认知行为治疗对脑卒中后抑郁、神经功能缺损的疗效观察

目的研究认知行为治疗对脑卒中后抑郁、神经功能缺损康复的作用。方法将脑卒中患者随机分为治疗组、对照组，治疗组在常规治疗基础上给予认知行为治疗，对照组给予常规治疗，于治疗前、治疗第4周后分别进行神经功能缺损和HAMD抑郁量表评分。结果共348例脑卒中患者，其中，治疗组197例，对照组151例；神经功能缺损评分显示：治疗前两组无差异，治疗4周后与治疗前比较，两组评分有极显著性差异（P〈0．001）；4周后治疗组神经功能缺损评分较对照组显著性改善（t=2．044，P=0．045）。治疗组的PSD发生率为23．35％，对照组为34．44％，前者显著低于后者（X^2=66．391，P〈0．001）。结论认知行为治疗可显著改善患者的神经功能，并降低PSD的发生率。     

Toward a framework for best practices and research guidelines for perinatal depression research

This review article highlights the current state of perinatal depression (PND) research including established standards of care and innovative research in progress. PND can have a significant adverse impact on mother, child, and family; however, to date, wide-scale identification, prevention, and treatment have been limited. PND is heterogenous in presentation with likely multifactorial etiologies for each woman. Challenges in PND research are discussed including a need for universal tools, standardized measures, benchmarks, and best practices. Current examples are reviewed that highlight approaches to novel treatment paradigms and interventions. This includes reviewing epidemiologic studies in PND research, examining the biological underpinnings of PND, and discussing examples from this field and other fields currently developing translational research that spans from bench to bedside. Current and future challenges and opportunities in developing best practices for the treatment of PND are outlined. We also discuss the use of the NIMH Research Domain Criteria approach for PND research and provide recommendations for future directions in PND research collaboration. In conclusion, greater precision in perinatal psychiatry can be possible in the future with the development of guidelines and best practices that build on current work and apply innovative and collaborative approaches of scientists, providers, patients, community members, and government officials.     

Diagnosis and treatment of older adults with depression in primary care.

This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.     

Lack of evidence for elevated obstetric complications in childhood onset schizophrenia.

BACKGROUND: Pre-, peri-, and postnatal obstetric complications (OC) are reported to be more frequent in adult patients with schizophrenia and have been linked to both greater severity and to "earlier" age of onset (before either age 18 or 22) in studies of adult patients. We hypothesized that by extrapolation, patients with childhood-onset schizophrenia (COS), with very early onset and very severe illness, would have had more numerous or more salient OC compared with their healthy siblings. METHODS: We compared the obstetric records of 60 COS children and 48 healthy siblings using the Columbia Obstetrics Complication Scale, a comprehensive measurement scale consisting of 37 variables having included a separate scale for fetal hypoxia. RESULTS: Patients with COS did not have a higher incidence of OC than the healthy sibling control group with the exception of increased incidence of maternal vomiting. CONCLUSIONS: Obstetric complications, with the possible exception of maternal vomiting, are unlikely to play a major role in the etiopathogenesis of childhood-onset schizophrenia.     

Older adults' attitudes toward depression screening in primary care settings and exploring a brief educational pamphlet

Objectives

This study aimed to assess older adults' (OAs') attitudes toward depression screening in primary care settings with a survey and explore the impact of an educational pamphlet on these attitudes.

Methods

Older adults above age 55 (N = 140) were randomly stratified by sex to an intervention or control group. The study included a baseline assessment, posttest, the Geriatric Depression Scale‐Short Form, a two‐page pamphlet on health and mood, and a 10‐question quiz.

Results

On the basis of survey responses, most participants (93.6%) were willing to complete a depression screen at their doctor's office, and 92.1% perceived depression screening as valuable to their health care. Participants rated the Geriatric Depression Scale‐Short Form positively. The survey also provided information on how screening could be conducted in primary care settings to maximize OAs' comfort. Participants preferred screening in the waiting room or examination room instead of the nurse's station. Those receiving the pamphlet became significantly more willing to be screened for depression than those who did not, F(1, 134) = 4.47, p = 0.04.

Conclusion

Most OAs appear receptive to completing a depression screen in primary care settings. Educating OAs about the value of depression screening and tailoring recognition systems to account for preferences may be an initial step in improving recognition rates. Copyright © 2017 John Wiley & Sons, Ltd.     

围产期卒中

常见的围产期卒中的三个主要亚型为动脉性缺血性卒中（arterial ischemic stroke,AIS）、大脑静脉窦血栓形成（cerebral venous sinus thrombosis,CVST）和出血性卒中（hemorrhagic Stroke,HS）。围产期是人生卒中相对高发的特殊时期,据估计围产期AIS的发病率在17～43.4/10万活产;新生儿期CVST的发病率在41/10万活产;足月婴儿HS的发病率为6.7/10万活产。癫发作是新生儿卒中急性期最常见的表现;在急性期过后,可能会遗留认知障碍和感觉损害、脑瘫（运动功能障碍）和癫等后遗症。由于无明显或无特定的临床表现,围产期卒中的临床诊断主要依赖超声和神经影像学的诊断。对围产期卒中的流行规律、发病机制、诊断、治疗、预防和康复的认识,急待进一步研究。     

不同频度服用氟西汀持续治疗抑郁症的对照研究

目的比较不同频度服用氟西汀持续治疗抑郁症的效果。方法将45例治愈后的抑郁症患者随机平分为每日1次、每周2次及每周1次服用氟西汀三个组，并持续治疗24周。分析服药依从性、复发情况以及采用汉密顿抑郁量表(HAMD)及不良反应量表(TESS)分别评定疗效及不良反应。结果每日1次组4例停药；每周2次组1例停药、2例复发；每周1次组4例复发。三组间治疗依从性有显著性差异，复发情况无显著性差异。每周1次组人组后HAMD的各次评分均显著高于人组时，第24周评分与另两组问差异均有显著性。结论国产氟西汀用于抑郁症的长期治疗，每周2次给药最合适。     

The undertreatment of depression

In spite of considerable progress in the establishment of physical and psychological treatments for major depression in clinical trials, little is known of the impact of treatment on the prevalence and course of depression in the population. Improved methods for assessing need for care have not yet been applied systematically to such a population. One hundred and thirty men and women attending psychiatric hospitals with depressive disorders were interviewed at the time of their initial contact. After a mean 4-month interval, 119 were reassessed in order to determine the extent to which potentially effective treatments were being fully deployed in those who had not made a complete recovery. Half had made a good recovery. At least 78% of those remaining at threshold level or above apparently had not been offered alternative, potentially effective physical or psychosocial treatment, and were therefore rated as having unmet need. Older male patients were less likely to have unmet need. This study thus raises doubts about the effectiveness of routine clinical management of depression. However, we will remain uncertain of how far the routine falls below the ideal until systematic needs for care procedures (Brewin et al. 1987) are applied prospectively to depressed populations.     

Treatment fidelity evidence for BE-ACTIV – a behavioral intervention for depression in nursing homes

Objectives: Evidence-based depression therapies are difficult to implement in nursing homes. We present data for BE-ACTIV, a 10-week depression treatment designed for implementation in nursing homes, to address questions of treatment fidelity (delivery, receipt, and enactment) in that context.

Method: Participants were 41 patients from 13 nursing homes in the treatment arm of a clinical trial, treated by graduate student therapists. Therapists and their supervisor rated their audio-recorded sessions for adherence to treatment protocol and session quality.

Results: Delivery of core program elements averaged from 80–94% across all sessions; mean quality was 5.6 (SD 0.61) out of 6 points. Delivery of core components to nursing home activities staff who collaborated in the treatment was similarly high. Patients received an average of 7.32 sessions (SD 3.39); 17 completed 10 sessions. The theoretical basis of BE-ACTIV is behavioral activation; therapist-client dyads planned new pleasant events weekly, from a mean of 3.66 (SD 1.35) after the first session to a mean of between 5 and 6 activities a week across sessions 6–9, with a similar progression in percent activities completed. Activities enactment was significantly related to the likelihood of remission at post-treatment, and of maintaining improvement at 3-month follow-up. Treatment receipt and enactment were also related to improved mood from baseline to 3 months.

Conclusion: Results demonstrate delivery, receipt, and successful enactment of BE-ACTIV core components in diverse nursing homes and patients, and support the theoretical premise of the intervention. These findings support further implementation work for the BE-ACTIV intervention.     

Screening for depression in medical care: pitfalls,alternatives, and revised priorities

Depression is a disorder seen commonly in general and specialty medical settings. Screening has been advocated as a means of ensuring that depressed patients are identified and receive appropriate treatment. Yet, recommendations for routine screening are frequently made without reference to empirical data demonstrating that it will have its intended effect. We examine the literature regarding screening in medical settings and suggest that screening in itself is unlikely to improve patient outcomes. Further, we identify costs to screening that are not readily apparent and that may negatively affect both patient outcomes and health-care delivery systems. We offer suggestions for how screening instruments might be used to improve the outcomes of depressed persons while minimizing negative effects on health care.     

Race,quality of depression care,and recovery from major depression in a primary care setting

Racial variations in the use of effective medical care and subsequent clinical outcomes have been identified for many medical conditions. Still, it is unclear whether racial variations in care and clinical outcomes exist for depressed primary care patients. Primary care patients presenting for routine treatment were screened for major depression as part of a study to disseminate a depression treatment guideline. Primary care physicians (PCPs) were informed of their patients’ depression via an electronic medical record system and asked whether they agreed with the diagnosis. Treatment patterns and depressive symptoms over the following six-months were assessed by chart review and the Hamilton Rating Scale for Depression, respectively. Over a 20-month period, 8,944 African-American and Caucasian patients aged 18–64 were approached for screening. African-Americans were less likely to agree to undergo screening than Caucasians (83% vs. 88%; P<.0001), but those doing so were more likely to report mood symptoms (26% vs. 15%; P<.001). 204 patients, including 52 African-Americans (25%), met protocol-eligibility criteria and completed a baseline interview. Baseline sociodemographic and clinical characteristics, and PCPs’ agreement rate with the depression diagnosis were similar. Although PCPs were less likely to counsel their African-American than Caucasian patients for depression (P=.03), this difference resolved after adjusting for education level, employment, and insurance status and we found no other variations in the depression care provided or in clinical outcomes by race. We found little racial variation in either process measures or clinical outcomes for depression in our sample of African-American and Caucasian primary care patients.     

The relationship between treatment settings and diagnostic attributions of depression among African Americans

Objective

To explore the relationship between treatment setting characteristics and diagnostic attributions of depression among community-dwelling African Americans.

Methods

Data come from the National Survey of American Life, a nationally representative sample of African Americans and Caribbean Blacks. Major Depression (MD) was assessed using the Composite International Diagnostic Inventory. Participants were categorized into four diagnostic groups: never MD, MD never attributed to physical health problems (i.e., affective depression), MD sometimes attributed to physical health problems (i.e., complicated depression), and MD always attributed to physical health problems (i.e., physical depression). Multinomial regression was used for assessment.

Results

Among 441 participants, 66.4% were classified as affective depression, 17.8% as complicated depression and 15.8% as physical depression. Seeking treatment from a mental health professional was associated with increased likelihood of being in the complicated depression group [adjusted odds ratio (AOR): 5.52; 95% confidence interval (CI): 2.28-13.36]. Seeking treatment from a family doctor was associated with physical depression (AOR: 2.93; 95% CI: 1.18-7.26). Seeking care from three or more different health care providers was associated with complicated depression (AOR: 1.99; 95% CI: 1.17-3.40).

Conclusion

Results suggest that encounters with health care providers influence the diagnostic attribution of depression in a systematic manner.     

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care

OBJECTIVE: This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. METHOD: Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. RESULTS: Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. CONCLUSIONS: Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.     

Perinatal Arterial Ischemic Stroke: Presentation,Risk Factors,Evaluation, and Outcome

BackgroundPerinatal arterial ischemic stroke is as common as large vessel arterial ischemic stroke in adults and leads to significant morbidity. Perinatal arterial ischemic stroke is the most common identifiable cause of cerebral palsy and can lead to cognitive and behavioral difficulties that are amortized over a lifetime.MethodsThe literature on perinatal arterial ischemic stroke was reviewed and analyzed.ResultsRisk factors for perinatal arterial ischemic stroke include those that are maternal, neonatal, and placental. The most common clinical signs at presentation are seizures and hemiparesis. Evaluation should begin with thorough history acquisition and physical examination followed by magnetic resonance imaging of the brain, with consideration of magnetic resonance angiography of the head and neck, echocardiogram, and thrombophilia evaluation. Treatment beginning early to include physical, speech, and occupational therapies including constraint-induced movement therapy and close cognitive and developmental follow-up may be beneficial. Future treatments may include transcranial magnetic stimulation, hypothermia, and erythropoietin.ConclusionsPerinatal arterial ischemic stroke comprises a group of arterial ischemic injuries that can occur in the prenatal, perinatal, and postnatal periods in term and preterm infants with different types of perinatal arterial ischemic stroke having different clinical presentations, risk factors, and long-term outcomes.     

Clock Drawing in Children With Perinatal Stroke

BackgroundChildren with perinatal stroke may show evidence of contralateral spatial neglect. The goal of this study was to determine whether the Clock Drawing Test commonly used in adults to identify neglect would be effective in detecting neglect in children with perinatal stroke.MethodsThirty-eight individuals (age range 6-21 years) with left hemisphere or right hemisphere perinatal onset unilateral lesions and 179 age-matched controls were given a free-drawn Clock Drawing Test in a cross-sectional design. An adapted scoring system that evaluated right- and left-sided errors separately was developed as part of the investigation.ResultsChildren with right hemisphere lesions made a greater number of errors on both the right and left sides of the clock drawings in all age subgroups (6-8 years, 9-14 years, and 15-21 years) compared with controls. Children with right hemisphere lesions showed greater left and right errors in the younger groups compared with controls, with significantly poorer performance on the left at 6-8 years, suggestive of contralateral neglect. However, by ages 15-21 years, the right hemisphere lesion subjects no longer differed from controls.ConclusionsClock drawing can identify spatial neglect in children with early hemispheric damage. However, brain development is a dynamic process, and as children age, spatial neglect may no longer be evident. These findings demonstrate the limitations of predicting long-term outcome after perinatal stroke from early neurocognitive data. Children with perinatal stroke may require different neural pathways to accomplish specific skills or to overcome deficits, but ultimately they may have “typical” outcomes.