Course and risk factors for depression in late life

描述(申请人提供)：本申请建立在初级保健中进行的一项随机临床试验的基础上，以研究抑郁症状和医学共病的轨迹与两年后严重抑郁和自杀意念的结果有关，符合NIMH战略计划，并根据2007年5月11日发布的PA-07-082“使用现有数据集进行精神病理学的风险因素”提交。最近的研究表明，各种初级保健干预措施可以改善晚年重度抑郁症的预后。然而，这些干预措施并未被发现对轻度抑郁症有效。虽然之前的一些研究已经确定了抑郁症的亚型，但很少有工作关注晚年抑郁症的亚型，而且这项工作是在横断面数据中进行的，而不是在干预试验的背景下进行的。这项研究的具体目的是：(1)根据基线特征和两种不同类型的纵向特征确定初级保健老年患者的亚组：1)抑郁症状和2)总体医疗合并症，以及2年后亚组与基于标准的重度抑郁和/或自杀意念的关联；(2)评估目标1中基于抑郁症状或总体医疗合并症确定的不同亚组是否改变了协作性护理干预对2年后基于标准的重度抑郁和/或自杀意念的影响，从而使干预在某些亚组中显示出显著效果；以及(3)评估在目标1的2年中，干预效果对基于标准的严重抑郁或自杀意念的影响是如何通过不同强度的抗抑郁药物或心理治疗来调节的。为了达到这些目标，我们将利用在未来两年内进行的筛查、临床评估、治疗和随访评估(“预防基层护理长者自杀：合作试验”)。总共有1226名患者参加了这项为期2年的纵向研究，其中包括所有筛查抑郁症阳性的患者和筛查阴性的随机抽样患者。初级保健实践被随机分为：(1)初级保健实践照常治疗(n=617名患者)；(2)指南管理干预，由初级保健医生负责，由一名大师级专家协助(干预条件；n=609名患者)。在1226名初级保健老年患者的样本中，我们想强调的是，我们的分析将基于抑郁症状的病程，而不是DSM-IV诊断。我们建议用用药记录来补充前景数据，以分类和量化两年随访期间的医学合并症。分析的基础将是一般生长曲线混合模型(GGCMM)，以提高我们对抑郁症状和医学共病病程的动态关联的理解。这一项目可以对公共卫生产生重大影响，因为进一步了解老年初级保健患者抑郁症状的病程与其发病和病程的关系，将是改善对老年抑郁症的认识和治疗的干预措施的关键一步。公共卫生相关性：这项应用的总体目标是根据基线特征和两种不同类型的纵向概况确定初级保健老年患者的亚组：1)抑郁症状和2)总体医疗合并症，对他们来说，协作性护理干预减少了严重抑郁和/或自杀意念的持续或发作。这一项目可以对公共卫生产生重大影响，因为进一步了解抑郁症病程与初级保健老年患者的发病和病程之间的关系，将是采取干预措施改善老年抑郁症的认识和治疗的关键一步。

DESCRIPTION (provided by applicant): This application building on a randomized clinical trial carried out in primary care to study trajectories of depressive symptoms and medical comorbidity in relation to the outcomes of Major Depression and suicidal ideation at 2 years aligns with the NIMH Strategic Plan and is submitted in response to PA-07-082, "Risk factors for psychopathology using existing data sets," released 11 May 2007. Recent studies have demonstrated that a variety of primary care interventions can improve late life Major Depression outcomes. However, these interventions have not been found to be effective for minor depression. While some research has previously identified subtypes of depression, little work has focused on subtypes of late life depression, and that work has been conducted in cross-sectional data and not in the context of an intervention trial. The specific aims of this study are: (1) To identify subgroups of primary care elderly patients based on baseline characteristics and two different types of longitudinal profiles: 1) depressive symptoms and 2) overall medical comorbidity, and the association of subgroups with criterion-based Major Depression and/or suicidal ideation at 2 years; (2) To assess whether the different subgroups identified in Aim 1 on the basis of either depressive symptoms or overall medical comorbidity modify the effect of the collaborative care intervention on criterion- based Major Depression and/or suicidal ideation at 2 years, such that the intervention will show significant effects in certain subgroups; and (3) To assess how the effect modification of the intervention effect on criterion-based Major Depression or suicidal ideation at 2 years in Aim 1 is mediated by varying intensity of exposure to antidepressant medication or psychotherapy. To accomplish these aims, we will capitalize on screening, clinical assessment, treatment, and follow-up assessments which have occurred for up to 2 years in PROSPECT (the "Prevention of Suicide in Primary Care Elderly: Collaborative Trial"). In all, 1,226 patients, including all patients who screened positive for depression and a random sample of patients who screened negative, were enrolled in the 2-year longitudinal study. The primary care practices were randomized into: (1) treatment as usual by the primary care practice (n = 617 patients); and (2) a guideline management intervention consisting of antidepressant or psychotherapeutic treatment for depression following AHCPR guidelines, revised for the elderly, under the responsibility of the primary care physician who is assisted by a Masters-level specialist (the intervention condition; n = 609 patients). Among the sample of 1226 primary care elderly patients, we want to emphasize that our analysis will be based on course of depressive symptoms and not DSM-IV diagnoses. We propose to supplement PROSPECT data with medication records to classify and quantify medical comorbidity over the course of the 2-year follow-up interval. The foundation for the analysis to improve our understanding of the dynamic association of course of depressive symptoms and medical comorbidity will be the general growth curve mixture model (GGCMM). This project can have a significant public health impact because a further understanding of the association of the course of depressive symptoms and the onset and course of medical comorbidity among elderly primary care patients would be a key step in intervening to improve recognition and treatment of late life depression. PUBLIC HEALTH RELEVANCE: The overall goal of this application is to identify subgroups of primary care elderly patients, based on baseline characteristics and two different types of longitudinal profiles: 1) depressive symptoms and 2) overall medical comorbidity, for whom the collaborative care intervention reduces the persistence or onset of Major Depression and/or suicidal ideation. This project can have a significant public health impact because a further understanding of the association of the course of depressive symptoms and the onset and course of medical comorbidity among primary care elderly patients would be a key step in intervening to improve recognition and treatment of depression in late life.