Transcript 憂鬱症的診斷與治療

憂鬱症與身體症狀
振興醫院精神醫學部
游佩琳醫師
終生盛行率： 5-11%
美國每年有一千萬到一千五百萬人
症狀可以長達數年
單次發作後 有 50 % 以上的復發率、多次
發作後 復發率更高
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
憂鬱症的分類
重鬱症(MAJOR DEPRESSION)
輕鬱症(DYSTHYMIC DISORDER)
混合焦慮與憂鬱症( MIXED ANXIETY AND
DEPRESSIVE DISORDER)
適應障礙症( ADJUSTMENT DISORDER)
雙極性情感性疾病憂鬱期( BIPOLAR DISORDER,
DEPRESSIVE TYPE)
次發性憂鬱症（其他精神疾病、人格違常、身體
疾病或藥物使用）
憂鬱症的診斷
Affect
情緒
Behavior
行為
Cognition
認知功能
Drive
生理驅力
美國精神醫學會「精神疾病診斷及
統計手冊第四版」
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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。
憂鬱症的病因
真正病因：未知
生物病因
-基因遺傳
-單胺神經介質假說
-神經內分泌失調
性格病因
社會心理壓力病因
Physiological / behavioral roles
of NE, 5-HT and DA
Norepinephrine
Energy
Interest
Serotonin
Anxiety
Irritability
Impulse
Mood, Emotion,
Cognitive function
Sex
Appetite
Aggression
Motivation
Drive
Dopamine
Relation of Depression and
Somatic symptoms
Common Somatic Manifestations
Pain---headache, backache, visceral or
abdominal
Soreness
Fatigue
Dizziness
Shortness of breath
Others
Overall Assessment
Medical syndromes
Non-somatoform disorders
--Depressive disorders
--Anxiety disorders
--Psychosis
Somatoform disorders
Functional Somatic Syndromes
Several related syndromes characterized
by a collection of somatic symptoms,
suffering and disability rather than by an
identifiable tissue abnormality
Highly prevalent
Ill-defined pathological mechanisms
Considerably disability and functional
impairment
Examples of FSS
GI---Irritable bowel syndrome
Rheumatology---Fibromyalgia
Neurology---Tension headache
CV---Atypical or non-cardiac chest pain
Infection---Chronic fatigue syndrome
CM---Hyperventilation syndrome’
Dentistry---TM joint
ENT---Globus syndrome
Depression and Anxiety
45-95% of primary care patients with depression
present with only somatic symptoms
Medically unexplained symptoms should
increase the suspicion of these disorders
FSS are more frequently associated with anxiety
and depression than with well-defined medical
diseases
Simon et al. N Engl J Med 1999; 341:1329-1335
International Study of the Relation between
Somatic Symptoms and Depression
Patients from non-Western culture and lower
socioeconomic status are less willing or less
able to express emotional distress
A somatic presentation of depression was
related to characteristics of physicians and
health care systems, and cultural differences
Simon, G.E. et al (1999) The New England Journal of Medicine
A somatic presentation was more common
at centers where patient slacked an
ongoing relationship with a primary care
physician
Half of the depressed patients reported
multiple unexplained somatic symptoms
11% denied psychological symptoms of
depression on direct questioning
Somatization
Patients with psychiatric illness but
present with somatic symptoms
The association between depression and
medically unexplained somatic symptoms
(the influence of psychological distress on
the perception or reporting of somatic
symptoms)
The denial of psychological distress and
the substitution of somatic symptoms
BSRS-5 > 10 points
全身疲累
頭痛
疼痛
頭不舒服
失眠
暈眩
心病? 裝病? 身心病?
Mood disorders affect the course of
medical illnesses
A growing body of evidence suggests that
biological mechanisms underlie a bidirectional
link between mood disorders and many medical
illnesses. In addition, there is evidence to
suggest that mood disorders affect the course of
medical illnesses.
mood disorders
BIOL PSYCHIATRY 2005;58:175–189
medical illnesses
Prevalence of depression
in medically ill
Wide variation of the prevalence
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Major depression (by diagnostic interview)
4.8%-9.2% in medical outpatients
8%-15% in medical inpatients
1.5%-50% in cancer patients (mean 24%)
(McDaniel
et al. 1995)
8-60% in different populations (by questionnaire)
(Meakin et al.)
30% had psychiatric morbidity (using GHQ)
12% had major depressive disorder (Clarke et al.
1991)
Major depression rates range from 4.8% to 13.5%
Minor depression rates range from 3.4% to 6.4%
(Lobo and Campos 1997)
Prevalence of Depression in
Chronic Diseases
Alzheimer's disease
HIV
CAD
Stroke
MI
Diabetes
Cancer
11%
12%
17%
23%
25%
27%
42%
Parkinson's disease
NHDS, NAMCS, NHAMCS
Sutor B, et al. Mayo Clin Proc. 1998;73(4):329-337; Jiang et al, CNS Drugs, 2002
51%
What kinds of chronic medical illnesses
increased prevalence of depression ?
various forms of vascular disease
X 3 risk
- cardiovascular
- cerebrovascular
- peripheral vascular
diabetes mellitus
Arthritis
J Am Geriatr Soc 2004;52:86–92.
X 2~3 risk
 40~60% risk
Relationship between the
depressive Ss/ Dis. and the
physical illness
Depressive dis. is a reaction to the physical
illness and its treatment
Depression which precedes the onset of
physical illness
Depressive dis. precedes the onset of the
physical symptoms
Depressive dis. itself is induced by physical
condition
Factors associated with
emotional disturbances
Nature of physical disease
Measuring the illness: diagnosis, anatomical
location, course, severity, loss of function or
self-esteem
Nature of treatment
Patient factors: biological and psychological
vulnerability, personality, supporting system,
other life stressors
Social consequences of the illness
其實你不懂我的心
心病與心臟病曾經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，其症狀與一般心臟病所呈現的略有
不同，醫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。
隨著醫學的進一步研究發現，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現，可以得到的答案是憂
鬱症與冠心病，可能互為因果關係。
根據一項新的研究顯示，在罹患心臟病病人中具有嚴重憂鬱
與焦慮症狀者，只有三分之一獲得必要的治療。顯示一般的心
臟科醫師常會忽略這個大問題。
Depression as a predictor for coronary
heart disease
 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，初步資料發現 2,832 個案中，11.1% 有憂鬱症狀，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。
這些個案與沒有症狀者比較的結果，發生缺血性心臟病者，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)，與沒有憂鬱症者比較，高出 50% 有產生
心血管疾病的危險。
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 這是 1993 年的報告，也是第一個流行病學研究結果，顯示憂鬱症與心
血管疾病相關。憂鬱症是好發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。
Anda R, Williamson D, Jones D: Depressed affect, hopelessness and the risk of ischemic
heart disease in a cohort of US adults. Epidemiology 1993;4:285-294.
Depression in MI patients
30-40% had depressive syndromes in the
1st week after MIs, 15-30% had MD (by
DSM-III-R)
Such disorders persist in a similar
percentage for up to 3-6 months (vs. 3% in
general population)
Absence of social support as a risk factor
for MI
(Tranella 1994; Garcia 1994)
Depression and outcome of MI
Depression increase the risks of vascular-related
deaths in H/T patients (Wells 1995)
Post-MI patients with MD had a risk of mortality in the
6 months 3 times higher than in non-depressed postMI patients
(Frasure-Smith et al. 1993)
Presence of depression constitute a factor
predictive of mortality following dx of MI
(Carney et al. 1988, Schleifer et al. 1989, Freedland et al. 1992)
Depression as a risk factor for mortality after coronary
artery bypass surgery.
Lancet 2003; 362: 604-09
Background： Studies that have shown clinical depression to be a risk factor for
cardiac events after coronary artery bypass graft (CABG) surgery have had small
sample sizes, short follow-up, and have not had adequate power to assess mortality.
We sought to assess whether depression is associated with an increased risk of
 Patients with moderate to severe depression
mortality.
at assessed
baseline
higher
ratesCABG
(HR:2.2-2.4)
of Medical
Methods： We
817had
patients
undergoing
at Duke University
Center between
May, than
1989, and
2001.with
Patients
the Center for
death
didMay,
those
no completed
depression.
Epidemiological Studies-Depression (CES-D) scale before surgery, 6 months after
 followed-up
Despite for
advances
in surgical and medical
CABG, and were
up to 12 years.
Findings： management of patients after CABG, depression
 In 817 patients there were 122 deaths (15%) in a mean follow-up of 5·2 years.
is an important independent predictor of death
310 patients (38%) met the criterion for depression (CES-D 16): 213 (26%) for mild
after 16-26)
CABG
should
be carefully
depression (CES-D
andand
97 (12%)
for moderate
to severemonitored
depression (CES-D
27).
and treated if necessary.
 Survival analyses, controlling for age, sex, number of grafts, diabetes, smoking,
LVEF, and previous MI, showed that patients with moderate to severe depression at
baseline (adjusted hazard ratio [HR] 2·4, [95% CI 1·4-4·0]; p=0·001) and mild or
moderate to severe depression that persisted from baseline to 6 months (adjusted
HR 2·2, [1·2-4·2]; p=0·015) had higher rates of death than did those with no
depression.
Post-stroke depression (PSD)
Rates of PTD have ranged from 18 to 61
%
(House 1987)
50% developing depression during the
acute post-stroke period
30% among outpatient stroke patients
(Strarkstein and Robison 1989)
Depression and vascular disease
Elderly H/T subjects with severe depression sxs (CES-D
>=15) were 2.3-2.7 times more likely to suffer from
stroke than non-depressed H/T patients
(Simonsick et al. 1995)
Depressive symptoms were associated with increased
risk of stroke mortality
(Everson et al. 1998)
Increase propensity for platelets to aggregate and high
levels of cholesterol and high density lipoproteins
(Musselman et al. 1996)
Aged 60  with H/T depressive elderly had more than
twice the risk of heart failure as non-depressed patients
(Musselman et al. 1996)
Depression is a risk factor for
noncompliance with medical treatment
Arch Intern Med 2000;160:2101-2107
Increased mortality may relate to
decreased adherence to treatment
recommendations or possibly to direct
effects of the depressed state on
autonomic tone, platelet aggregation, or
immune and inflammatory responses.
the prognosis of depression is worsened
by the presence of significant medical
comorbidity.
Watch out for a clinically occult
medical illness when:
Severe new-onset depression, including
melancholia and psychotic depression
New-onset depression in an older adult
New-onset or recurrent depression that is not
readily understood in the context of the patient's
psychosocial stressors and circumstances
Depression that has not responded to treatment
attempts
Depression with significant coexisting cognitive
impairment, anxiety, substance use disorder, or
other comorbid psychopathology
Differential Diagnosis
廣泛性焦慮症
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、颤抖頭痛
冒汗、心悸、呼吸困難、胃痛、腹瀉、失
眠
恐慌症
公司大老闆症候群?
突然嚴重焦慮發作、胸悶心悸、呼吸困難、
手腳發麻、瀕死的感覺
擁擠或密閉空間、一直擔心再次發作
心臟科、急診的常客
Treatment
憂鬱症的治療
藥物治療
電痙治療 (ECT)
心理治療
其他(照光 etc)
憂鬱症的藥物治療
TCA (Tricyclic antidepressants)
MAOI/RIMA (Monoamine oxidase inhibitors)
SSRI (Selective serotonin reuptake inhibitors)
SNRI (Selective noradrenergic reuptake
inhibitors)
NaSSA (Noradrenergic and specific
serotonergic antidepressant)
NDRI (Norepinephrine and dopamine reuptake
inhibitors)
Cardiovascular Effects with TCA
α-blockade
Orthostatic hypotension
Dizziness and Syncope
PR prolongation
Conduction block
QT prolongation
Class IA antiarrythmia
Increased heart rate
Vagolytic effect
Contraindicated in structural heart disease
Decreased HRV
VT
VF
MAOI/RIMA
Classical MAO inhibitors---irreversible and
nonselective
phenelzine (Nardil)
tranylcypromine (Parnate)
isocarboxazid (Marplan)
Reversable inhibitors of MAO A
moclobemide (Aurorix)
Selective inhibitors of MAO B
deprenyl (Selegiline; Eldepryl)
MAOI
Irreversible inhibition of MAO A and B
Hypertensive crisis after tyraminecontaining food
MAO B used in the prevention of
neurodegenerative processes, such as
those in Parkinson’s disease
RIMA
Atypical depression
Second-line treatment for anxiety
disorders, such as panic disorder or social
phobia
RIMASSRI washout for 2 weeks
SSRIRIMA washout for one week
(except fluoxetine, whose metabolic
product has a longer half-life, hence
washout time being two weeks)
血清素再回收抑制劑 (SSRI)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Cipram)
Paroxetine (Seraxet)
SSRI
Fewer side effects
Safety even in high dose/overdose
Side effects related to serotonin receptor
subtypes 5HT2A, 5HT2C, 5HT3, 5HT4
Indications other than major depression
OCD, Panic disorder, Bulimia, Social
phobia, PTSD, PMS
SSRI的限制
對重度到極重度憂鬱症個案, 療效似乎較
dual mechanisms antidepressants來得差
SSRI discontinuation syndrome
Serotonin syndrome
Drug interactions
Rationale for Agents with
Dual Reuptake Inhibition
Serotonin-related symptoms
Norepinephrine-related symptoms
Impulse • Appetite
Aggression
Motivation • Zest
Energy • Social drive
Anxiety • Irritability
Mood • Emotion
Anxiety • Irritability
Mood • Emotion
Stahl S. J Clin Psychiatry 1999; 60: 213-214.
Healy D et al. J Psychopharmacol 1997; 11 (Suppl): S25-S31.
EFEXOR XR
NaSSA
Mirtazapine (Remeron)
Alpha 2 antagonism, therefore increases
5HT and NE
Only 5HT1A receptors are stimulated
because 5HT2A, 5HT2C and 5HT3
receptors are blocked.
Sedation and weight gain due to H1
receptor blockage
NDRI
Bupropion
Norepinepherine and Dopamine reuptake
inhibitors
NDRI
Sustained release formulation (bupropion
SR, Wellbutrin) reduces risk of seizure
Used on retarded, low energy depression
Decreasing the craving associated with
smoking cessation
No sexual dysfunction
Side effects
Risk of seizure, insomnia, agitation
Criteria for referral to
psychiatrists
• Severe/recurrent depression and /or high suicidal
risk
• No/partial response to conventional tx for
depression
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Type of treatment with documented efficacy
Adequate dose and duration of antidepressant
• Diagnostic complexity
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Comorbidity (physical/psychiatric)
Differential diagnosis
• Patient’s preference for psychiatric treatment
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