RESUMO
OBJECTIVE: The Personalized Intervention for Depressed Patients with Chronic Obstructive Pulmonary Disease (PID-C) is an intervention aiming to help patients adhere to their rehabilitation and care. This study tested the hypothesis that the Problem-Solving Adherence (PSA) intervention, which integrates problem-solving into adherence enhancement procedures, reduces dyspnea-related disability more than PID-C. Exploratory analyses sought to identify patients with distinct dyspnea-related disability trajectories and to compare their clinical profiles. METHODS: In this randomized controlled trial in an acute inpatient rehabilitation and community, 101 participants diagnosed with chronic obstructive pulmonary disease (COPD) and major depression were included after screening 633 consecutive admissions for acute inpatient rehabilitation. Participants underwent 14 sessions of PID-C versus PSA over 26 weeks using the Pulmonary Functional Status and Dyspnea Questionnaire. RESULTS: The study hypothesis was not supported. Exploratory latent class growth modeling identified two distinct disability trajectories. Dyspnea-related disability improved in 39% of patients and remained unchanged in the rest. Patients whose dyspnea-related disability improved had more severe disability and less sense of control over their condition at baseline. CONCLUSION: Improvement or no worsening of disability was noted in both treatment groups. This is a favorable course for depressed patients with a severe, deteriorating medical illness. PID-C is compatible with the expertise of clinicians working in community-based rehabilitation programs, and after further testing in the community, it can be integrated in the care of depressed COPD patients.
Assuntos
Terapia Comportamental/métodos , Transtorno Depressivo Maior/reabilitação , Dispneia/reabilitação , Avaliação de Processos e Resultados em Cuidados de Saúde , Cooperação do Paciente , Resolução de Problemas , Doença Pulmonar Obstrutiva Crônica/reabilitação , Adulto , Comorbidade , Transtorno Depressivo Maior/epidemiologia , Dispneia/epidemiologia , Feminino , Humanos , Masculino , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles. DESIGN: Randomized controlled trial. SETTING: Acute inpatient rehabilitation and community. PARTICIPANTS: A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation. INTERVENTION: Fourteen sessions of PID-C versus PSA over 26 weeks. MEASUREMENTS: 24-item Hamilton Depression Rating Scale. RESULTS: PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores. CONCLUSIONS: Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions. .
Assuntos
Transtorno Depressivo Maior/terapia , Doença Pulmonar Obstrutiva Crônica/reabilitação , Idoso , Idoso de 80 Anos ou mais , Ansiedade/psicologia , Transtorno Depressivo Maior/complicações , Transtorno Depressivo Maior/psicologia , Dispneia/etiologia , Dispneia/psicologia , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Neuroticismo , Resolução de Problemas , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/psicologia , Autoeficácia , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
OBJECTIVE: We developed a personalized intervention for depressed patients with COPD (PID-C) aimed to mobilize patients to participate in the care of both conditions. We showed that PID-C reduced depressive symptoms and dyspnea-related disability more than usual care over 28 weeks. This study focused on untangling key therapeutic ingredients of PID-C. DESIGN: Randomized controlled trial. SETTING: Community. PARTICIPANTS: 138 patients who received the diagnoses of COPD and major depression after screening 898 consecutive admissions for acute inpatient pulmonary rehabilitation. INTERVENTION: Nine sessions of PID-C compared with usual care over 28 weeks. MEASUREMENTS: Primary outcome measures were the 17-item Hamilton Depression Rating Scale and the Pulmonary Functional Status and Dyspnea Questionnaire-Modified. Other measures were adherence to rehabilitation exercise (≥2 hours per week) and adherence to adequate antidepressant prescriptions. RESULTS: Low severity of dyspnea-related disability and adherence to antidepressants predicted subsequent improvement of depression. Exercise and low depression severity predicted improvement of dyspnea-related disability. CONCLUSIONS: PID-C led to an interacting spiral of improvement in both depression and disability in a gravely medically ill population with a 17% mortality rate over 28 weeks and an expected deterioration in disability. The interrelationship of the course of depression and dyspnea-related disability underscores the need to target adherence to both antidepressants and chronic obstructive pulmonary disease rehabilitation. PID-C may serve as a care management model for depressed persons suffering from medical illnesses with a deteriorating course.
Assuntos
Transtorno Depressivo Maior/complicações , Medicina de Precisão/métodos , Doença Pulmonar Obstrutiva Crônica/psicologia , Idoso , Idoso de 80 Anos ou mais , Antidepressivos/uso terapêutico , Transtorno Depressivo Maior/terapia , Feminino , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/terapia , Testes de Função Respiratória , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Chronic obstructive pulmonary disease (COPD) is often complicated by depression and exemplifies the challenge in managing chronic illnesses that require active patient participation in care. In a clinical trial (NCT00151372), we compared a novel personalised intervention for depression and COPD (PID-C) targeting treatment adherence with treatment as usual (TAU). In 138 patients with major depression and severe COPD, PID-C led to a higher remission rate and a greater reduction in depressive symptoms and in dyspnoea-related disability than TAU over 28 weeks and 6 months after the last session. If replicated, PID-C may serve as a care model for patients with both depression and medical illnesses with a deteriorating course.
Assuntos
Transtorno Depressivo Maior/tratamento farmacológico , Conhecimentos, Atitudes e Prática em Saúde , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/reabilitação , Adulto , Transtorno Depressivo Maior/complicações , Transtorno Depressivo Maior/psicologia , Progressão da Doença , Dispneia/prevenção & controle , Humanos , Análise de Intenção de Tratamento , Método de Monte Carlo , Cooperação do Paciente/psicologia , Escalas de Graduação Psiquiátrica , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Indução de Remissão , Análise de SobrevidaRESUMO
BACKGROUND: COPD is a major cause of all-cause mortality. We examined predictors of 1-year mortality in patients with severe COPD and major depression after inpatient treatment in a rehabilitation hospital. METHODS: We screened 898 consecutively admitted patients. Of these, 138 patients received the diagnoses of COPD according to American Thoracic Society Guidelines and major depression by Diagnostic and Statistical Manual of Mental Disorders, 4th edition and signed consent; 67 were randomized to a treatment adherence enhancement intervention and 71 to usual care. We assessed history of falls, dyspnea-related disability, severity of depression, medical burden, and cognitive functioning. Following discharge from inpatient rehabilitation, participants were prospectively followed, and mortality was ascertained over 52 weeks from hospital notes and reports of primary care physicians and relatives. RESULTS: One-year, all-cause mortality was 22% (31 of 138). Multivariate Cox regression analysis showed that history of falls in the 6 months preceding hospital admission was the strongest predictor of mortality (OR, 3.05; 95% CI, 1.40-6.66; P < .005). Dyspnea during activities (Pulmonary Functional Status and Dyspnea Questionnaire-Modified domain) was also associated with mortality (OR, 1.05; 95% CI, 1.02-1.08; P < .002). Depression severity, medical burden, and cognitive impairment were not predictors of mortality. CONCLUSIONS: Recent falls and dyspnea during activities identify subgroups of depressed patients with COPD at increased risk for all-cause mortality. These subgroups are in need of clinical attention and follow-up and can serve as targets for prevention research aiming to inform clinical strategies and public health planning.
Assuntos
Transtorno Depressivo Maior/mortalidade , Admissão do Paciente , Doença Pulmonar Obstrutiva Crônica/mortalidade , Centros de Reabilitação , Acidentes por Quedas/mortalidade , Idoso , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Transtorno Depressivo Maior/etiologia , Transtorno Depressivo Maior/reabilitação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/etiologia , Doença Pulmonar Obstrutiva Crônica/reabilitação , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: Approximately 30% of patients with chronic obstructive pulmonary disease (COPD) experience depression. Pulmonary rehabilitation for COPD focuses on physical conditioning, but includes behavioral interventions that may address depressive symptoms. This study tested the hypothesis that brief inpatient pulmonary rehabilitation is followed by improvement in both depressive symptoms and function in patients with COPD with major depression. METHODS: The subjects, who were recruited from the pulmonary rehabilitation unit of the Burke Rehabilitation Hospital in White Plains, NY, who had COPD and major depression were consecutively admitted patients to a pulmonary rehabilitation unit. Symptoms of depression, disability, medical burden, the experience of support, and satisfaction with treatment were systematically ascertained on admission and before discharge. RESULTS: Three hundred sixty-one patients were screened and 63 met criteria for COPD and major depression. Depressive symptoms improved by discharge (z = -6.785, p <0.0001); median length of stay was 16 days. Approximately 51% of subjects met criteria for response (50% or greater reduction in depressive symptoms scores from baseline), and 39% met criteria for remission (final Hamilton Depression scale score equal to or less than 10). History of treatment for depression was associated with limited change in depressive symptoms, whereas social support and satisfaction with treatment were predictors of improvement. All disability domains were lower at discharge compared to baseline (z = -3.928, p <0.0001). Subjects with pronounced disability at baseline had the greatest improvement if their depression improved by discharge. CONCLUSIONS: Acute inpatient rehabilitation is followed by improvement of depressive symptoms and disability in older patients with COPD and major depression. Improvement of depression may be the result of behavioral interventions rather than the use of antidepressant drugs.