1986年至2006年间4个年份唐山市精神分裂症住院患者抗精神病药物使用变化趋势

目的 分析近20年精神分裂症住院患者抗精神病药物治疗种类和剂量变化趋势.方法 调查1986年、1996年、2001年和2006年4个年份在唐山市6所精神病院出院的2 718例精神分裂症患者的3 195份住院病历,用专门设计的调查表记录患者的社会人口学资料、疾病特征以及患者出院时药物治疗信息.结果 ①治疗药物的变化:1986年、1996年、2001年和2006年最常使用的抗精神病药物分别是第一代抗精神病药物、氯氮平、氯氮平、除氯氮平外的第二代抗精神病药物,使用率分别为93.8%(396/422)、45%(285/634)、59.9%(557/930)、51.6%(623/1206).2006年氯氮平使用率达35.7%(431/1206).4个年份间患者出院时合并使用2种以上抗精神病药物治疗的比例旱升高趋势(趋势X~2=99.10,P＜0.001),从1986年的10.43%(44/422)渐升至2006年的26.29%(317/1209).②药物剂量变化:4个年份出院时患者服用抗精神病药物的氯丙嗪等效日剂量组间比较差异有统计学意义(Kruskal-Wallis X~2=43.32,P＜0.001),4个年份的出院患者日服药剂量随年份增长而呈下降趋势(Spearman R=-0.13,P＜0.001);抗精神病药的单一治疗日剂量低于合并治疗,差异有统计学意义(Kruskal-Wallis X~2=14.23,P＜0.001).③多元回归分析表明,患者出院时服用抗精神病药物的氯丙嗪等效剂量与抗精神病药物联合治疗(b=163.86,P＜0.001)、住院大数(b:25.76,P＜0.001)呈正相关;与使用第二代抗精神病药物(b=-114.92,P＜0.001)、发病年龄(b=-3.87,P＜0.001)呈负相关.结论 近20年第二代抗精神病药物已逐渐成为抗精神病治疗的主要用药,抗精神病药合并治疗的比例增加.临床实践中应考虑到氯氮平一直保持较高使用率的利弊和合并用药可能带来的药物不良反应.     

抗精神病药的不良反应

编辑:本期精神药物不良反应的综合报告共收集10篇稿件,由7个单位17位作者所撰写。1抗精神病药致锥体外系反应(EPS)钱峰,陈兵,洪涛,沐杭军:锥体外系反应(EPS)是抗精神病药最常见的不良反应之一,会影响治疗的依从性,2种药物联用时较易引起。现收集本院的住院病历中2种抗精神病药联用的患者就EPS的问题作分析。共300份,其中2种第二代抗精神病药联用者79例,于用药后2～40d有22例出现EPS(占27.8%);2种第一代抗精神病药联用者65例,于3～27d后有30例出现EPS(占46.2%);第一代与第二代抗精神病药合用者156例,于2～34d后有112例出现EPS(占71.7…     

苏州市精神分裂症患者抗精神病药物使用现况调查

目的:调查苏州市精神分裂症患者抗精神病药物使用现况。方法:采用患者药物使用调查表,对苏州市3家精神疾病专科医院的544例住院和门诊精神分裂症患者进行抗精神病药物使用情况调查。结果:使用居前6位的抗精神病药物分别是氯氮平(25.6%)、利培酮(16.5%)、奥氮平(13.9%)、奎硫平(11.4%)、阿立哌唑(9.1%)、氯丙嗪(6.8%)。门诊和住院患者抗精神病药物使用频率存在差异(χ2=37.361,P=0.003)。门诊患者氯氮平、利培酮、奥氮平、奎硫平、阿立哌唑、氯丙嗪、奋乃静、帕利哌酮的使用剂量低于住院患者;舒必利、齐拉西酮、氟哌啶醇使用剂量高于住院患者(P均0.01)。单一抗精神病药治疗的比率(54.4%,293例)高于联合药物治疗(45.6%,246例);单一药物治疗者中84.2%(247例)使用第2代抗精神病药(SGAs);联合用药者中97.8%(241例)主要抗精神病药物及65.0%(160例次)次要药物为SGAs;最常合并使用的药物是镇静催眠药(20.2%)、心境稳定剂(12.2%)、抗胆碱能药(12.1%)、抗抑郁药(7.8%)和β-受体阻断剂(4.3%)。结论:单一用药和选择SGAs是苏州市精神分裂症患者药物治疗的主要方式。     

住院精神分裂症患者抗精神病药物联合治疗的处方调查

目的了解住院精神分裂症患者抗精神病药物联合治疗(APP)的情况,为精神分裂症的临床用药提供参考。方法连续入组2014年1月1日-12月31日在广州医科大学附属脑科医院住院的精神分裂症患者,收集患者的社会人口学资料,使用临床总体印象量表-病情严重程度量表(CGI-SI)评估患者疾病严重程度,在患者出院日记录抗精神病药物的使用情况,比较接受单一抗精神病药物治疗患者(单药组)与接受APP患者(APP组)的临床特点,描述APP中具体抗精神病药物的使用情况。结果共入组801例住院精神分裂症患者,其中364例(45.4%)使用APP。与单药组相比,APP组发病年龄更小、本次住院时间和总病程更长、住院次数更多,差异均有统计学意义(P均0.05)。APP组中78.0%的患者为同时使用两种第二代抗精神病药物(SGA),常见的联用方式为利培酮(47.3%)、氯氮平(44.5%)和奥氮平(40.1%)联合另一种抗精神病药物。结论住院精神分裂症患者中,接受APP方案的患者发病较早且病程迁延;两种SGA联用是APP中最常见的疗法,APP方案中使用频率最高的药物依次为利培酮、氯氮平和奥氮平。     

10省市抗精神病药使用现况的调查

目的调查中国10省市精神药物治疗精神分裂症的使用现状.方法按人均国内生产总值将各省分为五个经济发展等级,以一定的抽样比例,选择10个省市的46家精神疾病专科医院或综合医院精神科的4 779例住院和门诊精神分裂症患者,于2002年5月20～24日用自制调查问卷进行精神分裂症药物治疗的现况调查.结果 (1)在4 779例患者中,门诊为1 969例(41.20%),住院为2 810例(58.80%).与门诊患者比较,住院患者中的男性患者比例高、年龄大、病程长、公费医疗比例高(均P<0.01).(2)使用频率在前六位的药物依次是氯氮平、利培酮、舒必利、氯丙嗪、奋乃静和氟哌啶醇.换算为氯丙嗪等效剂量后,治疗剂量为12.5～4 125 mg/d,平均(365±253)mg/d.其中住院患者的使用剂量[(409±274)mg/d]高于门诊患者[(300±201)mg/d;F=223,P<0.01].(3)2 617例次(54.99%)使用典型抗精神病药,2 940例次(61.78%)使用非典型抗精神病药(包括氯氮平在内).312例接受长效抗精神病药.3 523例(74.03%)接受单一抗精神病药治疗,1 236例(25.97%)联合使用2种及其以上抗精神病药.(4)常见的合并治疗药物有抗胆碱能药、β-受体阻断剂、苯二氮NFDA3类药、抗抑郁药和心境稳定剂.结论国内精神分裂症药物处方方式逐渐以非典型抗精神病药占主流,经济负担和患者的症状表现对精神药物的处方方式影响较大.     

第二代抗精神病药致静坐不能的研究进展

目前第二代抗精神病药物(SGAs)广泛用于各类精神病治疗,与第一代抗精神病药物(FGAs)比较,引起锥体外系副反应(EPSEs)比较少[1],但是SGAs并不是没有EPSEs,通常认为与FGAs有关EPSEs也同样与SGAs有关联.在所有的EPSEs里,本文着重关注静坐不能,一个抗精神病药物和其他一些药物引起的最常见的、致残的药物副反应之一[2].本文对第二代抗精神病药物所致静坐不能的发生率、病理生理学、最新的治疗进展等文献作一综述,以提高对静坐不能的重视.     

住院未成年精神疾病患者抗精神病药物使用情况调查

目的调查2018年广州医科大学附属脑科医院住院未成年精神疾病患者抗精神病药物使用情况。方法通过电子住院信息系统收集2018年广州医科大学附属脑科医院所有住院年龄≤18岁且确诊为精神疾病的患者的临床、人口学和出院当日使用抗精神病药物情况,进行统计和分析。结果共入组626例未成年精神疾病患者,出院时93例(14.9%)患者未使用抗精神病药物,92例(14.7%)患者接受两种抗精神病药物联合治疗,441例(70.4%)患者使用一种抗精神病药物治疗;双相障碍(233例)、抑郁症(124例)、精神分裂症(108例)是诊断频率最高的三种精神疾病,其抗精神病药物使用率为别为94.0%、74.2%和99.1%。使用频率最高五种抗精神病药物依次为喹硫平、奥氮平、阿立哌唑、利培酮和帕利哌酮;双相障碍和抑郁症使用频率最高的抗精神病药物为喹硫平,精神分裂症最常使用奥氮平;儿童组患者最常使用阿立哌唑,青少年组患者最常使用喹硫平;男性患者最常使用奥氮平,女性患者最常使用喹硫平。儿童组患者阿立哌唑、利培酮和喹硫平剂量显著低于青少年组,男女两组间抗精神病药物剂量无显著差异。结论大部分住院未成年精神疾病患者在出院时接受单种抗精神病药物治疗,不同诊断抗精神病药物使用种类不同,不同年龄组抗精神病药物使用种类、剂量不同。     

老年精神病人诊治分析

目的了解住院老年精神病人诊疗情况及应对措施。方法采取定点调查法,于2014-07-23记录在我院住院的105例老年精神病人当日用药与康复等治疗情况。结果诊断主要为精神分裂症占39.05%,老年痴呆占42.86%,老年性情感障碍占16.19%;合并躯体疾病者65例(61.90%)。105例患者均参与康复治疗,其中单一用药69例,合并用药36例。以抗精神病药治疗为主,83例使用第二代抗精神病药,1例使用第一代抗精神病药。结论加强老年性精神病的诊断和治疗,同时关注合并躯体疾病的治疗,在药物治疗的同时,加强康复治疗和心理治疗,可改善老年患者的各种功能,提高生活质量。     

2006年我国十省市抗精神病药处方方式的现况调查

目的 调查2006年我国10省市抗精神病药处方方式;分析4年间我国抗精神病药处方方式的变化趋势.方法 按照作者2002年的调查方法,选择10省市41所精神疾病专科医院或综合医院精神科的5898例精神分裂症门诊和住院患者,于2006年5月22-28日使用自制修订的调查问卷进行精神分裂症处方方式的现况调查.结果 (1)5898例患者中,门诊患者为2716例(46.0%);住院患者为3182例(54.0%);男3041例(51.6%),女2803例(47.5%),缺失54例数据.(2)99.1%的患者接受了抗精神病药治疗,使用频率在前7位的药物依次为:氯氮平(31.7%),利培酮(30.5%),舒必利(14.5%),氯丙嗪(10.8%),奋乃静(9.2%)、喹硫平(7.2%),氟哌啶醇(5.8%).换算为氯丙嗪等效剂量后,住院患者平均药物剂量显著高于门诊患者.(3)72.7%的患者使用第2代抗精神病药治疗;第1代抗精神病药的使用频率为38.3%;6.19%的患者接受了长效药物治疗.(4)75.6%的患者接受了单一非长效抗精神病药治疗;24.4%的患者联合使用2种或2种以上抗精神病药.(5)54.1%的患者联合了抗胆碱能药、苯二氮革类、β-受体阻断剂、抗抑郁药和心境稳定剂,主要用于控制不良反应或增效治疗.结论 第2代抗精神病药已经成为我国治疗精神分裂症的主流药物,反映出精神分裂症治疗理念和治疗技术的进展.     

346例住院患者抗精神病药物使用情况分析

目的了解住院患者抗精神病药使用情况,为临床医生规范、合理、安全使用精神科药物提供参考。方法采用整群抽样抽取我院接受抗精神病药物治疗的住院患者346例,其中普通收治患者198例,城市流浪救治患者148例;男性188例,女性158例,年龄(46.22±14.50)岁,住院时间为(7.91±9.84)年。结果单一用药252例(72.8%),合并用药94例(27.2%);合并用药中,氯氮平联合利培酮使用率达33.0%,高于其他合并用药组合。单一用药的患者平均年龄低于合并用药患者[(44.92±14.74)岁vs.(49.72±13.30)岁,P=0.001],且住院时间也较合并用药患者短[(6.72±9.54)年vs.(11.10±9.96)年,P=0.006],单一用药患者中救治患者多于普通患者(135例vs.117例,P=0.008),而合并用药患者中普通患者多于救治患者(81例vs.13例,P=0.008)。结论我院住院患者的用药特点以单一用药为主,少数合并用药,而合并用药则为联合一种药物。     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.     

Un nouveau cadre conceptuel de travail pour une psychiatrie revisitée ? Introduction à deux articles de E. Kandel

In two articles which appeared in the American Journal of Psychiatry and that were subsequently translated for Évolution Psychiatrique, E. Kandel examines the bases for a reinterpreted psychiatry that is prepared to confront the major challenge of the 3rd millenium: that of insight into the mind and brain. This requires a major reorganization of the discipline, which involves a reinvestment of the scientific approach and a critical  assessment of the data provided by psychoanalytical psychiatry and cognitive neurosciences. Seven concepts have therefore been proposed for interactive re-examination: consciousness, the unconscious, memory, emotion, development, desire, impulse. The dynamic relations existing between genetics and the environment allow one to see how evolutions are possible from actions at different levels, both psychotherapeutic and pharmacological. Imaging and other techniques provide additional objective information to the process of human interaction which remains the basis of psychiatry. A common framework for psychiatry and the neurosciences, a reconsideration and renewal of the psychoanalytical approach are both possible and necessary.     

Opioids and the developing organism: A comprehensive bibliography, 1984–1988

A comprehensive bibliography of the literature concerned with opioids and the developing organism for 1984-1988 is presented. Utilized with companion papers (Neurosci. Biobehav. Rev. 6:439-479; 1982; 8:387-403; 1984), these articles cover the clinical and laboratory references beginning in 1875. For the years 1984, 1985, 1986, 1987, and 1988, a total of 877 citations were recorded. A series of indexes accompanies the citations in order to make the literature more accessible. These indexes are divided into clinical and laboratory topics, and subdivided into such topics as the type of opioid explored and the general area of biological interest (e.g., physiology).     

La biologie et le futur de la psychanalyse : un nouveau cadre conceptuel de travail pour une psychiatrie revisitée

The American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Facteurs de risque environnementaux à la schizophrénie

Schizophrenia is currently a major concern, its prevalence being estimated at around 1% and its social consequences being severe. The elucidation of the pathophysiology of the disease is difficult due to the great variability of clinical expressions, the instability of the clinical symptoms during the evolution and the absence of reliable biological markers. The existence of a familial aggregation in schizophrenia is well known, the risk of presenting the disease for first-degree relatives of patients being 5 to 10 times higher than the risk observed in the general population. The genetic component was further confirmed by twin and adoption studies. Although the concordance for the disease is higher (40 to 70%) among monozygotic twins as compared with dizygotic twins (15%) it does not reach 100%, which implies that environmental factors modulate the effects of the genotype. However, the role of these factors and especially their interaction with genetic factors remain unclear but the implications of some specific environmental factors are well documented by recent research data. The current literature on sex differences in schizophrenia is consistent. Several studies have suggested that male and female patients may differ in age at the onset and expression of clinical symptoms. Complications during pregnancy or birth-giving may increase the risk of developing schizophrenia later in life. The major complications are oxygen deprivation during pregnancy, bleeding, maternal malnutrition or infection (exposure to influenza, for example). A low birth weight is associated with an increased risk of schizophrenia. Psychoses are more common among people living in an urban environment and among those born during winter months. Schizophrenia is probably more prevalent in people who are living promiscuously, are subject to toxic abuse, poor nutrition and stress but here more precise data are needed. Moreover, immigrants have a higher risk of developing psychotic disorders. In addition, head traumas are associated with an increased risk of schizophrenia. Though they are contentious, some studies suggest that substance abuse (cannabis use in European countries) is related to the development of schizophrenia, especially in people with genetic vulnerability. Moreover, substance misuse may worsen the symptoms. If the environment is sufficiently stressful, people with a high genetic vulnerability will develop some degree of mental illness, including schizophrenia. Conversely, a less stressful or a protective environment may decrease the risk of its onset in persons with a predisposition to schizophrenia.