Home-Delivered Intervention for Depressed, Cognitively Impaired Elders

描述(申请人提供)：晚年严重抑郁、认知障碍和残疾会导致医疗和精神疾病的发病率和死亡率。现有的抗抑郁药物使不到40%的抑郁、认知受损的老年人得到缓解，而对这一群体的心理社会干预措施还不发达，也没有得到充分的研究。拟议的随机临床试验，PI的第一个R01，将测试问题适应疗法(PATH)的疗效，与家庭交付的支持疗法(ST)相比，PATH是一种新的家庭交付的心理社会干预措施，适用于患有严重抑郁症、认知障碍和残疾的老年人。Path是创新的，因为它关注患者的生态系统(即患者、照顾者和家庭环境)，并针对与抑郁和残疾相关的行为问题。本研究建立在PI的K23奖的基础上，支持PATH的发展，为PATH的招募、随机、保留、评估程序和实施的可行性提供了证据，并提供了一个信号，表明PATH在减少这一人群中的抑郁和残疾方面是有效的。招募将通过康奈尔干预和服务研究高级中心(ACISR)社区网络股的3个合作机构的上门送餐计划进行。研究对象为单相重度抑郁症、轻度认知障碍至轻中度痴呆症、日常生活工具能力障碍的老年人()。所有参与者将有一名可用的照顾者(家庭、重要的其他人或专业人员)，并将随机参加PATH或ST的每周12次会议。研究评估将在研究开始时(基线)以及随机分组后的2、4、6、8、10、12和24周进行。这项研究旨在验证这样的假设：在12周的治疗期间，家庭交付路径比家庭交付ST a)在减少患者的抑郁和残疾方面更有效，以及b)在提高患者和照顾者的自我效能方面。在完成12周的治疗后，参与者将再被跟踪12周，以衡量治疗的持续效果。治疗师将成为ACISR的硕士级别社会工作者(MSW)。我们选择对MSW进行培训，为未来的有效性和实施项目铺平道路。在全国许多以社区为基础的社会服务中都有MSW，他们经常提供心理社会干预，并可以通过医疗保险报销这些服务。该建议与NIMH的战略目标以及NIMH老年科的建议是一致的。

DESCRIPTION (provided by applicant): Late-life major depression, cognitive impairment and disability contribute to medical and psychiatric morbidity and mortality. Available antidepressants bring to remission fewer than 40% of depressed, cognitively impaired elders while psychosocial interventions for this population are underdeveloped and understudied. The proposed randomized clinical trial, the PI's first R01, will test the efficacy of Problem Adaptation Therapy (PATH), a new home-delivered psychosocial intervention for elders with major depression, cognitive impairment, and disability, compared to home-delivered Supportive Therapy (ST). PATH is innovative because it focuses on the patient's ecosystem (i.e. the patient, the caregiver, and the home-environment) and targets behavioral problems related to both depression and disability. This study builds on the PI's K23 award that supported the development of PATH, provided evidence for the feasibility of recruitment, randomization, retention, assessment procedures and implementation of PATH, and offered a signal that PATH is efficacious in reducing depression and disability in this population. Recruitment will be conducted through the Home Delivered Meals programs of 3 collaborating agencies of the Community Network Unit of the Cornell Advanced Center for Interventions and Services Research (ACISR). Participants will be 176 elders (>64 years) with unipolar major depression, cognitive impairment ranging from mild cognitive deficits up to the levels of mild to moderate dementia, and impairment in instrumental activities of daily living. All participants will have an available caregiver (family, significant other, or professional) and will be randomized to 12 weekly sessions of PATH or ST. Research assessments will be performed at study entry (baseline), and at 2, 4, 6, 8, 10, 12 and 24 weeks after randomization. The study is designed to test the hypotheses that home-delivered PATH is more effective than home-delivered ST a) in reducing patient's depression and disability and b) in increasing patient and caregiver's self- efficacy over the 12-week treatment period. After the completion of 12 weeks of treatment, participants will be followed for an additional 12 weeks to measure sustained effects of treatment. Therapists will be Master's level Social Workers (MSW) of the ACISR. We elected to train MSWs to pave the way towards future effectiveness and implementation projects. MSWs are available in many community-based social services across the country, often offer psychosocial interventions, and can be reimbursed through Medicare for these services. The proposal is consistent with NIMH strategic objectives as well as recommendations from the NIMH Geriatric Branch.