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神经系统疾病伴发抑郁焦虑障碍的诊断治疗专家共识 耿德勤 (徐州医学院附属医院神经科),目的和意义,常见神经系统疾病均易伴发或共病抑郁焦虑障碍 脑血管病和卒中 认知功能障碍 帕金森病 多发性硬化 癫痫 原发性头痛共病使得疾病迁延不愈、显著地增加了疾病的负担旨在提高医师对神经系统疾病伴发抑郁焦虑障碍的认识和处理,体现“以人为本”的医学宗旨,更好地实践生物心理社会的医学模式,概 要,流行病学神经系统疾病伴发抑郁焦虑障碍的特点神经科抑郁/焦虑状态常见的躯体化表现头痛和焦虑抑郁的关系抑郁和焦虑状态的初查和识别抑郁症的治疗目标神经科抑郁焦虑障碍的治疗抗抑郁剂的药物相互作用,流行病学,流行病学,脑血管病和卒中后抑郁焦虑障碍16 各研究报道的卒中后抑郁(PSD)发病率和患病率变异很大 有研究认为卒中后1个月是发病的高峰,但也有研究认为卒中后36月是发病高峰 社区研究: PSD在卒中急性期为33,慢性期为34 医院研究:PSD在卒中急性期为36、 恢复期为32, 慢性期为34 我国研究发现,PSD在卒中后1月为39%、36个月为53%、1年为24%,1 Benedetti F, Bernasconi A,Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry,2006,19:1418. 2 Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry,2002,7:213-220. 3 Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry,2006,19:294298. 4 Rickards H. Depression in neurological disorders: Parkinsons disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry,2005,76;48-52. 5 Pohjasvaara T, Leppavuori A,Siira I,et al. Frequency and clinical determinants of poststroke depression. Stroke,1998,29:2311-2317. 6 Hackett ML, Yapa C, Parag V, et al. Frequency of depression after stroke:A systematic review of observational studies. Stroke,2005,36:1330-1340.,流行病学,认知功能障碍伴抑郁焦虑障碍13 抑郁障碍多见于痴呆前期或早期,有研究认为抑郁是痴呆的前驱症状或危险因素 有抑郁的轻度认知障碍 (MCI)者向老年性痴呆(AD)的转化率是无抑郁者的2倍 AD伴发抑郁的患病率可达75%,一般约为3050 血管性痴呆(VaD)或血管性认知损害(VCI)者的抑郁症状的发生率约为40%60% MCI的抑郁累计患病率约为26%,1 Holtzer R, Scarmeas N, Wegesin DJ, et al. J Am Geriatr Soc,2005,53:2083-2089. 2 Modrego PJ, Ferrndez J Arch Neurol,2004,61:1290-1293. 3. Potter GG, Steffens DC. Contribution of depression ,Neurologist,2007,13: 105117.,流行病学,帕金森病(PD)伴抑郁焦虑障碍17 PD患者的抑郁障碍患病率为8%76%,平均25%40% 约40%患者有焦虑障碍 有研究认为抑郁和焦虑障碍可能先于患者的运动症状出现,1 Benedetti F, Bernasconi A,Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry,2006,19:1418. 2 Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry,2002,7:213-220. 3 Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry,2006,19:294298. 4 Rickards H. Depression in neurological disorders: Parkinsons disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry,2005,76;48-52. 5. Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia. J Neurol Neurosurg Psychiatry,2002,72:1221. 6. Okun MS, Watts RL. Depression associated with Parkinsons disease:. Neurology, 2002,58(Suppl 1):S63S70. 7. Ehrt U,Aarsland D. Psychiatric aspects of Parkinsons disease. Curr Opin Psychiatry,2005,18: 335-341.,流行病学,多发性硬化(MS)伴抑郁焦虑障碍17 终身患病率近50%,是普通人群的3倍 社区问卷调查研究发现41%患者有抑郁,其中29%为中-重度抑郁 对3000例16岁以上MS患者的死因调查显示,15%的患者死于自杀 流行病学调查结果显示35.7%的患者合并各种焦虑,其中18.6%为广泛性焦虑、10%为惊恐发作,1 Benedetti F, Bernasconi A,Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry,2006,19:1418. 2 Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry,2002,7:213-220. 3 Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry,2006,19:294298. 4 Rickards H. Depression in neurological disorders: Parkinsons disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry,2005,76;48-52. 5. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder:JAMA 2003,289:30953105. 6. Janssens AC, Buljevac D, van Doorn PA. Prediction of anxiety and distress following diagnosis . Mult Scler,2006 ,12:794-801. 7. Siegert RJ,Abernethy DA. Depression in multiple sclerosis: a review. J Neurol Neurosurg Psychiatry,2005,76;469-475.,流行病学,癫痫伴抑郁焦虑障碍16抑郁症的患病率为50%55% 住院患者中,控制良好者的抑郁发病率为10%、患病率为20%,控制不良者则分别为20%和60% 癫痫患者发作间期的焦虑症的患病率为10%25%,1 Benedetti F, Bernasconi A,Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry,2006,19:1418. 2 Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry,2002,7:213-220. 3 Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry,2006,19:294298. 4 Rickards H. Depression in neurological disorders: Parkinsons disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry,2005,76;48-52. 5. Lambert M, Robertson M. Depression in epilepsy: etiology, phenomenology and treatment. Epilepsia,1999,40(suppl 10):S21S47. 6. Gaitatzis A,Trimble MR,Sander JW. The psychiatric comorbidity of epilepsy. Acta Neurologica Scandinavica,2004,110:207-220.,流行病学,原发性头痛伴抑郁焦虑障碍12原发性头痛门诊患者调查发现27%的患者有中-重度抑郁,其中偏头痛人群为17.1%、转化型偏头痛为36.1%、紧张型头痛(TTH)为28.3%; 偏头痛患者终身的抑郁障碍患病率约为30%80%,是普通人群的3-4倍。同时,易有惊恐和强迫等焦虑障碍; 有先兆的偏头痛和转化型偏头痛者的伴发率更高。频发型和慢性TTH者抑郁焦虑障碍的伴发率可达2/3; 青少年慢性头痛者调查,有抑郁障碍30%(抑郁症21%)、焦虑障碍36%、高度自杀危险者20%,1 Radat F,Swendsen J. Psychiatric comorbidity in migraine: a review. Cephalalgia,2005,25:165-178. 2 Wang SJ,Juang KD,Fuh JL,et al. Psychiatric comorbidity and suicide risk in adolescents with chronic daily headache. Neurology, 2007,68:14681473.,流行病学的启示,脑血管病和卒中、认知功能障碍、帕金森病、多发性硬化、癫痫、原发性头痛伴发抑郁焦虑比例高,使相关疾病地治疗更加复杂、困难,延长病程,同时增加了疾病负担; 因此,有必要对神经科常见伴发抑郁焦虑的患者进行识别和诊治。,
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