伴抑郁、焦虑情绪障碍的2型糖尿病患者血糖水平与抗抑郁焦虑干预

背景抑郁、焦虑等负性情绪在2型糖尿病发病及血糖控制中起重要作用.目的探讨改善2型糖尿病患者的抑郁、焦虑情绪对血糖代谢的影响.设计随机对照观察.单位解放军第三军医大学西南医院临床心理咨询中心和内分泌科.对象选择1999-10/2000-11在解放军第三军医大学西南医院内分泌科病房住院的2型糖尿病患者43例,均自愿参加观察.男24例,女19例,年龄(51±9)岁.随机分为2组,观察组23例,对照组20例.方法观察组除糖尿病常规药物治疗外,辅以抗抑郁及抗焦虑剂治疗,帕罗西汀20mg每天早餐后顿服,阿普唑仑0.4mg每天中午及晚睡前各1次.对照组仅进行糖尿病常规药物治疗.两组患者分别于治疗前、治疗4周后用Zung氏抑郁及焦虑自评量表自评其抑郁及焦虑评分.Zung氏抑郁、焦虑自评量表标准分分别≥50为有抑郁、焦虑症状.以抑郁、焦虑量表减分率作为情绪改善的标准.减分率50%～100%为显效,25%～49%为有效,＜25%为无效.减分率=(治疗前评分-治疗后评分)/治疗后评分×100%.分别测定治疗前、治疗4周后空腹血糖、餐后2h血糖水平及糖化血红蛋白.同时于治疗前、治疗后第10,20,30天时测3餐前、后1 h血糖(6次/d),血糖下降率=(治疗前血糖-治疗后血糖)/治疗前血糖.主要观察指标①两组患者治疗前、治疗4周后抑郁、焦虑评分、空腹血糖、餐后2 h血糖及糖化血红蛋白水平.②治疗后两组患者的血糖下降率.结果观察过程中脱落6例,其中观察组脱落5例,主要原因是经济压力、不能耐受帕罗西汀药物副作用及担心服用精神药物成瘾;对照组1例,原因是失访.最终完成观察37例,观察组18例,对照组19例.①抑郁、焦虑评分比较治疗4周后观察组较治疗前显著下降(41.05±7.05,41.88±10.57);(59.80±10.24,55.03±8.31),(t=2.41,2.21,P＜0.05)].②空腹血糖、餐后2 h血糖水平及血糖下降率比较治疗4周后观察组空腹血糖、餐后2 h血糖低于对照组(t=2.11,2.98,P＜0.05～0.01),而空腹血糖、餐后2 h血糖下降率则明显高于对照组(t=2.94,2.93,P＜0.01).③糖化血红蛋白比较治疗4周后观察组糖化血红蛋白较治疗前呈显著降低(8.2±2.0)%,(9.1±1.9)%,(t=2.14,P＜0.05)].结论抗抑郁及焦虑药物的使用不仅能显著改善糖尿病患者的抑郁、焦虑情绪,而且显著改善糖代谢.其原因可能与抗抑郁、焦虑药物增加患者对糖尿病药物的依从性,减少负性情绪带来的胰岛素抵抗现象有关.

Relationship between blood glucose levels in patients with type 2 diabetes mellitus, depression and anxiety and the anti-depression/anxiety intervention

BACKGROUND: Psychological disorders, such as depression and anxiety are relevant to pathogenesis and management of type 2 diabetes mellitus.OBJECTIVE: It was designed to investigate the influence of improving depression and anxiety in diabetes on metabolism of blood glucose.DESIGN: It was a randomized controlled comparative study.SETTING: It was conducted at the Cousulting Center for Clinical Psychology and the Endocrinology Department of Southwest Hospital Affiliated Third Military Medical University of Chinese PLA .PARTICIPANTS: Totally 43 inpatients with type 2 diabetes mellitus in the Endocrinology Department of Southwest Hospital Affiliated toThird Military Medical University of Chinese PLA were selected from October, 1999 to November 2000. All of them participated the investigation voluntarily, 24males and 19 females, with an age of 51±9 years old. They were randomly divided into 2 groups, 23 in experimental group and 20 in control group.METHODS: For experimental group, besides routine medications for diabetes, patients also Accepted anti-depression and anti-anxiety treatment, including paroxetine (20 mg, taking after breakfast everyday) and Alprazolam (0.4 mg, taking at noon, at evening and before sleep everyday). For control group, patients only Accepted routine medication for diabetes. Patients in the two groups were assessed before medication and after 4 weeks medication by Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS). They were identified as depression and anxiety according to the Scales. Reduction rate of SDS/SAS score was used to assess the therapeutic effects: When the reduction rate was 50%-100%, the medication was significantly effective, when it was 25%-49% the treatment was effective, and when it was less than 25%, the treatment was noneffective.Reduction rate =(pre-treatment score-post-treatment score)/post-treatment score×100%. The fasting blood glucose level, 2-hour postprandial blood glucose level and the Glycosylated Hemoglobin (GHB, HbAl) were measured before treatment and after 4 weeks medication. Meanwhile, preprandial blood glucose level and 1-hour postprandial blood glucose level (6 times per day) were detected before treatment and at the 10th, 20th and 30th day during treatment. Reduction rate of blood glucose-(pre-treatment blood glucose level-post-treatment glucose level)/pre-treatment blood glucose level.MAIN OUTCOME MEASURES: These were main outcome measureglucose ①SDS/SAS scores, fasting blood glucose, 2-hour postprandial blood glucose and GHB before treatment and after 4 weeks treatment were measured in two group, ② and reduction rate of blood glucose.RESULTS: Six cases were omitted, 5 was in experimental group for financial pressure, intolerance to side effects of paroxetine and fears of the addiction of psychotropic drugs; the other one was in control group due to drop-out. There were 37 patients finished the investigation, 18 in experimental group and 19 in control group.①Comparison of SDS score/SAS core: After 4 weeks medication, it was observed that the post-treatment scores were significantly lower than pre-treatment scores in experimental group compared to control group(41.05±7.05,41.88±10.57); (59.80±10.24,55.03±8.31 ), (t=2.41, 2.21, P ＜ 0.05)].②Comparison of fasting blood glucose, 2-hour postprandial blood glucose and reduction rate of blood glucose: After 4 weeks medication, the fasting blood glucose and 2-hour postprandial blood glucose in experimental group were significantly lower than those in control group(t=2.11,2.98, P ＜ 0.05-0.01)and the reduction rate of fasting blood glucose and 2-hour postprandial blood glucose in experimental group were significantly greater than those in control group (t=2.94,2.93, P ＜ 0.01). ③Comparison of GHB: After 4 weeks medication, the posttreatment GHB level in experimental group were significantly lower than pre-treatment GHB level(8.2±2.0)%,(9.1±1.9)%, (t=2.14, P ＜ 0.05)].CONCLUSION: Anti-depression and anti-anxiety drugs not only can alleviate depression and anxiety symptoms significantly, but also can improve blood glucose metabolism. This may be attributed to an effect of anti-depression and anti-anxiety drugs in increasing the compliance of the patients to the medication for diabetes and decreasing the insulin resistance induced by negative moods.