奎硫平辅助治疗抑郁症的临床疗效及安全性研究

目的探讨奎硫平合并抗抑郁药治疗抑郁症的疗效及安全性。方法将60名抑郁症患者随机分为合并奎硫平治疗组和对照组，合并奎硫平治疗组在原抗抑郁药物治疗的基础上合并使用奎硫平，对照组继续使用原抗抑郁药物，疗程为4周。入组时及入组第1、2、3、4周末对患者进行汉密顿抑郁量表（HAMD-17）、汉密顿焦虑量表（HAMA）、副反应量表（TESS）评定。结果合并奎硫平组共完成25例，1例在加用50mg奎硫平后出现双下肢水肿，故退出研究。1例在治疗过程中出现严重精神病性症状，在治疗第1周由研究者中止研究。2例在第2周脱落，1例在第四周时脱落。治疗第1周末起两组HAMD、HAMA总分差异有统计学意义（P〈0．01），合并奎硫平组低于对照组。研究组总有效率为83．3％，痊愈与显效占56．7％，对照组分别为50％和20％。研究组与对照组疗效存在显著差异。研究组出现不良反应共13例（43．3％），1例因服用50mg奎硫平后出现双下肢水肿而退出研究，其余均为可疑或极轻到中度。对照组共12例（40％）出现不良反应。结论奎硫平合并抗抑郁药治疗抑郁症是1种有效且相对安全的治疗方法。     

临床痊愈在抑郁症治疗中的意义及用药选择

抑郁症是一种常见、慢性且容易复发的精神疾病,发病率较高,在全世界范围内8％～12％在一生中会患有抑郁症。抑郁症会给患者带来极大的健康负担和经济负担,同时也会严重影响患者的社会功能和生活质量。世界卫生组织预计,至2020年抑郁症会成仅次于缺血性心脏病的全球第二大影响伤残调整生命年（disability—adjusted lif eyear,DALY）的疾病。     

A cost utility analysis of treating different adult spinal deformity frailty states

The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states.     

Heat-shock protein-70 genes and response to antidepressants in major depression

In the search of predictors of antidepressant efficacy, much interest has recently focused on pro-inflammatory proteins, as they were found to be elevated during major depressives states and decreased by antidepressant drugs. In the present paper we investigated the role of the genes coding for heat-shock-70 family proteins, recently hypothesized to be activated by antidepressants and thus mediate the reduction of pro-inflammatory cytosines. One hundred and forty two hospitalised patients, affected by major depression and treated with antidepressants drugs for a major depressive episode were evaluated for depressive severity at the baseline and at the discharge and genotyped for five SNPs within the genes HSPA1L, HSPA1A and HSPA1B. Markers were not individually associated with symptom severity after treatment. Instead, we found a three markers haplotype, including SNPs within HSPA1L and HSPA1A, associated with a poorer response to antidepressant treatment (p=0.005). Single markers as well as haplotypes were not associated with other clinical features. In conclusion, genetic variants within the genes coding for HSP-70 family proteins may affect the action of antidepressants and thus their therapeutic efficacy.     

Differential effects of the antidepressants tranylcypromine and fluoxetine on limbic cannabinoid receptor binding and endocannabinoid contents

The goal of this study was to determine whether the endocannabinoid system is altered by chronic antidepressant treatment. The effects of 3-week administration of the monoamine oxidase inhibitor, tranylcypromine (10 mg/kg) and the selective serotonin reuptake inhibitor, fluoxetine (5 mg/kg) on cannabinoid CB₁ receptor densities and endocannabinoid contents were determined in limbic brain regions of the rat. Tranylcypromine significantly reduced tissue content of the endocannabinoid N-arachidonylethanolamine (anandamide) in the prefrontal cortex, hippocampus and hypothalamus and increased 2-arachidonoylglycerol content in the prefrontal cortex. Tranylcypromine treatment significantly increased CB₁ receptor binding density in the prefrontal cortex and hippocampus, but not in the hypothalamus. Treatment with fluoxetine increased CB₁ receptor density in the prefrontal cortex, but had no effect on endocannabinoid contents in any brain region examined. These data suggest that monoaminergic neurotransmission can regulate the endocannabinoid system and further indicates a role of the endocannabinoid system in affective illness and its treatment. An erratum to this article can be found at     

卒中后抑郁新的病因假说——谷氨酸能障碍

卒中后抑郁（post-stroke depression,PSD）是卒中后常见的神经精神症状之一,以心境低落、 兴趣下降为主要特征,不仅影响患者神经功能的康复,而且显著增加卒中病死率。其发病机制尚未 明确,伴随离子型谷氨酸受体拮抗剂氯胺酮的快速抗抑郁作用的出现,谷氨酸（glutamate,Glu）能神 经系统在抑郁症及PSD中的作用日益突出,也为抗抑郁治疗带来新的契机。     

早期合用丁螺环酮对抗抑郁剂西酞普兰所致性功能障碍的影响

目的：观察早期合用丁螺环酮对抗抑郁剂西酞普兰所致性功能障碍的影响.方法本研究为随机、双盲、前瞻性研究,纳入天津市复员退伍军人精神病疗养院就诊的200例首发抑郁症患者,按随机数字表分为丁螺环酮组(85例,西酞普兰＋丁螺环酮)和安慰剂组(91例,西酞普兰＋安慰剂),采用HAMD、HAMA、亚利桑那性体验量表(ASEX)在就诊时,治疗第2,4,6,8周时对两组患者进行评估,比较两组患者的一般资料、抑郁、焦虑及性功能障碍情况.结果两组患者在年龄、文化程度、性别方面比较,差异无统计学意义(P ＞0．05);丁螺环酮组8周末时 HAMD 评分显著低于安慰剂组,差异有统计学意义(P ＜0．05);丁螺环酮组第2,4,6及8周末 ASEX 评分别低于安慰剂组,差异有统计学意义(P ＜0．05);两组患者第2,4,6及8周末时 HAMD、HAMA 及 ASEX 评分与就诊时比较,差异有统计学意义(P ＜0．05);丁螺环酮组女性第2,4,6及8周末 ASEX 评分显著低于安慰剂组,差异有统计学意义(P ＜0．05).结论丁螺环酮可改善抗抑郁剂西酞普兰所致的性功能障碍程度,尤其是女性首发抑郁症.     

丁螺环酮对抗抑郁剂的增效作用

目的：对抗抑郁剂合用丁螺环酮治疗抑郁的疗效进行临床研究。方法：符合中国精神障碍分类与诊断标准第3版抑郁发作诊断标准的患者86例，单用抗抑郁剂治疗8周。将疗效不佳的45例分为两组，一组继续原抗抑郁剂治疗，另一组在原抗抑郁剂治疗基础上合用丁螺环酮。疗程8周。以汉密尔顿抑郁量表(HAMD)、副反应量表(TESS)评定疗效和不良反应。结果：8周末合用组的HAMD评分均比各单用组明显下降。两组的TESS评分相仿。结论：丁螺环酮合用抗抑郁剂治疗抑郁症具有良好的协同疗效，不增加不良反应。     

Pain and Depression: A Neurobiological Perspective of Their Relationship

Remarkable progresses have been achieved regarding the understanding of the neurobiological bases of pain and depression. The principal role of neurotransmitters, neuromodulators, and neurohormones has been proposed in the development of pain and depression. With the progression of molecular biology, an intricate interaction among biological factors accountable to the development and management of pain and depression has been also shown in a numerous preclinical and clinical researches. This mini-review will briefly describe the current issues and future research direction for better understanding of the relationship between pain and depression.     

Chronic pain and major depressive disorder in the general population

This study aims (1) to assess the prevalence of Chronic Painful Physical Condition (CPPC) and major depressive disorder (MDD) in the general population; (2) to evaluate their interaction and co-morbidity with sleep and organic disorders; and (3) to investigate their daily functioning and socio-professional consequences. A random sample of 3243 subjects (?18 years), representative of California inhabitants, was interviewed by telephone. CPPC duration was at least 6 months. Frequency, severity, duration and consequences on daily functioning, consultations, sick leave and treatment were investigated. MDD were assessed using DSM-IV criteria. The point prevalence of CPPC was 49% (95% confidence interval: 47.0-51.0%). Back area pain was the most frequent; 1-month prevalence of MDD was at 6.3% (95% CI: 5.5-7.2%); 66.3% of MDD subjects reported at least one CPPC. In 57.1% of cases, pain appeared before MDD. Pain severity was increased by poor sleep, stress and tiredness in MDD subjects. Being confined to bed, taking sick leave and interference of pain with daily functioning were twice as frequent among MDD subjects with CPPC than in non-MDD subjects with CPPC; obese individuals with CP were 2.6 times as likely to have MDD. Pain is highly linked with depressive disorder. It deteriorates physical, occupational and socio-professional activities. Pain and sleep disturbances are a prime motive of consultation rather than depressed mood, underlining the risk of missing a depression diagnosis.     

Impact of comorbidities on the cost of depression drug therapy in general practices in Germany

BackgroundThe goal of this study was to analyze the impact of comorbidities on the cost of antidepressant drug therapy in patients with depression treated in German general practices (GPs).MethodsThe present study included 31,741 patients diagnosed with depression and treated with antidepressant drugs in 2015. Demographic data included age, gender, and type of health insurance coverage. Twenty comorbidities were included. The study sample was stratified by age, gender, type of health insurance coverage, type of comorbidity, and number of comorbidities. The annual antidepressant treatment cost per patient was calculated based on pharmacy sale prices. The multivariate regression analysis was fitted to estimate the adjusted treatment cost differences.ResultsThe annual cost of antidepressant drugs was €107 in the population. It was similar in men and in women (difference of €1) but was significantly higher in individuals with private health insurance coverage than in people with public health insurance coverage (difference of €63). The annual cost increased with age, from €85 in patients aged 40 years or younger to €116 in patients aged between 61 and 70 years (difference of €11), and with the number of comorbidities, from €78 when there was no comorbidity to €134 when there were more than 5 comorbidities (difference of €57).ConclusionThe cost of antidepressant treatment in Germany increased with the number of comorbidities.     

Management of knee osteoarthritis in primary care: pain and depression are the major obstacles

OBJECTIVES: Osteoarthritis (OA) management is a challenge, as OA consists of a spectrum of pathologies requiring a multifaceted treatment approach. Patient education programmes (PEP) are attractive, as they may be cost effective and potentially efficacious.The goals of the study were to determine what may hinder the efficacy of a PEP for knee OA by determining the relevance of depression, pain, disease knowledge and physical ability in patients to their response to a PEP. METHODS: Clinical and demographic data relating to 170 patients who completed a trial of a PEP were analysed to determine how they interrelate during patient management. RESULTS: All patients showed a progressive decrease in mental health over the duration of the study (P<.001). Greater pain was associated with reduced coping, increased depression and reduced physical ability (P<.05). Women were more likely to experience disability (P<.05). Disability was associated with reduced ability to cope, increased depression and the experience of more pain (P<.05). Subjects with a Caucasian background were significantly (P<.05) more likely to possess knowledge of OA than other ethnic groups. The lowest knowledge group experienced more pain; the highest knowledge group was coping better and had less depression (P<.05). CONCLUSION: A complex interrelationship between depression, pain, disease knowledge, and physical ability in patients with knee OA has been demonstrated. Specifically, the treatment of depression and pain may be paramount to the successful treatment of knee OA, and these factors should be considered in each patient and management priorities made.     

Alexithymia in fibromyalgia syndrome: Associations with ongoing pain, experimental pain sensitivity and illness behavior

Objective

Alexithymia, a lack of emotional awareness, is common in chronic pain patients. The aim of the study was to investigate the relationship of alexithymia to ongoing pain, experimental pain sensitivity, and illness behavior in patients with chronic musculoskeletal pain.

Methods

Sixty-eight women with fibromyalgia (age: average, 43.4 years; range, 19-72 years) completed self-report measures on alexithymia (20-Item Toronto Alexithymia Scale), ongoing pain [Visual Analogue Scale, Questionario Italiano del Dolore (QUID), Margolis], psychological distress (Center for Epidemiology Studies—Depression Scale, State-Trait Anxiety Inventory Form Y), and illness behavior (Illness Behavior Questionnaire). Psychophysical tests were performed to assess experimental pain sensitivity, including pain thresholds for mechanical (von Frey, tender point count) and thermal (heat, cold) stimuli, and cold pressor pain threshold and tolerance.

Results

Alexithymia “difficulty identifying feelings” (DIF) was related to higher ratings of the affective—but not the sensory—dimensions of ongoing pain (QUID) and to a lower cold pressor pain tolerance, while alexithymia scores were independent of all pain thresholds. Multiple regression demonstrated that alexithymia DIF ceased to uniquely predict affective ongoing pain when psychological distress or illness behavior was separately controlled for. Higher alexithymia DIF scores were predictive of hypochondriacal illness behavior, over and above what was explained by psychological distress and affective pain.

Conclusion

Alexithymia is associated with increased affective pain and hypochondriacal illness behavior. The former relationship is better explained, and possibly mediated, by psychological distress and illness behavior. The hypothesis of a generally increased sensitivity to unpleasant stimuli in alexithymic chronic pain patients is not supported by the data.     

Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: design and practical implications of an intervention for comorbid pain and depression

OBJECTIVE: Depression and pain are common comorbid conditions that have reciprocal adverse effects on disability and treatment outcomes. The objective of this article is to describe a study that tests the effectiveness of a stepped-care approach using a combined medication-behavioral intervention. METHOD: Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) is an NIMH-sponsored randomized clinical trial nested within a prospective cohort study. A total of 250 patients with clinically significant depression (PHQ-9 scores > or =10) and musculoskeletal pain of the lower back or legs (hip or knee) and 250 nondepressed patients with similar pain are enrolled, with baseline and serial follow-up assessments to be conducted over 12 months. The depressed patients are randomized to either a stepped-care intervention group or a usual-care control group. Stepped-care patients receive 12 weeks of optimized antidepressant management (Step 1) followed by six sessions of a pain self-management (PSM) program over the next 12 weeks (Step 2), all delivered by a nurse care manager who is supervised by a physician specialist. Approximately two thirds of the care manager contacts are by telephone. RESULTS: The target sample of 500 subjects has been successfully enrolled, and randomization of the depressed patients has resulted in balanced groups of patients with moderately severe pain and depression. Mean SCL-20 depression severity in the clinical trial group is 1.9, with most meeting DSM-IV criteria for major depression (76.3%) and the rest having dysthymia only (18.4%) or minor depression (5.3%). Pain is about equally distributed between lower back (53%) and hip or knee (47%). A rational algorithmic approach to antidepressant selection and dosing, as well as an overview of the PSM program, is provided. CONCLUSIONS: When completed, SCAMP will test whether optimized antidepressant management improves outcomes in patients with comorbid depression and pain and whether PSM produces additional benefits. The findings will be important for both primary care and mental health clinicians confronted by the prevalent depression-pain dyad.     

The relationship of alexithymia to pain severity and impairment among patients with chronic myofascial pain: comparisons with self-efficacy,catastrophizing, and depression

OBJECTIVE: Alexithymia is elevated among patients with chronic pain, but the relationship of alexithymia to the severity of pain among chronic pain patients is unclear. Also, studies have rarely examined whether alexithymia is unique from other, more widely studied constructs in the chronic pain literature (i.e., self-efficacy, catastrophizing, and depression), and research has not examined how alexithymia relates to the sensory versus affective dimensions of pain. METHODS: Among 80 patients with chronic myofascial pain, we tested how alexithymia (Toronto Alexithymia Scale-20) was related to three competing constructs--self-efficacy, catastrophizing, and depression--and to the sensory and affective dimensions of pain as well as physical impairment. We then determined whether alexithymia remained correlated with pain and impairment when tested simultaneously with each of the three competing constructs. RESULTS: Analyses controlled for patients' sex, age, marital status, and duration of pain. Alexithymia was moderately correlated with less self-efficacy and greater catastrophizing, and substantially correlated with greater depression. Alexithymia was positively related to both affective pain and physical impairment, but was unrelated to sensory pain, whereas all three of the competing constructs were related to both types of pain as well as physical impairment. Regression analyses indicated that alexithymia remained a significant and independent correlate of affective pain severity while controlling for either self-efficacy or catastrophizing, but depression accounted for alexithymia's relationship with affective pain. Also, alexithymia was no longer related to physical impairment, after controlling for any of the other three constructs. CONCLUSION: Although alexithymia is not related to the sensory component of pain, it is correlated positively with the affective or unpleasantness component of pain, independent of self-efficacy or catastrophizing. The emotional regulation deficits of alexithymia may lead to depression, which appears to mediate alexithymia's relationship to affective pain. Alexithymia's relationship with physical impairment appears to be better accounted for by self-efficacy or catastrophizing.