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.     

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。     

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。     

抗精神病药对精神分裂症首次发病患者听感觉门控P50的影响

目的探讨抗精神病药对精神分裂症首次发病患者听感觉门控电位P50的影响。方法采用配对听觉条件（S1）、测试（S2）刺激范式，对33例未经抗精神病药治疗的精神分裂症首次发病患者（患者组），给予第一代和第二代抗精神病药治疗，分别于治疗前、治疗6周后进行听觉诱发电位P50检测，并与30名健康成年人（对照组）对照。结果（1）治疗前，患者组S1波幅[（1．86±0．90）μV]低于对照组[（2．79±1．70）μV]，波幅比值S2／S1（1．03±0．61）高于对照组（0．46±0．26），差异均有统计意义（P〈0．05～0．01）；两组s2波幅及潜伏期的差异均无统计意义。（2）治疗6周后，患者组P50检测结果与治疗前相比，差异均无统计意义。（3）与第一代抗精神病药相比，第二代抗精神病药能提高S1波幅（P〈0．05）。结论精神分裂症患者治疗前已存在P50抑制异常，经两类抗精神病药治疗6周仍未能明显改善；与第一代抗精神病药相比，第二代抗精神病药治疗可提高S1波幅。     

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.     

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.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.