Improving Depression Outcome by Enhancing Memory for Cognitive Therapy

摘要 开发有效的精神障碍干预措施的进展必须包括识别新的 安全、强大、廉价和可部署的干预目标。我们的重点是这样一个目标- 患者记忆治疗内容。选择该目标是因为：（1）患者对 治疗效果差，（2）对治疗的记忆力差与依从性差和预后差有关，（3） 记忆障碍的影响可以通过使用记忆支持策略来最小化，以及（4）改善 治疗记忆改善疗效。在这个提案中，我们建立在NIMH资助的R34的基础上， 这提供了新目标已经被使用和验证的初步证明。具体而言， 我们开发并试点测试了一种预防性干预-记忆支持干预-以改善 患者记忆治疗。这种干预是从基本的、非病人的认知研究中提炼出来的。 科学和教育，包括八个强大的记忆促进策略，积极主动， 战略性地，并集中整合到常规治疗中。这项建议的目的是进行一项 验证性有效性试验，以测试记忆支持干预是否改善疾病进程， 功能性成果。作为下一步研究这一方法的“平台”，我们将重点关注 抑郁症（MDD）和认知疗法（CT）。理由是：（1）MDD普遍存在;（2） 需要改善MDD的治疗;（3）MDD的CT很好地表达，有有希望的证据表明， 有效性，但仍有改善的空间;（4）MDD患者对治疗的记忆较差;（5）MDD患者对治疗的记忆较差。 MDD是可修改的，（6）来自R34的有希望的数据表明，在CT中添加记忆支持可以改善 结果，具体说明了16岁以下患者的长期获益。 教育在四年的时间里，MDD成人（n = 178，包括20%的潜在自然减员）将被纳入研究。 随机分配至CT+记忆支持组或CT常规组，并在基线、治疗后 治疗以及6个月和12个月随访时。我们将比较CT+记忆支持与CT-as- 通常用于确定新的干预措施是否改善了病程并减少了功能障碍 (Aim 1）。我们将确定患者对治疗的记忆（目标）是否介导了 治疗条件和结果（目标2）。我们将评估先前报告的不良治疗反应 亚组中度目标参与（目标3）。这项研究有可能提高跨 广泛的干预措施。在社区治疗和医患关系方面具有专长的顾问 沟通将有助于小组开始开发更广泛的应用程序。这项研究将有助于 知识RDoC作为一个交叉诊断结构相关的认知系统RDoC域穷人 治疗的记忆是干预的目标。此外，陈述性记忆和工作记忆， 认知系统RDoC域中的结构将被测量。

Abstract Progress toward developing effective interventions for mental disorders must include the identification of novel intervention targets that are safe, powerful, inexpensive and deployable. Our focus is on one such target— patient memory for the contents of treatment. This target was selected because: (1) patient memory for treatment is poor, (2) poor memory for treatment is associated poorer adherence and poorer outcome, (3) the impact of memory impairment can be minimized by the use of memory support strategies and (4) improved memory for treatment improves outcome. In this proposal we build on an NIMH-funded R34, the results of which provide a preliminary demonstration that the novel target has been engaged and validated. Specifically, we developed and pilot tested an adjunctive intervention—the Memory Support Intervention—to improve patient memory for treatment. The intervention was distilled from the basic, non-patient research in cognitive science and education and is comprised of eight powerful memory promoting strategies that are proactively, strategically, and intensively integrated into treatment-as-usual. The aim of this proposal is to conduct a confirmatory efficacy trial to test whether the Memory Support Intervention improves illness course and functional outcomes. As a `platform' for the next step in investigating this approach, we focus on major depressive disorder (MDD) and cognitive therapy (CT). The rationale is that: (1) MDD is prevalent; (2) there is a need to improve treatment for MDD; (3) CT for MDD is well articulated, there is promising evidence for efficacy, yet there is room for improvement; (4) memory for treatment is poor in MDD; (5) poorer memory in MDD is modifiable and (6) promising data from the R34 suggests that adding memory support to CT improves outcome, with a specific indication of longer-term benefit among individuals with less than 16 years of education. Over a four-year period, adults with MDD (n = 178, including 20% for potential attrition) will be randomly allocated to CT+Memory Support or CT-as-usual and they will be assessed at baseline, post- treatment, and at 6 and 12 months follow-up. We will compare the effects of CT+Memory Support vs. CT-as- usual to determine if the new intervention improves the course of illness and reduces functional impairment (Aim 1). We will determine if patient memory for treatment (the target) mediates the relationship between treatment condition and outcome (Aim 2). We will evaluate if previously reported poor treatment response subgroups moderate target engagement (Aim 3). This research has the potential to enhance outcomes across a broad range of interventions. Consultants with expertise in community-based treatment and doctor-patient communication will assist the team to begin to develop the broader applications. This research will contribute knowledge to RDoC as a cross-diagnostic construct related to the Cognitive Systems RDoC domain—poor memory for treatment—is the intervention target. Also, declarative memory and working memory, which are constructs within the Cognitive Systems RDoC domain, will be measured.