Social Inequalities in Outcomes for Treatment of Late-Life Depression

描述（由申请人提供）：晚年抑郁症（LLD）是一个主要的公共卫生问题。它与社会和认知领域的严重损害和残疾相关，增加合并症的风险并加剧其严重程度[4-6]，增加自杀风险，是死亡率的重要因素。这些关联和风险具有更大的意义，因为LLD通常诊断不足且治疗不充分。流行病学研究还表明，在长期性学习障碍中存在社会不平等。社会经济地位（SES），通常通过教育，收入，财富，职业和/或邻里特征的措施进行评估，与老年人（≥ 60岁）抑郁症的风险相关。事实上，这些风险似乎随着年龄的增长而扩大，SES较低的老年人患抑郁症的风险显着增加。关于种族/民族不平等的证据好坏参半。尽管白色男性的LLD率高于非洲裔美国人和西班牙裔男性，但老年白色男性的抑郁症状水平似乎低于老年非洲裔美国男性。此外，有证据表明，非洲裔美国人和西班牙裔美国人，一般来说，经历慢性抑郁症的发病率较高。种族/民族与抑郁症之间的关系本身受到性别，收入和教育的影响。本申请是一个小的研究补助金（R 03）进行二次数据分析，以调查社会和种族/民族不平等的抗抑郁药治疗的结果在老年人。这些分析来自科恩等人的初步研究，（2006）报道SES（通过人口普查区家庭收入中位数测量）是两项临床试验中抗抑郁治疗的重要调节剂，其中所有受试者都接受了高质量的护理。拟议的研究将通过调查前景（预防初级保健老年人自杀：合作试验）的有效性可能存在的社会不平等来扩大这项工作，PROSPECT是一项多中心随机临床试验，用于治疗LLD的干预措施（药物治疗，人际心理治疗和病例管理）。我们还将调查是否干预的相对有效性依赖于社会不平等的积极变化，在治疗过程中的社会支持和/或在何种程度上，患者利用了干预的各个组成部分。拟议的研究将受益于其使用的数据来自随机临床试验，该试验是在“现实世界”的初级保健环境中进行的，包括抑郁症老年人的异质样本，以及在个人和他们居住的社区水平上的多种措施SES和种族/民族的可用性。这项研究的结果可能会产生以下见解：1）影响治疗有效性的社会因素，即使在控制治疗的可及性和质量时; 2）人群亚组的临床和公共卫生需求;以及3）未来临床试验中方法学变化的必要性。更广泛地说，我们希望这项研究将为我们理解健康差异做出重要贡献。晚年抑郁症是一个主要的公共卫生问题，因为它与功能障碍，自杀和死亡的风险增加有关。在初步研究的基础上，建议在抗抑郁治疗的有效性方面存在社会不平等，拟议的研究将调查初级保健干预措施的有效性方面的社会不平等（以社会经济地位和种族/民族为衡量标准），以减少抑郁症状，绝望和自杀，并改善老年人的功能状态。这项研究的结果可能会产生新的见解：1）影响治疗有效性的社会因素，即使在控制治疗的可及性和质量时; 2）人群亚组的临床和公共卫生需求;以及3）未来临床试验中方法学变化的必要性。

DESCRIPTION (provided by applicant): Late-life depression (LLD) is a major public health concern. It is associated with substantial impairment and disability in social and cognitive domains, increases risk for and exacerbates the severity of comorbid medical conditions [4-6], elevates risk for suicidality, and is a significant contributor to mortality. These associations and risks take on greater significance because LLD is commonly under-diagnosed and inadequately treated. Epidemiological research also suggests the presence of social inequalities in LLD. Socioeconomic status (SES), usually assessed by measures of education, income, wealth, occupation, and/or neighborhood characteristics, is associated with risk of depression in older adults (=60 years). Indeed, these risks appear to widen with age, with older adults of lower SES having markedly elevated risk for depression. Evidence is mixed about racial/ethnic inequalities. Whereas rates of LLD are higher among White males than among African-American and Hispanic males, older White males appear to have lower levels of depressive symptoms than older African American males. Furthermore, there is evidence that African Americans and Hispanics, in general, experience higher rates of chronic depression. The relationship between race/ethnicity and depression is itself, influenced by gender, income, and education. This application is for a small research grant (R03) to conduct secondary data analyses to investigate social and racial/ethnic inequalities in outcomes of antidepressant treatments in older adults. These analyses emerge from an initial study in which Cohen et al., (2006) reported SES (as measured by census tract median household income) was a significant moderator of antidepressant treatment in two clinical trials in which all subjects received high quality care. The proposed research will expand on this work by conducting an investigation of possible social inequalities in the effectiveness of PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), a multi-site randomized clinical trial of an intervention (pharmacotherapy, interpersonal psychotherapy, and case management) for the treatment of LLD. We will also investigate whether the relative effectiveness of the intervention depended social inequalities in positive changes in social support during treatment and/or the extent to which patients took advantage of various components of the intervention. The proposed research will benefit from its use of data from a randomized clinical trial that was conducted in "real-world" primary care settings and included a heterogeneous sample of depressed older adults, as well as the availability of multiple measures SES and race/ethnicity at the level of individuals and the neighborhoods in which they lived. Results of this research may yield insights about: 1) the social factors that influence the effectiveness of treatments, even when controlling for access and the quality of treatment; 2) the clinical and public health needs of population subgroups; and, 3) the need for methodological changes in future clinical trials. More generally, we expect this research will make an important contribution to our understanding of health disparities. Late-life depression is a major public health concern in that it is associated with increased risk for functional disability, suicidality, and mortality. Expanding on preliminary research, which suggested social inequalities in the effectiveness of antidepressant treatments, the proposed research will investigate social inequalities (as measured by socioeconomic status and race/ethnicity) in the effectiveness of a primary care intervention for reducing depressive symptoms, hopelessness, and suicidality, and improving functional status in older adults. Results of this research may yield new insights about: 1) the social factors that influence the effectiveness of treatments, even when controlling for access and the quality of treatment; 2) the clinical and public health needs of population subgroups; and, 3) the need for methodological changes in future clinical trials.