精神病性抑郁症的临床处理

对精神病性抑郁症的临床诊断和处理进行归纳总结。     

非典型抗精神病药用于难治性抑郁症

本文介绍了难治性抑郁症的一般概念及处理方法，重点在于非典型抗精神病药在难治性抑郁症中的治疗效果、不良反应及可能的机制。     

非典型抗精神病药对难治性抑郁症的治疗作用

目的：探讨非典型抗精神病药合并抗抑郁药治疗不伴精神病性症状的难治性抑郁症的疗效和不良反应。方法：将75例患者随机平分为利培酮组（25例）,奥氮平组（25例）,奎硫平组（25例）,均合并使用同样剂量的氟西汀。疗程8周。采用汉密尔顿抑郁量表（HAMD）、社会功能缺陷筛选量表（SDSS）,在治疗前及治疗1、2、4、8周各测定1次;并在治疗前及治疗8周测血常规、肝功能、体质量及治疗中出现的症状量表（TESS）、锥体外系反应量表（RSESE）。以HAMD减分率评定疗效,比较3组的不良反应。结果：利培酮组、奥氮平组和奎硫平组的显效率分别为44％、88％、76％,奥氮平组和奎硫平组的疗效要好于利培酮组。均未出现严重的不良反应,奎硫平组不良反应最小。结论：非典型抗精神病药合并氟西汀治疗不伴精神病性症状的难治性抑郁症疗效好,起效较快,安全,不良反应少。     

舒必利治疗抑郁症临床对照研究

舒必利治疗抑郁症临床对照研究徐文英，昂慧玲，郁宇，王丛杰，唐玉和编者按：舒必利系抗精神病药物，近报告兼有抗抑郁作用，提出对抑郁症治疗有效。现报道两篇，均以舒必利治疗抑郁症，并以阿米替林为对照，均获相当疗效，可供参考。但这一结果尚待进一步临床实践证实。...     

非典型抗精神病药用于难治性抑郁症

本文介绍了难治性抑郁症的一般概念及处理方法 ,重点在于非典型抗精神病药在难治性抑郁症中的治疗效果、不良反应及可能的机制     

非典型抗精神病药治疗难治性抑郁症

抑郁症是一种高患病率、高复发率的严重精神疾患。在临床上约有30％—50％的抑郁症患者使用抗抑郁药物治疗没有疗效或疗效不完全,严重影响了患者及其家庭的正常生活。难治性抑郁症已成为近年来精神医学研究热点之一。     

无抽搐电休克治疗致窦性心动过缓者的药物使用研究

目的　研究无抽搐电休克(MECT)引起窦性心动过缓患者的药物使用情况。方法　将∧康摹⊙芯课蕹榇さ缧菘?MECT)引起窦性心动过缓患者的药物使用情况。方法　将MECT通电后出现窦性心动过缓,频率低于50次/min的患者为窦缓组,高于 50 次/min的患者为对照组,每组各22例。对两组MECT前3天用药的方式,频度,剂量进行调查和比较。结果　(1)窦缓组和对照组,单一用药分别为9例(41%)和17 例(77%),联合用药分别为 13 例(59%)和 5 例(23%),差异有非常显著性(χ2 值=11.08,P <0.01)。(2)两组使用频度在前5位的药物依次为:氟哌啶醇(29%),SSRI类(22%),氯氮平(20%),氯丙嗪(18%),舒必利(16%)。(3)精神药物使用剂量:窦缓组为 150~1 750 mg/d,平均(573±483)mg/d;对照组为 50~1 150 mg,平均(322±235)mg,差异有非常显著性(t =4.99,P <0.001)。结论　临床在MECT治疗前宜单一用药,小剂量维持,避免大剂量或联合用药,防止出现窦性心动过缓。     

抗抑郁药联合使用治疗难治性抑郁症的临床研究进展

抑郁症是一常见的精神障碍,多呈慢性、复发性病程。目前,药物治疗仍然是最常用治疗方法。然而,有些患者对单一抗抑郁药物系统治疗反应不佳,即通常所称的难治性抑郁症(TRD)。针对TRD的治疗已有多种疗法,其中之一为抗抑郁药物的联合治疗,即同时用两种或以上的抗抑郁药物治疗,如米氮平联合SSRIs等。本文就目前抗抑郁药联合治疗TRD的研究进展进行综述。     

文拉法辛联合治疗方案对难治性抑郁症疗效的随机对照研究

Objective To compare the efficacy of venlafaxine combination of cognitive behavior therapy or lithium or olanzapine for treatment-resistant depression. Method A prospective stratified randomized controlled clinical trial were adopted to the patients with treatment-resistant depression. 69 cases were divided into three groups with random number table, each group including 23 cases. One group was with venlafaxine combination of cognitive behavior therapy, others with combination of lithium, or olanzapine, for 6 weeks to observe the efficacy. The major indexes for therapeutic effects was Hamilton Depression Scale (HAMD) reducing score rate. Results The differences were significant in HAMD reducing score rate between the group with combination of cognitive behavior therapy[(61±5) %] and the group with combination of lithium [( 54 ± 7 ) %] ( t = 8.90, P < 0. 05 ), or olanzapine [( 47 ± 6 ) %] ( t =3.46,P < 0.05 ), with no significant difference is between the group with combination of lithium and the group with combination of olanzapine. Conclusion The total efficacy of venlafaxine combination of cognitive behavior therapy is superior to venlafaxine combination of lithium or olanzapine for treatmet-resistant depression.     

抗精神病药治疗抑郁症的机制探讨

对第2代抗精神病药作为抗抑郁药的增效剂治疗难治性抑郁症的机制进行探讨.     

抑郁症首次发病患者情绪加工特征及抗抑郁剂治疗前后的变化

目的 探讨首次发病(以下简称首发)抑郁症情绪加工特征及抗抑郁剂治疗前后变化与症状改善的关联作用.方法 17例抑郁症首发患者治疗前后及22名对照者完成情绪词识别任务.患者组抗抑郁剂治疗9周,以汉密尔顿抑郁量表(17项,HAMD)评估疗效.结果 (1)患者组治疗有效率为88%,HAMD总分减分率75%.(2)情绪词识别任务:抑郁症组治疗前后正性词遗漏数[分别为(7.4±6.9)个和(4.1±5.3)个]均大于负性词遗漏数[分别为(3.2±3.3)个和(1.8±2.7)个;P＜0.05),治疗后正性词遗漏数小于治疗前(P=0.002),与对照组[(3.0±2.6)个]差异无统计学意义(P=0.44);治疗前后负性词遗漏数[分别为(3.2±3.3)个和(1.8±2.7)个]与对照组[(2.1±2.4)个],以及正负性词错判数与对照组差异均无统计学意义(P＞0.05);正性词平均反应时治疗后[(514±68)ms]短于治疗前[(550±75)ms;P=0.036],负性词平均反应时治疗前后[分别为(540±80)ms和(521±61)ms]差异无统计学意义(P=0.16).(3)治疗前正性词遗漏数与抑郁症状和负性思维评分正相关(r=0.36～0.50,P＜0.05).(4)治疗前后正、负性词遗漏数变化对HAMD分数变化有不同预测作用(r_( chang) ~2=0.45,P=0.002).结论首发抑郁症患者可能存在正性情绪加工缺陷,治疗后可恢复至正常水平;以负性情绪加工占优势的认知结构不因抑郁症状缓解而改变;正负性情绪加工变化与症状改善可能有不同的关联作用.     

The association between antidepressant use and depression eight years later: a national cohort study

Investigations of the effects of antidepressant treatment for individuals with major depression have focused on short-term outcomes in individuals that meet very specific criteria; however, there is limited knowledge about long-term outcomes associated with antidepressant use in general population samples. This study aimed to investigate the long-term outcomes associated with antidepressant use by focusing on 486 depressed adults in a prospective observational Canadian cohort in 1998/99. We used logistic regression to investigate the association between antidepressant use and depression status 8 years later. Non-random allocation to treatment was accounted for by a propensity-for-treatment model which included thirteen predictors of antidepressant use, including: severity of depressive symptoms, previous episodes of depression (from 1994 to 1997), physical health condition, social support and socio-demographic characteristics. 29% of individuals with major depression reported antidepressant use. After adjusting for propensity for treatment in 1998/99, and antidepressant use from 2000 to 2007, depressed individuals who reported antidepressant use in 1998/99 were less likely to be depressed in 2006/07 compared to those who did not report antidepressant use (OR = 0.36, 95% CI: 0.15-0.88). Amongst individuals with symptoms of major depression, those reporting use of anti-depressants at baseline exhibited improved long-term outcomes in comparison to those who did not report treatment.     

阈下改良电休克治疗抑郁症的疗效和安全性评估

目的评估20%和40%电量的阈下低电量改良电休克治疗(modified electroconvulsive therapy,MECT)对抑郁症的疗效和安全性。方法本研究为随机对照研究;根据Excel中RAND程序制定随机数字表,对符合DSM-Ⅳ抑郁症诊断标准的108例患者分为20%电量组、40%电量组、80%电量组(对照组),每组36例;3组均给予MECT治疗8次,第1周每日1次,治疗5次;第2周隔日1次,治疗3次;访视点分别为基线、首次治疗后4~8 h内、末次治疗后4~8 h内及治疗开始后的第4周、第8周。分别采用HAMD17、重复成套神经心理状态测验(Repeatable Battery for the Assessment of Neuropsychological Status,RBANS)评估患者抑郁症状和认知功能,采用重复测量方差分析和单因素方差分析进行统计比较。结果(1)HAMD17(F=10.769,P<0.05)和RBANS(F=6.961,P<0.05)得分组间主效应均有统计学意义。(2)HAMD17(F=3.450,P<0.05)和RBANS(F=2.501,P<0.05)得分时间×电量分组交互作用均有统计学意义。(3)末次治疗后(F=3.673,P<0.05)、4周(F=4.570,P<0.05)、8周(F=4.122,P<0.05)HAMD17得分组间效应均有统计学意义,20%与40%电量组比较有统计学意义(P<0.05),20%及40%电量组与对照组比较均无统计学意义(P>0.05)。(4)末次治疗后,RBANS得分(F=7.890,P<0.05)组间效应有统计学意义,20%电量组[(65.2±12.2)分]、40%电量组[(63.9±11.5)分]与对照组[(55.2±11.2)分]比较差异均有统计学意义(P<0.05);而8周时RBANS得分(F=2.770,P>0.05)组间效应无统计学意义。结论40%电量MECT治疗抑郁症与标准电量相比疗效无差异,20%电量与标准电量相比疗效差,但认知功能损伤均较轻。     

Psykiatriska synspunkter på problemet dold kriminalitet och anonyma brottslingar,med särskild hänsyn till exhibitionism

Background: Electroconvulsive therapy, ECT, is an effective acute treatment for severe depression. Today ECT is usually discontinued when the patient's depressive symptoms abate, although relapse is common. Some studies suggest that continuation ECT (cECT) may prevent relapse of depression, but there are few studies available. Aims: The aim of this study was to describe the need for inpatient care before, during and after cECT. Methods: A retrospective chart review was conducted of all patients (n=27) treated with cECT between 2005 and 2007 at Örebro University Hospital, Sweden. All patients were severely depressed at the initiation of index ECT. The DSM-IV diagnoses were major depression (n=19), bipolar depression (n=5) or schizoaffective depression (n=3). Results: The hospital day quotient was lower (HDQ=15) during cECT (mean duration±standard deviation=104±74 days) than during the 3 years prior to cECT (HDQ=26). The rehospitalization rate was 43% within 6 months and 58% within 2 years after the initiation of cECT. Seven patients were rehospitalized while on cECT. Conclusion: The need for inpatient care was reduced during cECT. However, rehospitalization was common. At the initiation of the cECT, the patients were improved by the index ECT. Also cECT was often terminated after rehospitalization, which contributed to the lowered hospital day quotient during cECT. Randomized clinical trials are needed to establish the efficacy of cECT. Clinical implications: Relapses and recurrences in depressed patients are common after ECT treatment. The results indicate that continuation ECT combined with pharmacotherapy might be an alternative treatment strategy.     

伴与不伴焦虑症状的难治性抑郁症临床特征的比较

目的 探讨伴焦虑症状的难治性抑郁症的临床特征.方法 将327例难治性抑郁症患者,按照17项汉密尔顿抑郁量表(HAMD17)焦虑/躯体化因子≥7分,分为焦虑组(229例)和无焦虑组(98例),比较2组患者的人口学特征和临床特征;对伴焦虑症状的危险因素进行Logistic回归分析.结果 焦虑组平均年龄、首发年龄、HAMD17总分、汉密尔顿焦虑量表(HAMA)总分高于无焦虑组[(42.58±11.77)岁vs(36.78±11.84)岁,(34.60±11.66)岁vs(30.04±12.60)岁,(27.83±6.93)分vs(23.39±5.59)分,(21.11±6.61)分vs(13.88±4.68)分],差异有统计学意义(P＜0.01).焦虑组和无焦虑组性别(男:女,OR=0.51)、有无强迫症状(OR=3.67)、未成年和成年发病的构成比(OR=0.36)的差异有统计学意义(P＜0.01).年龄(OR=1.05)、HAMD17总分(OR=1.17)、有自杀观念(OR=2.70)和强迫症状(OR=4.59)与难治性抑郁症伴焦虑症状相关(P＜0.05).结论 伴焦虑症状的难治性抑郁症患者具有年龄较大、女性倾向较高、首发年龄较晚、成年发病的倾向较高、抑郁程度更严重、更可能伴强迫症状等特点;年龄、抑郁严重程度、自杀观念和强迫症状可能是难治性抑郁症伴焦虑症状的危险因素.     

西酞普兰治疗抑郁症的疗效及安全性的多中心临床研究

目的系统了解西酞普兰治疗抑郁症的疗效及安全性。方法采用多中心、开放性研究,对5052例抑郁症患者(单纯抑郁症4683例,伴发躯体疾病161例,伴发强迫症112例,双相抑郁96例)进行可变剂量西酞普兰治疗,剂量为10～80mg/d,共观察8周。分别在治疗前及治疗第2,4,6,8周末以汉密尔顿抑郁量表(17项,HAMD)总分减分率评价疗效,描述性记录不良反应。结果治疗第8周末,HAMD总分平均减分率达(81.1±16.8)%。5052例中3697例(73.18%)的患者达到临床痊愈标准。伴发躯体疾病、伴发强迫症及双相抑郁患者的病情均获显著改善,后两者第8周的平均治疗剂量[(28.5±10.9)mg/d,(26.9±11.7)mg/d]均明显高于单纯抑郁症患者[(24.5±9.1)mg/d],而伴发躯体疾病患者[(22.4±7.8)mg/d]的平均治疗剂量则低于单纯抑郁症患者,差异均有统计学意义(P<0.05)。病程短、首次发作及年龄<45岁患者的疗效明显优于病程较长、反复发作及≥45岁患者。治疗过程中西酞普兰的主要不良反应为中枢神经系统和消化系统反应,症状轻微,多出现于治疗早期。结论西酞普兰安全有效,可用于治疗抑郁症或其他疾病伴发的抑郁症。     

抑郁症患者治疗前后血清脑源性神经营养因子水平变化及相关因素分析

目的 探讨抑郁症患者血清脑源性神经营养因子(BDNF)水平及其变化与负性生活事件、抑郁症发病及治疗效应的关系.方法 采用横断面的病例-对照及前瞻性自身对照设计.对所有抑郁症患者给予抗抑郁治疗(包括抗抑郁药和改良电抽搐治疗),并随访治疗8周;采用酶联免疫吸附法测定63例抑郁症患者(抑郁症组)治疗前和治疗第2,4,8周末及80名正常对照(以下简称对照组)血清BDNF水平,并评定汉密尔顿抑郁量表(HAMD)和生活事件量表.结果 抑郁症组治疗前血清BDNF水平[(24±14)μg/L]显著低于对照组[(36±15)μg/L](t=-4.863,P=0.000),并与病前1年负性生活事件刺激值、治疗前HAMD总分均显著负相关(r=-0.331,P=0.008;r=-0.343,P=0.006),而后两者有相互正相关(r=0.292,P=0.020);治疗第2周末血清BDNF水平仍显著低于对照绢(t=-5.990,P=0.000),并与其抑郁症状严重度平行负相关(r=-0.269,P=0.033),且其血清BDNF增加率与HAMD减分率平行正相关(r=0.252,P=0.047);治疗第4,8周末血清BDNF水平均显著高于治疗前(经ISD检验,P=0.000;P=0.005),与对照组的差异均无统计学意义(P均＞0.05).治疗第2,4,8周末HAMD总分渐减并均低于治疗前(P均=0.001),且其HAMD平均减分率渐升(分别为40%,66%和74%).结论血清BDNF低下与负性生活事件、抑郁症发病密切相关,血清BDNF升高可能为抗抑郁治疗临床疗效的重要指标之一.     

A Cluster Model of Temperament as an Indicator of Antidepressant Response and Symptom Severity in Major Depression

Objective

Not enough is known about which patients suffering from major depressive disorder benefit from antidepressant drug treatment. Individual temperament is relatively stable over a person''s lifespan and is thought to be largely biologically predefined. We assessed how temperament profiles are related to depression and predict the efficacy of antidepressant treatment.

Methods

We recruited one hundred Finnish outpatients (aged 19 to 72) suffering from major depressive disorder, of whom 86 completed the 6-week study. We assessed their temperament features with the Temperament and Character Inventory and used cluster analysis to determine the patient''s temperament profile. We also categorized the patients according to the vegetative symptoms of major depressive disorder.

Results

There was an association between skewed temperament profile and severity of major depressive disorder, but the temperament profiles alone did not predict antidepressant treatment response. Those with higher baseline vegetative symptoms score had modest treatment response. Our model with baseline Montgomery Åsberg Depression Rating Scale (MADRS) vegetative symptoms, age and temperament clusters as explanatory variables explained 20% of the variance in the endpoint MADRS scores.

Conclusion

The temperament clusters were associated both with severity of depression and antidepressive treatment response of depression. The effect of the temperament profile alone was modest but, combined with vegetative symptoms of depression, their explanatory power was more marked suggesting that there could be an association of these two in the biological basis of MDD.     

喹硫平治疗老年抑郁症的对照研究

目的 探讨喹硫平治疗老年抑郁症的疗效和安全性.方法 将60例符合CCMD-3诊断标准的老年抑郁症患者随机分为二组,分别使用喹硫平和帕罗西汀治疗,疗程8周.用汉密尔顿抑郁量表(HAMD)、临床疗效总量表(CGI-SI)评定疗效,以治疗中出现的症状量表(TESS)评定不良反应.结果 治疗8周末,两组的HAMD、CGI-SI...