Treating Older Patients with Major Depression and Severe COPD

描述(申请人提供)：慢性阻塞性肺病影响15%的老年人，是美国第四大死因。超过20%的COPD患者患有严重的抑郁症。重度COPD患者每天身体不适，被迫妥协的生活方式，不得不应对由于知道自己不可避免的恶化和死亡而导致的士气低落。抑郁的悲观、无助和毫无价值，会导致他们听天由命，加剧他们的士气低落。执行功能障碍发生在大约一半的抑郁症COPD患者中，并降低了他们制定行为策略以解决他们的治疗需求和生活问题的能力。COPD的治疗要求苛刻，需要患者积极参与，这使这些问题变得更加复杂。抑郁、士气低落、认知受损和身体虚弱的患者最不想做的事情就是追求始终如一的锻炼计划，去看医生和治疗中心，并重新设计他/她生活的社会方面。结果，他们放弃了治疗和其他活动，经历了痛苦的生命终结。我们开发了一种将治疗依从性增强程序(AE)与问题解决疗法(PST)相结合的干预措施(PST-AE)。PST-AE提供提高治疗依从性的教育和直接建议，并提供满足患者复杂治疗需求、抑郁症状和残疾的行为策略。我们假设，与AE相比，PST-AE将更多地减少抑郁和残疾，改善COPD的生活质量和坚持治疗。我们建议在从一家住院康复医院连续招募的160名重度抑郁症和重度COPD患者中检验这些假设，他们将被随机分配接受14次PST-AE(N=80)或AE(N=80)，并在26周内系统地进行评级。我们的目标是残疾人最多、最痛苦的人群之一。在我们的设计中，我们使用了我们对抑郁症COPD患者的研究经验，初级保健老年患者的前景多中心研究，以及我们ACISR的老年抑郁症研究。如果被发现有效，PST-AE可以广泛实施，因为它可以被访问的护士专业人员在再培训后使用。除了COPD，PST-AE可能是各种慢性、衰弱疾病患者的护理模式，这些患者通常会发展成抑郁、放弃，结果很差，往往是致命的。由于PST-AE的主要关注点是改善治疗依从性，这种治疗抑郁症、内科疾病患者的方法可以产生一种实践模式，具有快速整合临床科学进步的能力。

DESCRIPTION (provided by applicant): COPD affects 15% of older adults and is the fourth leading cause of death in the US. More than 20% of COPD patients have major depression. Patients with severe COPD live with daily physical discomfort, are forced to a compromised life style, and have to cope with demoralization caused by the knowledge of their inescapable deterioration and death. The pessimism, helplessness, and worthlessness of depression, lead to resignation and worsen their demoralization. Executive dysfunction occurs in about half of depressed COPD patients and reduces their ability to develop behavioral strategies to address their treatment needs and their life problems. These problems are compounded by the demanding treatment of COPD that requires active patient participation. The last thing that a depressed, demoralized, cognitively compromised, and physically weak patient wants to do is to pursue a consistent exercise program, go to doctors and treatment centers, and reengineer the social aspects of his/her life. As a consequence, they give up on treatment and other activities and experience a painful end of life. We developed an intervention (PST-AE) that integrates treatment adherence enhancement procedures (AE) with problem solving therapy (PST). PST-AE offers education and direct suggestions for improving treatment adherence and imparts behavioral strategies for meeting the patients' complex treatment needs, depressive symptoms, and disability. We hypothesize that PST-AE will reduce depression and disability and improve quality of life and adherence to treatment of COPD more than AE. We propose to test these hypotheses in 160 patients with major depression and severe COPD consecutively recruited from an inpatient Rehabilitation Hospital who will be randomly assigned to receive 14 sessions of PST-AE (N=80) or AE (N=80) and be systematically rated over 26 weeks. We target one of the most disabled and suffering segments of the population. We used, in our design, our research experience with depressed COPD patients, the PROSPECT multicenter study of primary care elderly patients, and the geriatric depression studies of our ACISR. If found effective, PST-AE can be broadly implemented, as it can be used by visiting nurse professionals after retraining. Beyond COPD, PST- AE may be a model of care for patients with a variety of chronic, debilitating disorders, who often develop depression, give up, and have a poor and often fatal outcome. As a major focus of PST-AE is improvement of treatment adherence, this approach to the care of depressed, medically ill patients can generate a practice model that has the ability to rapidly incorporate advances made in clinical science.