Developing A Collaborative Care Strategy for Depression and Co-Morbid CHF

充血性心力衰竭（CHF）是一种常见且日益严重的健康问题，影响着500万美国人，每年有超过550，000例新诊断病例，287，000例死亡，直接和间接费用为300亿美元。尽管私人和公共支付者正在采用一些护理管理计划，但CHF患者的结局仍然很差。这些不良结局的潜在因素是抑郁症的存在，约20-50%的CHF患者存在抑郁症。 有效慢性病管理的类似原则适用于抑郁症和CHF。因此，我们建议，筛选CHF患者的抑郁症，然后利用一个单一的护士护理经理在医生的监督下工作，同时提供基于证据的治疗，这两种情况时，是一种新的和潜在的更可持续的战略，以改善临床结果比抑郁CHF患者单独的护理提供者。 我们修订的三年R34治疗开发提案响应NIMH PAR-06-248，从干预开发到服务，因为其具体目标是获得计划大规模R 01试验所需的必要可行性和临床数据，该试验将比较“混合”抑郁/CHF护理管理计划与当前CHF护理管理计划在减少抑郁症状方面的有效性，改善HRQoL和各种其他感兴趣的结果。它包括四个协调阶段：（1）培训;（2）手册开发;（3）队列研究;（4）试点干预。我们将从我们目前NIH资助的试验中派遣护士招募人员/护理经理，以治疗CABG后抑郁症，并在两个当地住院和门诊CHF护理管理项目中进行培训。随后，我们将整合我们在早期工作中开发的用于治疗抑郁症的阶梯式协作护理协议与用于治疗CHF的基于指南的协议。接下来，我们将进行一项队列研究，以估计372例抑郁和100例非抑郁CHF患者的招募和“常规护理”治疗模式。将应用ROC分析，以估计适当敏感和特异性的PHQ-9截止评分，用于识别在6个月随访时可能死亡或再次住院的抑郁患者。最后，我们将对30名抑郁性CHF患者试行基于电话的“混合”协作护理策略，以进一步完善我们的治疗策略。

DESCRIPTION (provided by applicant): Congestive heart failure (CHF) is a common and growing health problem that affects 5 million Americans, with over 550,000 newly diagnosed cases, 287,000 deaths, and $30 billion in direct and indirect costs yearly. Despite a number of care management programs that are being adopted by private and public payers, CHF patients continue to experience poor outcomes. A potential contributor to these poor outcomes is the presence of depression, present in approximately 20-50% of CHF patients. Similar principles of effective chronic disease management apply to both depression and to CHF. Thus, we suggest that screening CHF patients for depression and then utilizing a single nurse care manager working under a physician's supervision to simultaneously deliver evidence-based treatments for both conditions when present is a novel and potentially more sustainable strategy for improving clinical outcomes than referring depressed CHF patients to separate care providers. Our revised three-year R34 treatment development proposal is responsive to NIMH PAR-06-248, From Intervention Development to Services, as its specific aims are to obtain the necessary feasibility and clinical data required to plan a large-scale R01 trial which will compare the effectiveness of a "blended" depression/CHF care management program with current CHF care management programs in reducing depressive symptoms, improving HRQoL, and various other outcomes of interest. It consists of four coordinated phases: (1) Training; (2) Manual Development; (3) Cohort Study; and (4) Pilot Intervention. We will send nurse-recruiter/care managers from our present NIH-funded trial to treat post-CABG depression for training in two local in-patient and out-patient CHF care management programs. We subsequently will integrate the stepped collaborative care protocols for treating depression we developed in our earlier work with guideline-based protocols for treating CHF. Next, we will conduct a cohort study to estimate recruitment and "usual care" treatment patterns for 372 depressed and 100 non-depressed CHF patients. ROC analyses will be applied so as to estimate suitably sensitive and specific PHQ-9 cut-off scores for identifying depressed patients who are likely to die or become rehospitalized at 6-month follow-up. Finally, we will pilot our telephone-based "blended" collaborative care strategy to 30 depressed CHF patients to further refine our treatment strategy.