忧郁症的诊断与治疗

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(MAJORDEPRESSION)輕鬱症(DYSTHYMICDISORDER)混合焦慮與憂鬱症(MIXEDANXIETYANDDEPRESSIVEDISORDER)適應障礙症(ADJUSTMENTDISORDER)雙極性情感性疾病憂鬱期(BIPOLARDISORDER,DEPRESSIVETYPE)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AffectBehaviorCognitionDrive情緒行為認知功能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」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。其實你不懂我的心

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。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。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。

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(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症個案,療效似乎較dualmechanismsantidepressants來得差SSRIdisc