减少老年人的忧郁现象可以显著延长生命


  May 5, 2006 (芝加哥) — 老年者的忧郁与死亡是一体两面,将这两者的连结去除的话,可以显著提高存活率,这是发表于美国老年协会年会科学会议的一项随机控制试验研究结果。
  
  费城宾州大学、家庭医学与社区健康部的Hillary R. Bogner医师向Medscape表示,虽然我们知道忧郁伴随著死亡率,但是无人着眼于如何介入以影响死亡风险。
  
  Bogner医师表示,我们发现对忧郁的老年人介入后的4年追踪期间,与那些接受一般照护之未忧郁的老年者相比,降低了死亡率;她指出,此研究发现有统计上的显著意义。
  
  此研究检验对于老年人忧郁的介入治疗,是基于一项1999到2003年间的随机、多处的、基层照护老年人以预防自杀的合作性试验(PROSPECT)的数据。
  
  Bogner医师及其同僚对此试验的前提是,忧郁是死亡的危险因子之一,而此因子可以经由介入而修饰则尚未被适当地研究过;此研究以4年期间分析介入管理忧郁现象和死亡风险之间的关系。
  
  研究方法为募集硕士等级的忧郁症专家和病患的第一线照护医师(PCP)合作,目标是改善病患对药物治疗忧郁症的顺从度;专家们也教育PCP 和病患家属相关议题,由所谓的「忧郁症照护管理者」对所有参与研究的病患提供一般的治疗建议,但是不对个别病患提出个别的建议。
  
  Bogner医师发表的数据显示随机实务指派、病患初始忧郁状态、4年追踪期死亡率之间的关系。
  
  对于忧郁病患,介入和一般照护之间的校正后风险比率是0.69 (95% 信心区间 [CI], 0.46 - 1.05);对于非忧郁病患,校正后风险比率是1.20 (95% CI, 0.90 - 1.60);风险比率评估基于初始年纪、教育程度、自杀意图、抽菸史等校正;Bogner医师也发表忧郁病患(279位)和非忧郁病患(338 位)的存活率曲线清楚地显示对忧郁病患有改善。
  
  此研究的结论是忧郁的病患施以忧郁照护管理照护的4年追踪期间,与那些接受一般照护的忧郁老年者相比,降低了死亡率。
  
  Bogner医师对Medscape解释这些研究发现,第一线实施忧郁照护管理不仅可以减少失能,还可以降低死亡率,这是我们的研究发现中最突出的,过去无人提及。
  
  威斯康辛州密尔瓦基市全包式老人照顾计画(PACE) 的Attendee Paul Hunter医师,称赞此研究的方法,但是质疑应用上的可行性。
  
  Hunter医师向Medscape表示,我认为立论上来看是好的,但毕竟这是一个真实生活的比较,应该随地、随机找一个人,然后和当地其它的人比较,这样才能更接近真实世界的层面。
  
  不过,Hunter医师表示,要到处找人也的确困难,而要怎样转变为对价也难,这挺现实的;一旦有了治疗专家,就比较容易计算对价,如果只是寻求实务治疗观点,可能再怎么努力还是失败。
  
  此研究受精神卫生国家研究院赞助;Bogner医师领有罗伯特·伍德·詹森基金一般医师技能奖金。

Interrupting Depression in the

By Richard Hyer
Medscape Medical News

May 5, 2006 (Chicago) — Depression and death are closely linked in elderly populations, and interrupting the pathway between the two can significantly improve survival. This was the conclusion of a randomized controlled trial presented here at the annual scientific meeting of the American Geriatrics Society.

"Although we know that depression is associated with mortality, nobody has looked at whether an intervention condition can influence mortality risk," presenting author Hillary R. Bogner, MD, MSCE, from the Department of Family Medicine and Community Health at the University of Pennsylvania in Philadelphia, told Medscape.

"We found that depressed older adults in the intervention practices were less likely to die over a 4-year follow-up period compared to not-depressed older adults in the usual-care practices," Dr. Bogner said. She noted that her findings reached statistical significance.

The trial examined an intervention to treat depression in older adults in primary care. It was based on data from the randomized, multisite Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), taking place from 1999 to 2003.

The trial by Dr. Bogner and colleagues was based on the premise that depression is a risk factor for death, and whether this factor can be modified with intervention has not been adequately studied. It sought to analyze the relation between an intervention to manage depression and the risk of death during a 4-year period.

The study method involved deploying a masters level depression specialist to collaborate with the patient's primary care physician (PCP) with the goal of improving patient adherence to medical therapy for depression. The specialist also educated both the PCP and the patient's family about the issues involved. A "depression care manager" provided general treatment recommendations for all study patients. The manager did not make specific recommendations for individual patients.

Dr. Bogner presented data showing the relationship between random practice assignment, patient baseline depression status, and mortality at a 4-year follow-up interval.

The adjusted hazard ratio for intervention vs usual care was 0.69 (95% confidence interval [CI], 0.46 - 1.05) for depressed patients. For not-depressed patients, the adjusted hazard ratio was 1.20 (95% CI, 0.90 - 1.60). Hazard ratio estimates were adjusted for baseline age, education level, suicidal ideation, and smoking. Dr. Bogner also presented survival curves for depressed (n = 279) and nondepressed (n = 338) patients that clearly demonstrated improved survival among the latter.

The study concluded that depressed patients in practices implementing depression care management were less likely to die during a 4-year period than were depressed patients in usual-care practices.

Dr. Bogner interpreted these findings for Medscape. "Depression care management in primary care can not only reduce disability, which we've known, but it can have an impact on mortality. That's the significance of our findings. Nobody has looked at that."

Attendee Paul Hunter, MD, from the Milwaukee Program of All Inclusive Care for the Elderly (PACE) in Wisconsin, praised the study's methodology but questioned the "real-world" application.

"I think the practical part of splitting it up between practices is good, because that is more of a real-life comparison, so that you had one person, an MSW or whatever, at each site. Comparing the sites rather than the individual patients made it more real world," Dr. Hunter told Medscape.

"But it's hard to get my head around whether or not it would really make a difference, and how you would transition that to get paid for it, in the real world. Although I think if you had a therapist, it's a little bit easier to get paid for. If you're looking at the practice management point of view, you might be able to break even on it," Dr. Hunter said.

Support for this study was provided by the National Institutes of Mental Health. Dr. Bogner is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar.

AGS Annual Scientific Meeting: Abstract P9. Presented May 4, 2006.

Reviewed by Carol Peckham

    
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