Davidson Karina W, Rieckmann Nina, Clemow Lynn, Schwartz Joseph E, Shimbo Daichi, Medina Vivian, Albanese Gabrielle, Kronish Ian, Hegel Mark, Burg Matthew M
Department of Medicine, Columbia University College of Physicians and Surgeons, PH9 Center, 622 W 168th St, Room 948, New York, NY 10032, USA.
Arch Intern Med. 2010 Apr 12;170(7):600-8. doi: 10.1001/archinternmed.2010.29.
Depressive symptoms are an established predictor of mortality and major adverse cardiac events (defined as nonfatal myocardial infarction or hospitalization for unstable angina or urgent/emergency revascularizations) in patients with acute coronary syndrome (ACS). This study was conducted to determine the acceptability and efficacy of enhanced depression treatment in patients with ACS.
A 3-month observation period to identify patients with ACS and persistent depressive symptoms was followed by a 6-month randomized controlled trial. From January 1, 2005, through February 29, 2008, 237 patients with ACS from 5 hospitals were enrolled, including 157 persistently depressed patients randomized to intervention (initial patient preference for problem-solving therapy and/or pharmacotherapy, then a stepped-care approach; 80 patients) or usual care (77 patients) and 80 nondepressed patients who underwent observational evaluation. The primary outcome was patient satisfaction with depression care. Secondary outcomes were depressive symptom changes (assessed with the Beck Depression Inventory), major adverse cardiac events, and death.
At the end of the trial, the proportion of patients who were satisfied with their depression care was higher in the intervention group (54% of 80) than in the usual care group (19% of 77) (odds ratio, 5.4; 95% confidence interval [CI], 2.2-12.9 [P < .001]). The Beck Depression Inventory score decreased significantly more (t(155) = 2.85 [P = .005]) for intervention patients (change, -5.7; 95% CI, -7.6 to -3.8; df = 155) than for usual care patients (change, -1.9; 95% CI, -3.8 to -0.1; df = 155); the depression effect size was 0.59 of the standard deviation. At the end of the trial, 3 intervention patients and 10 usual care patients had experienced major adverse cardiac events (4% and 13%, respectively; log-rank test, chi(2)(1) = 3.93 [P = .047]), as well as 5 nondepressed patients (6%) (for the intervention vs nondepressed cohort, chi(2)(1) = 0.48 [P = .49]).
Enhanced depression care for patients with ACS was associated with greater satisfaction, a greater reduction in depressive symptoms, and a promising improvement in prognosis.
clinicaltrials.gov Identifier: NCT00158054.
抑郁症状是急性冠状动脉综合征（ACS）患者死亡率和主要不良心脏事件（定义为非致命性心肌梗死、因不稳定型心绞痛住院或紧急/急诊血运重建）的既定预测指标。本研究旨在确定强化抑郁治疗对ACS患者的可接受性和疗效。
先进行为期3个月的观察期以识别患有ACS且有持续抑郁症状的患者，随后进行为期6个月的随机对照试验。从2005年1月1日至2008年2月29日，招募了来自5家医院的237例ACS患者，其中包括157例持续抑郁患者，随机分为干预组（最初患者倾向于问题解决疗法和/或药物治疗，然后采用逐步护理方法；80例患者）或常规护理组（77例患者），以及80例非抑郁患者进行观察性评估。主要结局是患者对抑郁护理的满意度。次要结局是抑郁症状变化（用贝克抑郁量表评估）、主要不良心脏事件和死亡。
试验结束时，干预组中对抑郁护理满意的患者比例（80例中的54%）高于常规护理组（77例中的19%）（优势比，5.4；95%置信区间[CI]，2.2 - 12.9[P <.001]）。干预组患者的贝克抑郁量表评分下降幅度显著更大（t(155) = 2.85[P =.005]）（变化值，-5.7；95%CI，-7.6至-3.8；自由度 = 155），高于常规护理组患者（变化值，-1.9；95%CI，-3.8至-0.1；自由度 = 155）；抑郁效应大小为标准差的0.59。试验结束时，3例干预组患者和10例常规护理组患者发生了主要不良心脏事件（分别为4%和13%；对数秩检验，卡方(2)(1) = 3.93[P =.047]），还有5例非抑郁患者（6%）（干预组与非抑郁队列相比，卡方(2)(1) = 0.48[P =.49]）。
对ACS患者进行强化抑郁护理与更高的满意度、更大程度的抑郁症状减轻以及预后的有望改善相关。试验注册：clinicaltrials.gov标识符：NCT00158054。
