焦虑和抑郁障碍共病的临床现象学及心理社会因素和生物学研究

背景在当前的诊断分类标准中焦虑障碍和抑郁障碍是相互独立的两个疾病单元,但临床研究和流行病学研究均发现两者具有很高的共患率,焦虑和抑郁障碍共病与单纯焦虑或抑郁障碍相比具有症状重、病程慢性化、社会功能损害重、自杀率高和预后差等特征.认识焦虑和抑郁障碍共病的临床现象学、心理社会因素和生化学的特征,对介入临床康复干预措施具有理论指导意义.目的探讨焦虑和抑郁障碍共病的临床现象学、心理社会因素和生化学的特征,以阐明它与焦虑障碍和抑郁障碍的关系.设计以诊断为依据的病例-对照,研究. 单位两所大学医院的精神科.对象 1999- 11/2000- 11在南京医科大学脑科医院住院的患者.按 DSM IV诊断标准收集25例焦虑和抑郁障碍共病患者(共病组)、 30例主要抑郁症患者(抑郁组)、14例广泛性焦虑障碍和 6例惊恐障碍患者(焦虑组). 方法对所有病例使用一般情况问卷、病史问卷、汉密顿抑郁量表(HAMD)、汉密顿焦虑量表( HAMA)、生活事件量表( LES)、社会支持评定量表(SSRS)、艾森克个性问卷( EPQ)进行调查评定,并作血浆单胺类神经递质( 5羟色胺、去甲肾上腺素)测定.上述指标进行三组间比较或与中国常模比较.主要观察指标各组患者的一般情况、病史情况、 HAMD,HAMA,LES,SSRS,EPQ的评定结果和血浆5 羟色胺、 NE水平. 结果①共病组年龄 [(46.4± 9.2)岁 ]较抑郁组 [(37.4±11.3)岁 ]和焦虑组 [(34.7± 7.4)岁 ]大、起病晚( P< 0.01).②共病组急性起病者(13例)显著多于抑郁组( 9例)和焦虑组( 2例)( P< 0.01).③共病组的家族史(8例)与抑郁组( 10例)相似( P >0.05).④共病组( 23例)的自杀意念或行为的发生率显著高于焦虑组( 6例)( P< 0.01).⑤共病组的HAMD评分( 42.32± 7.26)显著高于抑郁组( 30.70± 7.69)和焦虑组( 22.20± 6.18)(P< 0.01).⑥共病组的 HAMA评分( 27.48± 7.23)显著高于抑郁组( 18.07± 6.20)和焦虑组(23.00± 6.84)( P< 0.01).⑦共病组的起效时间 [(12.4± 7.5) d]与抑郁组 [(11.7±8.0) d]和焦虑组 [(9.6± 6.7) d]的差异无显著性( P >0.05);共病组的显效时间[(52.2± 21.2) d]稍长于抑郁组 [(62.2± 17.1) d]( P >0.05),但显著长于焦虑组[(32.9± 20.6) d]( P< 0.01).而共病组出院时的显效率( 92%)与抑郁组( 87%)和焦虑组(85%)的差异无显著性( P >0.05).⑧共病组的负性生活事件评分( 22.1±15.7)与抑郁组( 26.7± 16.8)、焦虑组( 29.8± 19.6)差异无显著性( P >0.05).⑨共病组的社会支持分(43.5± 7.9)显著高于抑郁组( 36.2± 8.5)( P< 0.01),而与焦虑组( 39.9± 9.3)差异无显著性(P >0.05).⑩共病组和抑郁组、焦虑组一样, EPQ的神经质因子分均显著高于中国常模(P< 0.05～ 0.01). {11} 共病组存在着血浆单胺神经递质的异常,但与抑郁组、焦虑组均无显著差异(P >0.05). 结论焦虑和抑郁障碍共病具有不同于抑郁障碍和焦虑障碍的特征,但目前的证据尚不足以证明焦虑和抑郁障碍共病是一种新的疾病单元.

Study of clinicalphenomenology, psychosocial factor and biology of comorbid anxiety and depression

BACKGROUND:Anxiety and depression are two independent disease units in current diagnostic classification criteria;however,both clinical and epidemiological researches find that there is a very high comorbidity of these two disorders.Comorbid anxiety and depression(CAD) has the features of serious symptoms, chronic course of the disease,severe social functional lesion,high suicide rate and poor prognosis,etc.in the comparison with simple anxiety or depression. To understand the clinical phenomenological,psychosocial and biological characters of CAD has significance in the theoretical instruction for clinical intervention and rehabilitation. OBJECTIVE:To explore the clinical phenomenological, psychosocial and biochemical characters of CAD,and to clarify the relationship between CAD and simple depression or anxiety disorder. DESIGN:A case controlled trial based on diagnosis. SETTING:Department of psychiatry of two hospitals affiliated to university. PARTICIPANTS:Twenty five patients with CAD(CAD group),30 patients of major depression disorder(depression group),14 patients of generalized anxiety disorder and 6 patients with panic disorder(anxiety group) were selected from the patients admitted by the Brain Hospital affiliated to Nanjing Medical University from November 1999 to November 2000 according to the diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders(DSM IV). INTERVENTIONS:All the patients were interviewed with common data and case history questionnaire,Hamilton rating scale for depression(HAMD),Hamilton rating scale for anxiety(HAMA),life event scale(LES),social support rating scale(SSRS) and Eysenck personality questionnaire(EPQ).Plasma monoamine neurotransmitters[5 hydroxytryptamine(5 HT),noradrenaline(NA)] were detected as well. The above indicators were compared among the three groups or compared with the Chinese norm. MAIN OUTCOME MEASURES:General condition, case history, evaluation results of HAMD,HAMA,LES,SSRS and EPQ,plasma levels of 5 HT and NA in the patients of each group. CONCLUSION:CAD has some different characteristics from simple major depression or simple anxiety disorder;however,current evidences are not enough to prove that CAD is a new independent disease unit.