Shared Decision-Making for Elderly Depressed Primary Care Patients

描述（由申请人提供）：与传统的医疗决策相比，共享决策（SDM）涉及一个协作过程，患者阐明个人价值观和偏好，临床医生提供信息，以达成双方同意的治疗决策。SDM可能与抑郁症患者特别相关，因为它寻求以一种直接解决与抑郁症相关的无助和绝望的方式增强他们的自主性和赋权。针对初级保健中的抑郁症，正在开发共同决策干预措施，但尚未进行充分的测试。同样不清楚的是，关于共同决策增强自主和赋权能力的同样前提是否适用于老年人。拟议的研究将评估三阶段SDM护理干预对老年抑郁症初级保健患者的影响，与常规护理（UC）相比，患者对抗抑郁药物或心理治疗的依从性以及抑郁症状的减轻。SDM干预的重点是赋予老年抑郁症初级保健患者权力，并帮助他们有效地做出可以成功实施的治疗决定。基于我们之前的工作，证明了患者的先验治疗偏好对治疗开始和依从性的影响，我们建议对老年抑郁症初级保健患者进行随机对照试验，以确定SDM对治疗依从性和抑郁症状减轻的影响。该研究随机抽取了来自布朗克斯林肯医院的30名医生，这是一家大型的多种族初级保健诊所，他们分别参加共同决策（SDM）和常规护理（UC）的比较条件。共有210名抑郁症（PHQ-9 bb0 - 15）老年患者，根据医生随机分组，接受SDM或UC治疗。受试者将在基线和第4、8、12和24周进行评估，以确定治疗依从性和抑郁状态。如果SDM是有效的，它可以作为执业护士的一个简短的独立干预，并将提供一个平台，在各种初级保健实践环境和人群中定制和传播该模型。

DESCRIPTION (provided by applicant): Shared decision-making (SDM), in contrast to traditional medical decision-making, involves a collaborative process whereby patients articulate personal values and preferences and clinicians provide information to arrive at a mutually-agreed upon treatment decision. SDM may be particularly relevant for depressed individuals, as it seeks to enhance their autonomy and empowerment in a manner that directly addresses the helplessness and hopelessness associated with depression. Shared decision-making interventions are being developed for depression in primary care, but have yet to be adequately tested. It is also unknown whether the same premises regarding shared decision-making's ability to enhance autonomy and empowerment pertain to elderly populations. The proposed study will evaluate the impact of a three-session SDM nursing intervention among depressed elderly primary care patients, in comparison to Usual Care (UC), on patient adherence to antidepressant medication or psychotherapy and on reduction in depressive symptoms. The focus of the SDM intervention is to empower elderly depressed primary care patients and help them efficiently arrive at a treatment decision that can be successfully implemented. Based on our prior work that demonstrated the impact of patients' a priori treatment preferences on treatment initiation and adherence, we propose to conduct a randomized controlled trial of elderly depressed primary care patients to determine the impact of SDM on treatment adherence and reduction in depressive symptoms. The study randomizes 30 physicians from Lincoln Hospital in the Bronx, a large ethnically diverse primary care clinic, to either Shared Decision-Making (SDM) or the Usual Care (UC) comparison condition. A total of 210 depressed (PHQ-9>15) geriatric patients whose physicians' recommend starting depression treatment, will receive either SDM or UC according to physician randomization. Subjects will be assessed at baseline and at weeks 4, 8, 12, and 24 to determine treatment adherence and depressive status. If SDM is effective, it may serve as a brief independent intervention by practice nurses, and will provide a platform to tailor and disseminate the model throughout a variety of primary care practice settings and populations. PUBLIC HEALTH RELEVANCE: Shared decision-making, in contrast to traditional medical decision-making, involves a collaborative process whereby patients share personal values and preferences and clinicians provide information to arrive at a mutually-agreed upon treatment decision. The proposed study will evaluate the impact of a shared decision- making nursing intervention among depressed elderly primary care patients on patient adherence to depression treatment and on improvement in depression. The focus of the intervention is to empower elderly depressed primary care patients and help them efficiently arrive at a treatment decision that they can successfully implement.