憂郁癥的診斷與治療

憂鬱癥與身體癥狀振興醫(yī)院精神醫(yī)學部游佩琳醫(yī)師終生盛行率：5-11%美國每年有一千萬到一千五百萬人癥狀可以長達數(shù)年單次發(fā)作後有50%以上的復發(fā)率、多次發(fā)作後復發(fā)率更高嚴重性與心絞痛和冠狀動脈疾病相當若未治療，則有高自殺身亡率憂鬱癥的分類重鬱癥(MAJORDEPRESSION)輕鬱癥(DYSTHYMICDISORDER)混合焦慮與憂鬱癥(MIXEDANXIETYANDDEPRESSIVEDISORDER)適應障礙癥(ADJUSTMENTDISORDER)雙極性情感性疾病憂鬱期(BIPOLARDISORDER,DEPRESSIVETYPE)次發(fā)性憂鬱癥（其他精神疾病、人格違常、身體疾病或藥物使用）憂鬱癥的診斷AffectBehaviorCognitionDrive情緒行為認知功能生理驅(qū)力美國精神醫(yī)學會「精神疾病診斷及統(tǒng)計手冊第四版」1.幾乎每天都是憂鬱的心情。2.對日常生活中大部份的事物都失去興趣；或從事各種活動時，感覺不出快樂的心情。3.在未刻意改變飲食習慣下，體重改變超過5％。4.幾乎每天都失眠或嗜睡。5.思考行動變得躁動不安或遲緩呆滯。6.每天都覺得疲累不堪或失去能量。7.覺得活著沒有價值或心中充滿過多的罪惡感。8.思考及專注能力下降，猶豫不決無法做決定。9.一再地想起死亡和自殺的主題，甚至嘗試自殺的舉動。憂鬱癥的病因真正病因：未知生物病因

-基因遺傳

-單胺神經(jīng)介質(zhì)假說

-神經(jīng)內(nèi)分泌失調(diào)性格病因社會心理壓力病因NorepinephrineSerotoninDopamineEnergyInterestImpulseDriveMotivationSexAppetiteAggressionAnxietyIrritabilityMood,Emotion,

CognitivefunctionPhysiological/behavioralrolesofNE,5-HTandDARelationofDepressionandSomaticsymptoms

CommonSomaticManifestationsPain---headache,backache,visceralorabdominalSorenessFatigueDizzinessShortnessofbreathOthersOverallAssessmentMedicalsyndromesNon-somatoformdisorders--Depressivedisorders--Anxietydisorders--PsychosisSomatoformdisordersFunctionalSomaticSyndromesSeveralrelatedsyndromescharacterizedbyacollectionofsomaticsymptoms,sufferinganddisabilityratherthanbyanidentifiabletissueabnormalityHighlyprevalentIll-definedpathologicalmechanismsConsiderablydisabilityandfunctionalimpairmentExamplesofFSSGI---IrritablebowelsyndromeRheumatology---FibromyalgiaNeurology---TensionheadacheCV---Atypicalornon-cardiacchestpainInfection---ChronicfatiguesyndromeCM---Hyperventilationsyndrome’Dentistry---TMjointENT---GlobussyndromeDepressionandAnxiety45-95%ofprimarycarepatientswithdepressionpresentwithonlysomaticsymptomsMedicallyunexplainedsymptomsshouldincreasethesuspicionofthesedisordersFSSaremorefrequentlyassociatedwithanxietyanddepressionthanwithwell-definedmedicaldiseasesSimonetal.NEnglJMed1999;341:1329-1335InternationalStudyoftheRelationbetweenSomaticSymptomsandDepressionPatientsfromnon-WesterncultureandlowersocioeconomicstatusarelesswillingorlessabletoexpressemotionaldistressAsomaticpresentationofdepressionwasrelatedtocharacteristicsofphysiciansandhealthcaresystems,andculturaldifferencesSimon,G.E.etal(1999)TheNewEnglandJournalofMedicine

AsomaticpresentationwasmorecommonatcenterswherepatientslackedanongoingrelationshipwithaprimarycarephysicianHalfofthedepressedpatientsreportedmultipleunexplainedsomaticsymptoms11%deniedpsychologicalsymptomsofdepressionondirectquestioningSomatizationPatientswithpsychiatricillnessbutpresentwithsomaticsymptomsTheassociationbetweendepressionandmedicallyunexplainedsomaticsymptoms(theinfluenceofpsychologicaldistressontheperceptionorreportingofsomaticsymptoms)ThedenialofpsychologicaldistressandthesubstitutionofsomaticsymptomsBSRS-5>10points全身疲累頭痛疼痛頭不舒服失眠暈眩心病?裝病?身心病?MooddisordersaffectthecourseofmedicalillnessesAgrowingbodyofevidencesuggeststhatbiologicalmechanismsunderlieabidirectionallinkbetweenmooddisordersandmanymedicalillnesses.Inaddition,thereisevidencetosuggestthatmooddisordersaffectthecourseofmedicalillnesses.BIOLPSYCHIATRY2005;58:175–189mooddisordersmedicalillnessesPrevalenceofdepression

inmedicallyillWidevariationoftheprevalenceMajordepression(bydiagnosticinterview)4.8%-9.2%inmedicaloutpatients8%-15%inmedicalinpatients1.5%-50%incancerpatients(mean24%)(McDanieletal.1995)8-60%indifferentpopulations(byquestionnaire) (Meakinetal.)30%hadpsychiatricmorbidity(usingGHQ) 12%hadmajordepressivedisorder(Clarkeetal.1991)Majordepressionratesrangefrom4.8%to13.5% Minordepressionratesrangefrom3.4%to6.4%

(LoboandCampos1997)

DepressioninPatientsWithComorbidMedicalIllnessBIOLPSYCHIATRY2005;58:175–189PrevalenceofDepressionin

ChronicDiseasesNHDS,NAMCS,NHAMCSSutorB,etal.MayoClinProc.1998;73(4):329-337;Jiangetal,CNSDrugs,2002Whatkindsofchronicmedicalillnessesincreasedprevalenceofdepression?variousformsofvasculardisease

-cardiovascular

-cerebrovascular

-peripheralvascular

diabetesmellitus

ArthritisX3riskX2~3risk

40~60%riskJAmGeriatrSoc2004;52:86–92.RelationshipbetweenthedepressiveSs/Dis.andthephysicalillnessDepressivedis.isareactiontothephysical illnessanditstreatmentDepressionwhichprecedestheonsetof physicalillnessDepressivedis.precedestheonsetofthe physicalsymptomsDepressivedis.itselfisinducedbyphysical conditionFactorsassociatedwith

emotionaldisturbancesNatureofphysicaldiseaseMeasuringtheillness:diagnosis,anatomical location,course,severity,lossoffunctionorself-esteemNatureoftreatmentPatientfactors:biologicalandpsychological vulnerability,personality,supporting system,otherlifestressorsSocialconsequencesoftheillness

心病與心臟病曾經(jīng)被認為是互不相關的事，特別是有一些患者在主訴胸悶以及心悸時，其癥狀與一般心臟病所呈現(xiàn)的略有不同，醫(yī)生多半告訴病人是因為緊張、焦慮以及壓力的關係，那是心病的表徵而非心臟病。所以醫(yī)生會為患者開一些緩和情緒以及抗焦慮的藥物，病人可能得到相當程度的改善，但常復發(fā)。

隨著醫(yī)學的進一步研究發(fā)現(xiàn)，心病與心臟病並不一定是完全不相關的，近年來許多研究報告發(fā)現(xiàn)，可以得到的答案是—憂鬱癥與冠心病，可能互為因果關係。其實你不懂我的心

根據(jù)一項新的研究顯示，在罹患心臟病病人中具有嚴重憂鬱與焦慮癥狀者，只有三分之一獲得必要的治療。顯示一般的心臟科醫(yī)師常會忽略這個大問題。Anda等人在一項前瞻性研究中，針對2,832位沒有心血管疾病者，追蹤12.4年，初步資料發(fā)現(xiàn)2,832個案中，11.1%有憂鬱癥狀，10.8%有中度無望感，2.9%有重度無望感，在研究期間，有6.7%死亡，9.7%因心血管疾病住院。

這些個案與沒有癥狀者比較的結果，發(fā)生缺血性心臟病者，不管是否致死，其相對危險性均很高，致死性心肌梗塞相對危險率分別為1.4、1.6、2.1，非致死性心肌梗塞相對危險率分別為1.6、1.3、1.9，不論吸菸與否(吸菸是心臟血管疾病之危險因子)，與沒有憂鬱癥者比較，高出50%有產(chǎn)生心血管疾病的危險。這是1993年的報告，也是第一個流行病學研究結果，顯示憂鬱癥與心血管疾病相關。憂鬱癥是好發(fā)缺血性心臟病的獨立危險因子，與抽菸、高膽固醇、家庭史等同為獨立危險因子。

AndaR,WilliamsonD,JonesD:Depressedaffect,hopelessnessandtheriskofischemicheartdiseaseinacohortofUSadults.Epidemiology1993;4:285-294.DepressionasapredictorforcoronaryheartdiseaseDepressioninMIpatients30-40%haddepressivesyndromesinthe1stweekafterMIs,15-30%hadMD(byDSM-III-R)Suchdisorderspersistinasimilarpercentageforupto3-6months(vs.3%ingeneralpopulation)AbsenceofsocialsupportasariskfactorforMI (Tranella1994;Garcia1994)

DepressionandoutcomeofMIDepressionincreasetherisksofvascular-relateddeathsinH/Tpatients (Wells1995)Post-MIpatientswithMDhadariskofmortalityinthe6months3timeshigherthaninnon-depressedpost-MIpatients

(Frasure-Smithetal.1993)Presenceofdepressionconstituteafactor predictiveofmortalityfollowingdxofMI

(Carneyetal.1988,Schleiferetal.1989,Freedlandetal.1992)Depressionasariskfactorformortalityaftercoronaryarterybypasssurgery.Lancet2003;362:604-09Background：

Studiesthathaveshownclinicaldepressiontobeariskfactorforcardiaceventsaftercoronaryarterybypassgraft(CABG)surgeryhavehadsmallsamplesizes,shortfollow-up,andhavenothadadequatepowertoassessmortality.Wesoughttoassesswhetherdepressionisassociatedwithanincreasedriskofmortality.Methods：

Weassessed817patientsundergoingCABGatDukeUniversityMedicalCenterbetweenMay,1989,andMay,2001.PatientscompletedtheCenterforEpidemiologicalStudies-Depression(CES-D)scalebeforesurgery,6monthsafterCABG,andwerefollowed-upforupto12years.Findings：

In817patientstherewere122deaths(15%)inameanfollow-upof5·2years.310patients(38%)metthecriterionfordepression(CES-D16):213(26%)formilddepression(CES-D16-26)and97(12%)formoderatetoseveredepression(CES-D27).Survivalanalyses,controllingforage,sex,numberofgrafts,diabetes,smoking,LVEF,andpreviousMI,showedthatpatientswithmoderatetoseveredepressionatbaseline(adjustedhazardratio[HR]2·4,[95%CI1·4-4·0];p=0·001)andmildormoderatetoseveredepressionthatpersistedfrombaselineto6months(adjustedHR2·2,[1·2-4·2];p=0·015)hadhigherratesofdeaththandidthosewithnodepression.

Patientswithmoderatetoseveredepressionatbaselinehadhigherrates(HR:2.2-2.4)ofdeaththandidthosewithnodepression.DespiteadvancesinsurgicalandmedicalmanagementofpatientsafterCABG,depressionisanimportantindependentpredictorofdeathafterCABGandshouldbecarefullymonitoredandtreatedifnecessary.

Post-strokedepression(PSD)

RatesofPTDhaverangedfrom18to61% (House1987)50%developingdepressionduringtheacutepost-strokeperiod30%amongoutpatientstrokepatients (StrarksteinandRobison1989)

DepressionandvasculardiseaseElderlyH/Tsubjectswithseveredepressionsxs(CES-D>=15)were2.3-2.7timesmorelikelytosufferfromstrokethannon-depressedH/Tpatients (Simonsicketal.1995)Depressivesymptomswereassociatedwithincreasedriskofstrokemortality (Eversonetal.1998)Increasepropensityforplateletstoaggregateandhighlevelsofcholesterolandhighdensitylipoproteins (Musselmanetal.1996)Aged60

withH/Tdepressiveelderlyhadmorethantwicetheriskofheartfailureasnon-depressedpatients (Musselmanetal.1996)DepressionisariskfactorfornoncompliancewithmedicaltreatmentArchInternMed2000;160:2101-2107

Increasedmortalitymayrelatetodecreasedadherencetotreatmentrecommendationsorpossiblytodirecteffectsofthedepressedstateonautonomictone,plateletaggregation,orimmuneandinflammatoryresponses.theprognosisofdepressionisworsenedbythepresenceofsignificantmedicalcomorbidity.

Watchoutforaclinicallyoccultmedicalillnesswhen:Severenew-onsetdepression,includingmelancholiaandpsychoticdepressionNew-onsetdepressioninanolderadultNew-onsetorrecurrentdepressionthatisnotreadilyunderstoodinthecontextofthepatient'spsychosocialstressorsandcircumstancesDepressionthathasnotrespondedtotreatmentattemptsDepressionwithsignificantcoexistingcognitiveimpairment,anxiety,substanceusedisorder,orothercomorbidpsychopathologyDifferentialDiagnosis廣泛性焦慮癥什麼都想、什麼都擔心、什麼都不奇怪擔心、害怕、注意力不集中肌肉張力增加、顫抖頭痛冒汗、心悸、呼吸困難、胃痛、腹瀉、失眠恐慌癥公司大老闆癥候群?突然嚴重焦慮發(fā)作、胸悶心悸、呼吸困難、手腳發(fā)麻、瀕死的感覺擁擠或密閉空間、一直擔心再次發(fā)作心臟科、急診的常客Treatment憂鬱癥的治療藥物治療電痙治療(ECT)心理治療其他(照光etc)憂鬱癥的藥物治療TCA(Tricyclicantidepressants)MAOI/RIMA(Monoamineoxidaseinhibitors)SSRI(Selectiveserotoninreuptakeinhibitors)SNRI(Selectivenoradrenergicreuptakeinhibitors)NaSSA(Noradrenergicandspecificserotonergicantidepressant)NDRI(Norepinephrineanddopaminereuptakeinhibitors)CardiovascularEffectswithTCAOrthostatichypotensionPRprolongationConductionblockClassIAantiarrythmiaVagolyticeffectIncreasedheartrateDecreasedHRVQTprolongationVTVFDizzinessandSyncopeContraindicatedinstructuralheartdiseaseα-blockadeMAOI/RIMAClassicalMAOinhibitors---irreversibleandnonselective

phenelzine(Nardil)tranylcypromine(Parnate)isocarboxazid(Marplan)ReversableinhibitorsofMAOA

moclobemide(Aurorix)SelectiveinhibitorsofMAOB

deprenyl(Selegiline;Eldepryl)MAOIIrreversibleinhibitionofMAOAandBHypertensivecrisisaftertyramine-containingfoodMAOBusedinthepreventionofneurodegenerativeprocesses,suchasthoseinParkinson’sdiseaseRIMAAtypicaldepressionSecond-linetreatmentforanxietydisorders,suchaspanicdisorderorsocialphobiaRIMASSRIwashoutfor2weeksSSRIRIMAwashoutforoneweek(exceptfluoxetine,whosemetabolicproducthasalongerhalf-life,hencewashouttimebeingtwoweeks)血清素再回收抑制劑(SSRI)Fluoxetine(Prozac)Sertraline(Zoloft)Fluvoxamine(Luvox)Citalopram(Cipram)Paroxetine(Seraxet)SSRIFewersideeffectsSafetyeveninhighdose/overdoseSideeffectsrelatedtoserotoninreceptorsubtypes5HT2A,5HT2C,5HT3,5HT4IndicationsotherthanmajordepressionOCD,Panicdisorder,Bulimia,Socialphobia,PTSD,PMSSSRI的限制

對重度到極重度憂鬱癥個案,療效似乎較dualmechanismsantidepressants來得差SSRIdisc