提高认识和治疗晚年抑郁症。公共卫生相关性：本申请的总体目标是根据基线特征和两种不同类型的纵向特征（1）抑郁症状和2）总体医学合并症，确定初级护理老年患者的亚组，对于这些患者，协作护理干预可减少重度抑郁和/或自杀意念的持续或发作。这个项目可以有一个显着的公共卫生影响，因为进一步了解的协会的抑郁症状的过程中，初级保健老年患者的发病和病程的医疗合并症将是一个关键的一步，在干预，以提高认识和治疗抑郁症的晚年生活。

DESCRIPTION (provided by applicant): This application building on a randomized clinical trial carried out in primary care to study trajectories of depressive symptoms and medical comorbidity in relation to the outcomes of Major Depression and suicidal ideation at 2 years aligns with the NIMH Strategic Plan and is submitted in response to PA-07-082, "Risk factors for psychopathology using existing data sets," released 11 May 2007. Recent studies have demonstrated that a variety of primary care interventions can improve late life Major Depression outcomes. However, these interventions have not been found to be effective for minor depression. While some research has previously identified subtypes of depression, little work has focused on subtypes of late life depression, and that work has been conducted in cross-sectional data and not in the context of an intervention trial. The specific aims of this study are: (1) To identify subgroups of primary care elderly patients based on baseline characteristics and two different types of longitudinal profiles: 1) depressive symptoms and 2) overall medical comorbidity, and the association of subgroups with criterion-based Major Depression and/or suicidal ideation at 2 years; (2) To assess whether the different subgroups identified in Aim 1 on the basis of either depressive symptoms or overall medical comorbidity modify the effect of the collaborative care intervention on criterion- based Major Depression and/or suicidal ideation at 2 years, such that the intervention will show significant effects in certain subgroups; and (3) To assess how the effect modification of the intervention effect on criterion-based Major Depression or suicidal ideation at 2 years in Aim 1 is mediated by varying intensity of exposure to antidepressant medication or psychotherapy. To accomplish these aims, we will capitalize on screening, clinical assessment, treatment, and follow-up assessments which have occurred for up to 2 years in PROSPECT (the "Prevention of Suicide in Primary Care Elderly: Collaborative Trial"). In all, 1,226 patients, including all patients who screened positive for depression and a random sample of patients who screened negative, were enrolled in the 2-year longitudinal study. The primary care practices were randomized into: (1) treatment as usual by the primary care practice (n = 617 patients); and (2) a guideline management intervention consisting of antidepressant or psychotherapeutic treatment for depression following AHCPR guidelines, revised for the elderly, under the responsibility of the primary care physician who is assisted by a Masters-level specialist (the intervention condition; n = 609 patients). Among the sample of 1226 primary care elderly patients, we want to emphasize that our analysis will be based on course of depressive symptoms and not DSM-IV diagnoses. We propose to supplement PROSPECT data with medication records to classify and quantify medical comorbidity over the course of the 2-year follow-up interval. The foundation for the analysis to improve our understanding of the dynamic association of course of depressive symptoms and medical comorbidity will be the general growth curve mixture model (GGCMM). This project can have a significant public health impact because a further understanding of the association of the course of depressive symptoms and the onset and course of medical comorbidity among elderly primary care patients would be a key step in intervening to improve recognition and treatment of late life depression. PUBLIC HEALTH RELEVANCE: The overall goal of this application is to identify subgroups of primary care elderly patients, based on baseline characteristics and two different types of longitudinal profiles: 1) depressive symptoms and 2) overall medical comorbidity, for whom the collaborative care intervention reduces the persistence or onset of Major Depression and/or suicidal ideation. This project can have a significant public health impact because a further understanding of the association of the course of depressive symptoms and the onset and course of medical comorbidity among primary care elderly patients would be a key step in intervening to improve recognition and treatment of depression in late life.