抑郁癥治療研究新進展

瞿偉，谷珊珊

（第三軍醫(yī)大學(xué)西南醫(yī)院臨床心理科 全軍心理衛(wèi)生研究中心，重慶 400038）

An inventory for measuring depression

Beck AT； Erbaugh J； Ward CH； et al.

Collaborative Management to Achieve Treatment Guidelines — Impact On Depression in Primary-Care

Katon W； Vonkorff M； Lin E； et al.

Depression Following Myocardial-Infarction — Impact On 6-Month Survival

Frasuresmith N； Lesperance F； Talajic，M

Reduction of Prefrontal Cortex Glucose-Metabolism Common to 3 Types Of Depression

Baxter LR； Schwartz JM； Phelps ME； et al.

卒中后抑郁狀態(tài)的發(fā)生率及相關(guān)因素研究

龍潔，劉永珍，蔡焯基，等

熱點追蹤

抑郁癥

·編者按·

抑郁癥是一種常見的情感性精神障礙.據(jù)統(tǒng)計，全球約有3.4億人受其影響，我國的抑郁癥患者也已經(jīng)超過2600萬.有研究表明，大約16%的人在其一生中的某個階段可能經(jīng)歷抑郁發(fā)作.此外，抑郁癥患者自殺、自傷的危險性非常高.據(jù)報道，自殺死亡者中40%患有抑郁癥.根據(jù)WHO最新報告，預(yù)計到2020年，抑郁癥將成為導(dǎo)致人類死亡和致殘的第二大類疾病.“藍(lán)色隱憂”，讓人擔(dān)憂.

抑郁癥又稱抑郁障礙，以心境低落為主要的臨床特征，可以從不同程度上表現(xiàn)為悶悶不樂、興趣減退，甚至痛不欲生、悲觀絕望.部分病例有明顯的焦慮和精神運動型遲滯和激越，意志活動減退，嚴(yán)重者有自殺企圖或行為.除情緒癥狀外，患者還有可能出現(xiàn)睡眠障礙、食欲減退或增強、性欲減退或消失等軀體癥狀.同時伴發(fā)出現(xiàn)記憶力下降、注意力障礙等認(rèn)知功能缺損.

目前，抑郁癥的病因尚未有明確定論，但是可以確定，抑郁癥的發(fā)生有著明確的生物學(xué)特性.此外，心理和社會環(huán)境等因素也起到不可忽視的作用.在現(xiàn)代醫(yī)學(xué)模式下，很多研究者從生物、心理和社會三個方面探討抑郁癥的發(fā)病機理，并形成了生物-心理-社會的統(tǒng)一模式，其中涉及神經(jīng)、內(nèi)分泌以及免疫等方面.具體來說，遺傳因素、神經(jīng)生化改變、神經(jīng)內(nèi)分泌假說、抑郁癥的細(xì)胞因子學(xué)說以及心理社會因素都被納入到抑郁癥的發(fā)病機制探討當(dāng)中.其中，從神經(jīng)生化學(xué)角度探討抑郁癥發(fā)病機理的相關(guān)研究中，主要將五羥色胺（5-HT）、去甲腎上腺素（norepinephrine，NE）、多巴胺（Dopamine，DA）、乙酰膽堿（acetylcholine，Ach）中的一種或幾種歸納為抑郁癥發(fā)病的相關(guān)因素.

目前，藥物治療是最主要的抑郁癥治療方法，在這一部分研究中，很多研究者應(yīng)用了動物模型，取得了一定的效果.20世紀(jì)50～60年代，出現(xiàn)了包括單胺氧化酶抑制劑的第一代抗抑郁藥；20世紀(jì)80年代，第二代抗抑郁藥5- HT再攝取抑制劑誕生.目前，具有抗抑郁作用的中草藥也被用于治療抑郁癥.除藥物外，社會心理治療也是常用的方法，常用的社會心理治療包括：支持性心理治療、動力學(xué)心理治療、認(rèn)知治療、行為治療、人際心理治療、婚姻和家庭治療.此外，對于一些較為嚴(yán)重的狀況，還會應(yīng)用腦部刺激等治療方法.有研究者指出，聯(lián)合治療模式正在成為抑郁癥治療新趨勢，主要包括藥物治療與心理治療的聯(lián)合模式和藥物治療與物理治療的聯(lián)合模式.

本專題得到了袁勇貴主任醫(yī)師（東南大學(xué)附屬中大醫(yī)院）的大力支持.

·熱點數(shù)據(jù)排行·

截至2015年3月23日，中國知網(wǎng)（CNKI）和Web of Science（WOS）的數(shù)據(jù)報告顯示，以抑郁癥（depression）為詞條檢索到的期刊文獻(xiàn)分別為11320與44795條，本專題將相關(guān)數(shù)據(jù)按照：研究機構(gòu)發(fā)文數(shù)、作者發(fā)文數(shù)、期刊發(fā)文數(shù)、被引用頻次進行排行，結(jié)果如下.

研究機構(gòu)發(fā)文數(shù)量排名（CNKI）

研究機構(gòu)發(fā)文數(shù)量排名（WOS）

作者發(fā)文數(shù)量排名（CNKI）

作者發(fā)文數(shù)量排名（WOS）

期刊發(fā)文數(shù)量排名（CNKI）

期刊發(fā)文數(shù)量排名（WOS）

根據(jù)中國知網(wǎng)（CNKI）數(shù)據(jù)報告，以抑郁癥（depression）為詞條檢索到的高被引論文排行結(jié)果如下.

國內(nèi)數(shù)據(jù)庫高被引論文排行

根據(jù)Web of Science統(tǒng)計數(shù)據(jù)，以抑郁癥（depression）為詞條檢索到的高被引論文排行結(jié)果如下.

國外數(shù)據(jù)庫高被引論文排行

·推薦綜述·*摘編自《第三軍醫(yī)大學(xué)學(xué)報》2014年36卷11期1113～1117頁

抑郁癥治療研究新進展*

瞿偉，谷珊珊

（第三軍醫(yī)大學(xué)西南醫(yī)院臨床心理科 全軍心理衛(wèi)生研究中心，重慶 400038）

抑郁癥是一種高患病率、高疾病負(fù)擔(dān)、高復(fù)發(fā)率、高致殘率、高自殺率的慢性精神疾病.根據(jù)WHO最新報告，預(yù)計到2020年，抑郁癥將成為導(dǎo)致人類死亡和致殘的第二大類疾病.自20世紀(jì)80年代以來，抑郁癥治療的研究取得了長足的進步，特別是第 3代抗抑郁藥 5-羥色胺再攝取抑制劑的誕生，開啟了抑郁癥治療的新篇章，大大增強了藥物治療的安全性、方便性.隨后 10年相繼研發(fā)出第4代5-羥色胺與去甲腎腺素雙通道再攝取抑制劑（SNRI類，如萬拉法新）、5-羥色胺與去甲腎腺素雙通道調(diào)節(jié)劑（NaSSa類，如米氮平），為醫(yī)師給患者制訂個性化治療方案提供了更安全、更有效、更多的藥物選擇.隨著基因組學(xué)、腦影像學(xué)、神經(jīng)科學(xué)研究的深入，2010年《自然》雜志主編PhilipCampbel提出抑郁癥是腦部發(fā)育性疾病，至此，抑郁癥屬于功能性疾病的觀念被徹底更正，因此，藥物治療仍然是當(dāng)前抑郁癥治療的主要手段.盡管第3、4代抗抑郁藥有更高的治療緩解率、更好的耐受性而成為一線抗抑郁藥物，而且對中、重度抑郁癥也具有良好的療效，但目前一線抗抑郁藥物的治愈率僅為30%，導(dǎo)致患者及家屬對治療效果不滿意.癥狀的復(fù)燃和復(fù)發(fā)是抑郁癥的病程特征，抑郁癥狀復(fù)燃和復(fù)發(fā)的原因涉及生理、心理及社會等多種原因，因此，心理治療作為治療抑郁癥的一個重要手段越來越受到關(guān)注.盡管循證研究證實認(rèn)知行為治療（cognitive behavioral therapy，CBT）對抑郁癥治療有效，但心理治療起效是一個漸進、累積產(chǎn)生效應(yīng)的過程，比藥物起效更慢，因此，患者早期往往難以耐受逐漸起效的過程，甚至難以相信心理治療的效果，而更愿意接受藥物治療.抑郁癥的物理治療包括電休克治療（electroconvulsive therapy，ECT）、迷走神經(jīng)刺激（vagusnerve stimulation，VNS）及經(jīng)顱磁刺激（transcranial magnetic stimulation，TMS）等，其中改良型無抽搐電休克治療（modified electroconvulsive therapy，MECT）抑郁癥的有效率達(dá)70%～90%.研究顯示不同的物理治療其療效也因人而異.無論是藥物治療、心理治療，還是物理物治療均提示有效，但臨床實際效果不盡如人意，而且同樣的藥物、同樣的治療方法，不同人卻療效不同，是什么原因?qū)е炉熜У牟町?？還有哪些因素影響著療效與結(jié)局？如何提升抑郁癥治療的療效？這對患者和醫(yī)師都具有非常重要的意義.越來越多的研究證據(jù)表明抑郁癥是一種病因、機制及療效異質(zhì)性很大的疾病，很多學(xué)者發(fā)現(xiàn)患者依從性、治療偏好等因素均對治療結(jié)局產(chǎn)生微妙而重要的影響，現(xiàn)就對近年來抑郁癥治療領(lǐng)域研究中出現(xiàn)的新理念、新趨勢、新進展展開述評.

1抑郁癥治療管理新理念

1.1基于評估治療（measurement-based care，MBC）模式被推薦

雖然循證醫(yī)學(xué)及美國精神病協(xié)會抑郁障礙防治指南對抑郁癥治療過程評估作出了規(guī)范的推薦，但臨床實踐與規(guī)范推薦之間仍有較大差異.過去基于經(jīng)驗性治療方式、治療方法及治療過程不規(guī)范，醫(yī)院之間及醫(yī)師之間診治水平相差大，抗抑郁藥物治療用量不充分、療程不完整，常規(guī)評估未廣泛實施，導(dǎo)致患者或醫(yī)師對臨床癥狀、社會生活功能了解不充分、不全面，患者往往根據(jù)自己主觀癥狀改善而自行停藥，或醫(yī)師根據(jù)患者癥狀改善的描述而過早減少藥物劑量或停藥，導(dǎo)致較難達(dá)到抑郁癥的治療目標(biāo).在此背景下，MBC治療模式或量化治療模式應(yīng)運而生.國外學(xué)者提出 MBC治療是精神科或心理科臨床獲得更高療效的有效策略.MBC是一種在臨床實踐中實施循證醫(yī)學(xué)路徑的治療模式，由以下幾部分組成：①準(zhǔn)確評估癥狀及嚴(yán)重程度，確保足夠的抗抑郁藥物劑量；②評估藥物的耐受性、監(jiān)測藥物不良反應(yīng)，確保治療的安全性；③評估還包括患者社會、心理及生活功能損害和恢復(fù)狀態(tài)，以確定治愈的程度.MBC治療模式在慢性病如糖尿病、高血壓管理中早已被廣泛使用，醫(yī)師根據(jù)臨床量化指標(biāo)及時調(diào)整藥物劑量或治療方案，以提高醫(yī)療質(zhì)量，改善患者轉(zhuǎn)歸.精神科最早在抑郁癥的序貫治療研究（sequenced treatment alternatives to relieve depression*，STAR*D）中推廣使用MBC，采用簡單、可信的工具對患者的癥狀、不良反應(yīng)、安全性等方面進行系統(tǒng)評估.MBC在精神科的治療實用性和有效性已在多個臨床研究及臨床實踐中被驗證.2010年版美國精神病學(xué)會（American psychiatric association，APA）抑郁癥治療指南推薦將MBC加入抑郁癥疾病的管理，2012年第5版《精神疾病診斷與統(tǒng)計手冊》（DSM-Ⅴ）指出：精神疾病的評估是DSM-Ⅴ的工作目標(biāo)和重大更新之一.

目前，國外研究證明患者健康問卷-9項量表（patient health questionnaire-9，PHQ-9）是一種簡單、有效的評估工具.PHQ-9量表由9個條目組成，包括抑郁癥核心癥狀、生活、社會、心理功能，可以協(xié)助醫(yī)師判斷是否抑郁，以及抑郁嚴(yán)重程度，醫(yī)師可根據(jù)其評分結(jié)果決定后續(xù)治療方案，通過評估避免患者和醫(yī)師停留在疾病主觀感覺的認(rèn)識上，而讓患者和醫(yī)師對疾病狀態(tài)的變化有客觀、量化、系統(tǒng)、全面的認(rèn)識，提高患者的依從性，從而提高臨床療效.MBC在國內(nèi)精神科領(lǐng)域仍是一個較新的概念.2013年第十屆中國神經(jīng)精神科年會上王剛教授在報告中談到，采用隨機、對照方式驗證了MBC治療模式的有效性，其研究證實量化治療組在整體有效性和服藥依從性方面均顯著優(yōu)于常規(guī)治療組，量化治療作為一種更加系統(tǒng)、規(guī)范、高效標(biāo)準(zhǔn)化的治療模式，已成為精神科治療的新模式.

1.2提高依從性作為治療的重要策略被提出

藥物治療是控制癥狀和預(yù)防復(fù)發(fā)的主要手段.有研究表明，首次抑郁發(fā)作的患者其復(fù)發(fā)率至少為50%，已有2次抑郁發(fā)作的患者其復(fù)發(fā)率則高達(dá)80%～90%.研究顯示，在臨床抗抑郁藥治療研究中，未依從醫(yī)師治療方案的患者達(dá)40%～70%，而且隨著治療時間越長，患者依從性比例呈遞減趨勢，抑郁癥脫落率高達(dá)50%～70%.不依從行為包括患者自行減少藥物劑量或提前中斷治療等.抑郁癥是一種慢性疾病，決定了其需要長期治療的必要性.APA抑郁癥治療指南中推薦治療分4期：急性治療期、鞏固治療期、維持治療期、撤藥治療期，完成4個治療周期一般需要1～2年，甚至更長，對患者、家屬來說是一個很大的挑戰(zhàn).有學(xué)者提出患者依從性比有效的治療方案更重要.因此，患者依從性成為影響臨床療效的關(guān)鍵因素之一.影響患者依從性因素包括患者因素、藥物因素及疾病因素.其中患者因素包括對疾病的態(tài)度、患者治療偏好等，成為影響患者依從性的中介調(diào)節(jié)因素.藥物因素包括藥物吞服困難、日服藥的次數(shù)、服藥方法的復(fù)雜性、同時服藥的種類、藥物引起不良反應(yīng)的嚴(yán)重程度、藥物的物理性狀等.疾病的因素包括對疾病的認(rèn)知、對共患病的認(rèn)識、對藥物療效的了解、對治療起效時間的了解、對潛在不良反應(yīng)的了解、對癥狀改善的簡單認(rèn)識等.研究顯示良好的依從性有助于提高臨床治愈率.因此，2010年APA在抑郁癥治療推薦指南中增設(shè)了患者和家屬教育這一項，將提高依從性作為治療的重要策略提出.教育內(nèi)容包括疾病基本知識、治療方法及療效、藥物服用方法、藥物副作用應(yīng)對、療程、對治愈的識別與理解等，其目的是盡可能讓患者參與到治療決策中來，從而提高患者的依從性.

1.3患者治療偏好作為治療策略被建議

隨著健康理念不斷更新，治療中患者個人更傾向于某種治療方式或者某種治療藥物，這一患者治療偏向的概念在臨床實踐中得以廣泛應(yīng)用.在臨床實踐中，醫(yī)師往往選擇對患者最重要、最有價值、最大獲益的治療，但某些研究，包括STAR*D研究得到的數(shù)據(jù)顯示，患者對治療的不同偏好會導(dǎo)致治療反應(yīng)差異很大.2012年Steidtmann等對患者選擇匹配和不匹配治療結(jié)局效應(yīng)值的薈萃分析發(fā)現(xiàn)，主動接受醫(yī)師制訂治療方案的患者比未接受或被動接受醫(yī)師制訂治療方案的患者退出治療的可能性減少1/3～1/2，接受醫(yī)師制訂治療方案的患者不僅退出更少，而且臨床改善更快、結(jié)局更好.這提示患者治療偏好可通過影響依從性和合作性而最終影響治療結(jié)局.研究顯示，抑郁起效與治療偏好有關(guān)，僅選擇藥物治療的患者預(yù)后不佳，患者治療偏好是其療效不佳和脫落的預(yù)測因子.研究表明，40%～60%的抑郁癥患者選擇藥物聯(lián)合心理治療，而 20%～40%的抑郁癥患者沒有治療的偏好，其中偏向藥物治療往往更易脫落，偏向心理治療的患者依從性更高.患者偏好受年齡、疾病種類、花費、服藥方便性等多種因素影響.在治療上有偏向性的患者特征：年齡偏大，更加認(rèn)同抑郁癥是一種疾病，既往服用抗抑郁藥的比例更高，既往發(fā)作次數(shù)更多，既往就診率更高，且在治療3個月即呈現(xiàn)出更快的癥狀改善.這些研究結(jié)果給臨床醫(yī)師提供了一個有益的啟發(fā)，重視和利用患者治療偏好是提高臨床療效的策略之一.

1.4早期起效作為提高療效的重要策略被強調(diào)

抑郁癥治療早期療效一般在2～4周起效.抑郁癥治療起效慢一直困擾著患者、家屬和醫(yī)師，不但延長和加重患者及家屬痛苦，增加經(jīng)濟負(fù)擔(dān)，而且易導(dǎo)致患者對治療失去信心，中斷治療，從而降低依從性.研究發(fā)現(xiàn)，有些抗抑郁藥物可以在2周內(nèi)起效，且快速起效與最終治療結(jié)局密切相關(guān).一項包括1982—2003年42項臨床試驗、納入了6562例抑郁癥患者、評估抗抑郁藥物能否預(yù)測患者預(yù)后的薈萃分析研究顯示，研究結(jié)束時在獲得穩(wěn)定臨床治愈者中92%（1084/1172）為早期改善者，早期的療效可以有效預(yù)測臨床預(yù)后，早期療效預(yù)測穩(wěn)定療效及臨床治愈率的敏感度分別在81%和87%以上.一項前瞻性、多中心的包括705例抑郁癥住院患者的研究采用漢密頓抑郁自殺因子（Hamilton depression rating scale for depression，HAMD-3）評分，評估患者早期療效與自殺意念的關(guān)系，發(fā)現(xiàn)早期無效患者自殺意念的發(fā)生率比早期有效患者升高3～5倍，而且早期有效患者顯著降低了悲觀情緒.這些研究給臨床醫(yī)師啟示：在抗抑郁治療的同時，選擇起效快、臨床治愈率高的藥物可以更快改善患者的癥狀，減輕患者的痛苦，降低自殺的風(fēng)險，從而增加患者依從性；早期起效是抑郁癥早期治療的重要策略之一.

2聯(lián)合治療模式成為抑郁癥治療新趨勢

2.1藥物治療與心理治療聯(lián)合模式

抗抑郁藥物僅對1/3的患者完全有效，循證研究已表明CBT治療不僅對治療抑郁癥有效，而且可通過改變患者抑郁認(rèn)知模式、糾正其不合理信念從而降低復(fù)發(fā)率，但心理治療起效更慢，導(dǎo)致很多患者并不接受治療.什么樣的方法既能快速起效，又能降低復(fù)發(fā)率，提升療效的穩(wěn)定性呢？過去50年的精神病學(xué)實踐見證了精神藥物的迅速發(fā)展，同時心理治療也得到了越來越多的重視.大量證據(jù)顯示藥物治療和心理治療聯(lián)合方式可以更好地改善抑郁癥狀及其預(yù)后.2013年Wiles等的研究表明：在綜合醫(yī)院難治性抑郁癥藥物中輔以CBT治療，在治療6個月時，聯(lián)合CBT治療組患者有效性比常規(guī)藥物治療組增加了3倍，提示藥物治療與心理治療聯(lián)合使患者的獲益更多.研究顯示，在初始藥物治療失敗的情況下，最佳治療選擇是藥物治療與心理治療聯(lián)合.心理治療方法很多，在臨床實踐中，醫(yī)師會根據(jù)患者的具體情況而選擇不同的心理治療方法，如精神分析、家庭治療、人際關(guān)系治療以及團體治療等.除了CBT治療被循證醫(yī)學(xué)證實是有效的方法外，其他心理治療方法，如精神分析、系統(tǒng)家庭治療、人際關(guān)系治療等均在抑郁癥患者中應(yīng)用，但其治療效果受患者個體因素及醫(yī)師因素影響很大，而且心理治療更強調(diào)個案化，因此，至今尚少見大樣本或循證研究證實精神分析、家庭治療對抑郁癥治療有效，但并不能否定或低估精神分析、家庭治療以及人際關(guān)系治療抑郁癥有效的事實.事實上，臨床較多患者在接受家庭治療后，家庭溝通模式得到改善，家庭成員增加了對患者抑郁癥的認(rèn)識，從而改變了自己行為，家庭人際關(guān)系隨之變得友善、包容、互助；一些患者在接受人際關(guān)系治療后，學(xué)習(xí)了基本人際交往技巧，使自己變得自信起來，改變了自卑和壓抑，從而抑郁情緒得到了改善.臨床常見現(xiàn)象是家庭成員對患者越能理解和關(guān)心，患者癥狀改善更快而且維持療效越好，否則即使暫時好轉(zhuǎn)，也難以維持療效的穩(wěn)定.因此，藥物治療聯(lián)合心理治療成為抑郁癥治療領(lǐng)域的新趨勢.早期通過藥物治療改善患者睡眠，軀體癥狀以及緩解抑郁、焦慮情緒，后期實施心理治療，糾正患者不合理觀念，提高患者對自我的認(rèn)識與理解，從而更全面改變患者抑郁狀態(tài)，提升患者生活質(zhì)量.然而，開展心理治療需要醫(yī)師接受系統(tǒng)理論和操作技能的培訓(xùn)，還需考慮醫(yī)師的經(jīng)驗、倫理、法律，以及患者對心理治療的感受與信念等諸多問題.心理治療被倡導(dǎo)和重視，終將推動抑郁癥臨床治療模式的改變和完善.此外，由于CBT治療需要醫(yī)患雙方面對面，并且需要很長時間、多次，甚至長達(dá)幾十次的面談，患者心理阻抗比較大，為CBT治療帶來很大阻力和不便，能長期堅持治療對患者來說具有很大挑戰(zhàn).一種新的心理治療方式——電話CBT治療引起了學(xué)者的興趣與關(guān)注.Mohr等發(fā)現(xiàn)，在18個月治療過程中，電話訪談和面談均能降低HMAD和PQH-9評分，但6個月時面談患者HMAD和PQH-9評分均優(yōu)于電話訪談患者.在18個月治療過程中，與面談患者相比，接受電話訪談患者終止治療的比例更少，電話訪談和面談脫落率差異有統(tǒng)計學(xué)意義（20.9% vs 32.7%，P=0.02），前5個月中，面談較電話訪談脫落率更高（4.3% vs 13.3%）.該研究顯示，非傳統(tǒng)心理干預(yù)方式在抑郁癥治療中顯示出其積極的價值.

2.2藥物治療聯(lián)合物理治療

大腦中電脈沖是信息加工與傳遞的基礎(chǔ)，因此，大腦電刺激或脈沖的改變在理論上能夠改變大腦局部神經(jīng)生化學(xué)的變化，從而改變大腦局部的功能.精神醫(yī)學(xué)正處于快速發(fā)展的階段，對精神疾病的機制及治療手段研究近幾年不斷推陳出新.在精神科具有代表性的物理治療手段包括ECT、VNS及TMS等.ECT是整個新物理治療家族中的鼻祖，是APA指南推薦的嚴(yán)重抑郁癥的治療選擇.ECT聯(lián)合藥物治療是治療新發(fā)抑郁癥的有效手段，但有研究表明ECT與急性和部分慢性記憶缺失相關(guān)，故未能被充分利用.而MECT總體療效與傳統(tǒng)ECT療效相當(dāng)，且對記憶的影響較少，易被患者及家屬接受，目前在臨床得以推廣.在2011年164屆美國精神病年會上有學(xué)者報告MECT可以早期用于抑郁癥患者，能快速改善抑郁癥患者的臨床癥狀.TMS是20世紀(jì)80年代中期發(fā)展起來的一種影響和改變大腦功能的生物刺激技術(shù)，已有研究證實其治療抑郁癥的安全性及有效性，對初始藥物治療失敗的患者，TMS治療被APA推薦為抑郁障礙的治療方法之一.VNS是不適用于絕大多數(shù)其他治療方法的長期（慢性）抑郁癥患者的最佳治療選擇，被FDA批準(zhǔn)用于治療難治性抑郁.在臨床實踐中，有醫(yī)師針對患者個體化特征，采取藥物治療、心理治療、物理治療3種治療方法聯(lián)合，同樣收到一定效果.

3展望

目前研究顯示，抗抑郁藥有效率僅為60%～80%，治愈率也僅為30%，起效時間2～4周.近年，藥物研究最新的熱點是氯胺酮的快速起效.研究表明氯胺酮治療抑郁癥4～72 h治療有效率及治愈率平均為77%和43%，但維持療效時間較短.因此，抗抑郁藥仍然存在起效較慢、治愈率不高的問題，不能滿足患者對治療及時起效的需要以及對治療結(jié)局的期待.如何提升其療效的持久性與穩(wěn)定性已成為該領(lǐng)域研究熱點.此外，臨床醫(yī)師如認(rèn)識到患者依從性、治療偏好、早期起效等因素都潛在影響著治療的效果，不僅拓展了其臨床思維和視野，而且為其提供了新的治療策略和循證治療依據(jù).醫(yī)師將這些影響因素納入對疾病的管理和處置考慮中，將顯示出比既往更好的治療效果，這些重要發(fā)現(xiàn)對完善、規(guī)范抑郁癥的臨床治療有很大的指導(dǎo)意義.無論從病因?qū)W、疾病機制、流行病學(xué)、臨床現(xiàn)象學(xué)，還是治療學(xué)等方面考慮，抑郁癥都是一種復(fù)雜、異質(zhì)性很大的精神疾病.對抑郁癥的遺傳學(xué)、神經(jīng)回路標(biāo)記或心理學(xué)標(biāo)記潛在價值目前也不清楚，這些問題有望在將來得到澄清.即使這些問題得到澄清，不同的患者需要哪種治療方法，同樣需要醫(yī)師借助大量的臨床研究資料和豐富臨床經(jīng)驗，對患者進行全面判斷，做出治療決策時必須權(quán)衡科學(xué)證據(jù)，并了解藥理學(xué)和心理學(xué)知識，確保選擇最好的治療措施.因此，對抑郁癥的治療不僅需要從生物層面，從心理、社會的層面進行，還需要有一個完整的康復(fù)體系，全面提升抑郁癥患者生理、心理、社會功能.今后抑郁癥治療模式是精神科醫(yī)師、心理治療師、社會工作者三方聯(lián)合，以便真正提高抑郁癥的治愈率，使抑郁癥的整體發(fā)病率及致殘率降低.

·經(jīng)典文獻(xiàn)推薦·

基于Web of Science檢索結(jié)果，利用Histcite軟件選取LCS（Local Citation Score，本地引用次數(shù)）TOP 30文獻(xiàn)作為節(jié)點進行分析，得到本領(lǐng)域推薦的經(jīng)典文獻(xiàn)如下.

來源出版物：Journal of Neurology Neurosurgery and Psychiatry，1960，23（1）： 56-62

An inventory for measuring depression

Beck AT； Erbaugh J； Ward CH； et al.

Abstract： The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanickin a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective，measurable and verifiable criteria of classification based not on personal or parochial considerations，but on behavioral and other objectively measurable manifestations."

來源出版物：Archives of General Psychiatry，1961，4（6）： 561-571

Collaborative Management to Achieve Treatment Guidelines — Impact On Depression in Primary-Care

Katon W； Vonkorff M； Lin E； et al.

Abstract： Objective： To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of ''usual care'' by the primary care physician.

Design： A randomized controlled trial among primary care patients with major depression or minor depression.

Patients： Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized，with 91 patients meeting criteria for major depression and 126 for minor depression.

Interventions： lntervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment（visits 1 and 3 with a primary care physician，visits 2 and 4 with a psychiatrist）and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials.

Main Outcome Measures： Primary outcome measures included short-term（30 day）and long-term（90 day）use of antidepressant medication at guideline dosage levels，satisfaction with overall care for depression and antidepressant medication，and reduction in depressive symptoms.

Results： In patients with major depression，the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more（75.5% vs 50.0%； P＜0.01），were more likely to rate the quality of the care they received for depression as good to excellent（93.0% vs 75.0%； P＜0.03），and were more likely to rate antidepressant medications as helping somewhat to helping a great deal（88.1% vs 63.3%； P＜0.01）. Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls（P＜0.01），and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls（P＜0.004）. In patientswith minor depression，the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more（79.7% vs 40.3%； P＜0.001）and more often rated antidepressant medication as helping somewhat to helping a great deal（81.8% vs 61.4%； P＜0.02）. However，no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression（94.4% vs 89.3%），in the percentage who experienced a 50% or more decrease in depressive symptoms，or in the decrease of depressive symptoms over time.

Conclusion： A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist，intensive patient education，and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major，but not minor，depression.

來源出版物：JAMA-Journal of the American Medical Association，1995，（273）： 1026-1031

Depression Following Myocardial-Infarction — Impact On 6-Month Survival

Frasuresmith N； Lesperance F； Talajic，M

Abstract： Objective： To determine if the diagnosis of major depression in patients hospitalized following myocardial infarction（MI）would have an independent impact on cardiac mortality over the first 6 months after discharge.

Design： Prospective evaluation of the impact of depression assessed using a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. Cox proportional hazards regression was used to evaluate the independent impact of depression after control for significant clinical predictors in the data set.

Setting： A large，university-affiliated hospital specializing in cardiac care，located in Montreal，Quebec.

Patients： All consenting patients（N=222）who met established criteria for MI between August 1991 and July 1992 and who survived to be discharged from the hospital. Patients were interviewed between 5 and 15 days following the MI and were followed up for 6 months. There were no age limits（range，24 to 88 years； mean，60 years）. The sample was 78% male.

Primary Outcome Measure： Survival status at 6 months.

Results： By 6 months，12 patients had died. All deaths were due to cardiac causes. Depression was a significant predictor of mortality（hazard ratio，5.74； 95% confidence interval，4.61 to 6.87； P=0.0006）. The impact of depression remained after control for left ventricular dysfunction（Killip class）and previous MI，the multivariate significant predictors of mortality in the data set（adjusted hazard ratio，4.29；95% confidence interval，3.14 to 5.44； P=0.013）.

Conclusion： Major depression in patients hospitalized following an MI is an independent risk factor for mortality at 6 months. Its impact is at least equivalent to that of left ventricular dysfunction（Killip class）and history of previous MI. Additional study is needed to determine whether treatment of depression can influence post-MI survival and to assess possible underlying mechanisms.

來源出版物：JAMA-Journal of the American Medical Association，1993，（270）： 1819-1825

Reduction of Prefrontal Cortex Glucose-Metabolism Common to 3 Types Of Depression

Baxter LR； Schwartz JM； Phelps ME； et al.

Abstract： Using positron emission tomography，we studied cerebral glucose metabolism in drug-free，age- and sex-matched，right-handed patients with unipolar depression（n=10），bipolar depression（n=10），obsessive-compulsive disorder（OCD）with secondary depression（n=10），OCD without major depression（n=14），and normal controls（n=12）. Depressed patients were matched for depression on the Hamilton Depression Rating Scale，and subjects with OCD without depression and OCD with depression had similar levels of OCD without depression and OCD with depression had similar levels of OCD pathology. We also studied six non-sex-matched patients with mania. Mean（±SD）glucose metabolic rates for the left dorsal anterolateral prefrontal cortex，divided by the rate for the ipsilateral hemisphere as a whole（ALPFC/hem），were similar in the primary depressions（unipolar depression =1.05±0.05； bipolar depression =1.04±0.05），and were significantly lower than those in normal controls（1.12±0.06）or OCD without depression（1.15±0.05）. Results for the right hemisphere were similar. Values in subjects with OCD with depression（1.10±0.05）were also significantly lower than in subjects with OCD without depression，and values in subjects with bipolar depression were lower than those in manic subjects（1.12±0.03）on this measure in the left hemisphere，although results were not significant in the right hemisphere. There was a significant correlation between the HAM-D score and the left ALPFC/hem. With medication for depression（n=12），the left ALPFC/hem increased significantly and the percentage change in the Hamilton scale score correlated with the percentage change in the left ALPFC/hem.

來源出版物：Archives of General Psychiatry，1989，（46）： 243-250

·高被引論文摘要·

被引頻次：646

卒中后抑郁狀態(tài)的發(fā)生率及相關(guān)因素研究

龍潔，劉永珍，蔡焯基，等

目的：了解卒中后抑郁狀態(tài)（PSD）的發(fā)生率及其相關(guān)因素.方法：采用Hamilton抑郁量表和自制一般情況調(diào)查表，對520例腦卒中患者進行調(diào)查評分，并用逐步 Logistic回歸統(tǒng)計方法對各相關(guān)因素進行分析.結(jié)果：PSD總發(fā)生率為34.2%，其中輕度20.2%，中度10.4%，重度3.7%.對 PSD影響最大的相關(guān)因素是既往抑郁癥史，其次是性別、家庭和睦情況、合并疾病種類、神經(jīng)功能缺損嚴(yán)重程度和卒中后病程.結(jié)論：上述因素是本組PSD患者的主要預(yù)測因素，為預(yù)防PSD提供參考依據(jù).

腦血管意外；抑郁癥；Logistic模型

來源出版物：中華神經(jīng)科雜志，2001，34（3）： 145-148

被引頻次：175

腦卒中后抑郁癥的前瞻性研究

張通，孟家眉，項曼君

摘要：對81例初發(fā)大腦半球卒中患者于急性期和發(fā)病后3、6、12個月進行連續(xù)隨訪，旨在觀察腦卒中后抑郁癥的發(fā)生、演變情況及影響抑郁癥的因素.結(jié)果顯示：（1）抑郁癥在病后第3個月時總體評分最高，以后隨時間推移有下降趨勢；（2）病灶最前點愈接近額極，對抑郁癥的影響愈大；（3）神經(jīng)功能缺損的嚴(yán)重程度、合并癥、生活狀態(tài)、照料人是影響抑郁癥的主要相關(guān)因素，而病灶所在的大腦半球、CT掃描上顯示的陳舊病灶、性別、年齡等與抑郁癥的發(fā)生無明顯相關(guān)性.

關(guān)鍵詞：腦血管意外；抑郁癥

來源出版物：中華精神科雜志，1996，29（2）： 73-76

被引頻次：173

1977例抑郁癥患者中醫(yī)不同證候構(gòu)成比分析

胡隨瑜，張宏耕，鄭林，等

摘要：目的：了解抑郁癥中醫(yī)證候類型的構(gòu)成比例，為建立抑郁癥常見中醫(yī)證候標(biāo)準(zhǔn)提供依據(jù).方法：采用臨床流行病學(xué)調(diào)查方法，對湖南、天津、北京、哈爾濱、深圳、廣西、福建、貴州等南北方8個調(diào)查點1977例情感性障礙抑郁發(fā)作患者進行了中醫(yī)辨證及證候指標(biāo)調(diào)查.結(jié)果：抑郁癥患者存在12種證候類型，依據(jù)其構(gòu)成比大小，排前4位的依次是：肝郁氣滯證29.7%，肝郁脾虛證24.5%，肝郁痰阻證13.4%，心脾兩虛證12.8%.結(jié)論：抑郁癥的常見中醫(yī)證候是肝郁氣滯、肝郁脾虛、肝郁痰阻、心脾兩虛證4類，在抑郁癥常見中醫(yī)證型與單相障礙4亞型之間存在一定關(guān)系.

關(guān)鍵詞：抑郁癥；臨床流行病學(xué)；中醫(yī)證候；構(gòu)成比

來源出版物：中國醫(yī)師雜志，2003，5（10）： 1312-1314

被引頻次：157

產(chǎn)后抑郁癥

陳燕杰，鐘友彬

摘要：產(chǎn)后抑郁癥發(fā)病率國外報道為3.5%～33%，國內(nèi)報道為3.8%～16.7%.臨床表現(xiàn)涉及情緒、認(rèn)識、行為、生活等幾個方面，特點為產(chǎn)后2周發(fā)病，4～6周癥狀明顯.主要特征是以嬰兒、丈夫相關(guān)事為主，一般認(rèn)為病因是多因素的.但是，產(chǎn)婦分娩前后體內(nèi)的內(nèi)分泌變化及產(chǎn)婦的個性心理特點，是產(chǎn)后抑郁癥發(fā)生的重要先決條件，一些應(yīng)激性生活事件和產(chǎn)前產(chǎn)時的并發(fā)癥又是產(chǎn)后抑郁癥的主要促發(fā)因素.目前，診斷尚缺乏客觀指標(biāo)，多依據(jù)各種癥狀自評量表，由產(chǎn)婦自填后以相應(yīng)的評分結(jié)果判定.主要是心理治療，約1/3的患者需藥物治療.

關(guān)鍵詞：抑郁癥；產(chǎn)后；病因；防治

來源出版物：實用婦產(chǎn)科雜志，2000，16（1）： 13-15

被引頻次：125

腦卒中后的抑郁癥

李根華

摘要：對腦卒中后抑郁癥表現(xiàn)的發(fā)生率、發(fā)病機理、臨床特征、診斷及治療作一概述，以引起神經(jīng)內(nèi)科醫(yī)師及精神科醫(yī)學(xué)界的重視.

關(guān)鍵詞：腦卒中；抑郁癥

來源出版物：國外醫(yī)學(xué)（腦血管疾病分冊），1996，4（1）： 22-24

被引頻次：125

卒中后抑郁癥研究現(xiàn)狀

馮蓓蕾，王翹楚，顧麗芳

摘要：卒中后抑郁癥是指卒中發(fā)生后，以情緒低落、興趣減退為主的病癥.其發(fā)生率為22%～79%，與病灶部位、病人的個性、社會、家庭、卒中后遺癥等因素有關(guān)，發(fā)病機制尚不清楚，臨床分輕、重兩型.目前研究認(rèn)為，積極治療對卒中預(yù)后有一定作用.

關(guān)鍵詞：卒中；抑郁癥；卒中后抑郁癥

來源出版物：國外醫(yī)學(xué)（腦血管疾病分冊），1999，7（1）： 14-16

被引頻次：123

抑郁癥與中醫(yī)“郁證”的關(guān)系探討

曲淼，唐啟盛

摘要：結(jié)合古代文獻(xiàn)及臨床研究，從文獻(xiàn)記載和臨床癥狀、病因病機等方面論述抑郁癥與郁證的差異及共性.認(rèn)為中醫(yī)“郁證”本身含有兩層含義，一為以病機而立病名，二為情志之病，中醫(yī)有關(guān)抑郁癥的描述只見于后者，而且有關(guān)抑郁癥的描述也在多種中醫(yī)病名的癥狀群中出現(xiàn)，因此抑郁癥與郁證二者不是簡單的等同關(guān)系.并提出抑郁癥中醫(yī)辨證應(yīng)以虛證為綱，結(jié)合臨床觀察，以益腎補虛為大法治療抑郁癥，取得了較好的療效.

關(guān)鍵詞：抑郁癥；郁證；關(guān)聯(lián)研究

來源出版物：北京中醫(yī)藥大學(xué)學(xué)報，2004，27（1）： 11-13

被引頻次：121

針刺治療抑郁癥及其對患者下丘腦-垂體-腎上腺軸的影響

徐虹，孫忠人，李麗萍，等

摘要：目的：明確針刺治療抑郁癥的臨床療效，探討針刺抗抑郁作用的神經(jīng)內(nèi)分泌學(xué)機制.方法：將60例抑郁癥患者隨機分為針刺組和藥物治療對照組.針刺組針刺內(nèi)關(guān)、太沖、三陰交等穴治療4周，對照組口服帕氟西汀治療4周，在治療前后分別作地塞米松抑制試驗（DST），并檢測血漿皮質(zhì)醇和促腎上腺皮質(zhì)激素（ACTH）的濃度.結(jié)果：針刺治療抑郁癥愈顯率約73%，且不良反應(yīng)??；兩組血漿皮質(zhì)醇和ACTH濃度，在治療前后差異均有顯著性意義.

關(guān)鍵詞：抑郁癥/針灸療法；氫化可的松/血液；促腎上腺皮質(zhì)激素/血液

來源出版物：中國針灸，2001，24（2）： 78-80

被引頻次：121

產(chǎn)后抑郁癥的篩查標(biāo)準(zhǔn)及發(fā)病因素探討

金燕志，彭濤，王聯(lián)，等

摘要：分析了我院1992年2月1日～4月30日住院分娩產(chǎn)婦中167例應(yīng)用艾氏產(chǎn)后抑郁量表（EPDS）的情況，并分析其發(fā)病因素.其產(chǎn)后抑郁癥陽性率為11.38%（19/167），真陽性率為15.25%（9/59）.EPDS在產(chǎn)后抑郁癥的篩查中其靈敏性高，對高危婦女的篩查是可行的，使患者得到盡早發(fā)現(xiàn)及治療.產(chǎn)后抑郁癥的發(fā)病因素與社會的支持及夫妻關(guān)系有密切關(guān)系.其癥狀往往與關(guān)于嬰兒或丈夫的事為主，表現(xiàn)愛哭，孤僻，悲觀厭世，犯罪感等，在產(chǎn)后4～6周明顯，持續(xù)2周～3個月，嚴(yán)重者可發(fā)展為產(chǎn)后精神病，影響母嬰的身心健康.

關(guān)鍵詞：產(chǎn)后；抑郁癥；艾氏產(chǎn)后抑郁量表

來源出版物：中國婦幼保健，1995，10（5）： 287-288

被引頻次：17200

A rating scale for depression

Hamilton M

Abstract： 參見本期“經(jīng)典文獻(xiàn)推薦”欄目

被引頻次：16720

An inventory for measuring depression

Beck AT； Erbaugh J； Ward CH； et al.

Abstract： 參見本期“經(jīng)典文獻(xiàn)推薦”欄目

被引頻次：12142

The hospital anxiety and depression scale

Zigmond，AS ； Snaith，RP

Abstract： A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.

來源出版物：Acta Psychiatrica Scandinavica，1983，67（6）： 361-370

被引頻次：5840

New depression scale designed to be sensitive to change

Montgomery SA； Asberg M

Abstract： The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inner-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression，the Hamilton Rating Scale（HRS），indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS，indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.

來源出版物：British Journal of Psychiatry，1979，134（4）： 382-389

被引頻次：5111

Development and validation of a geriatric depression screening scale： a preliminary report

Yesavage JA； Brink，TL； Rose TL； et al.

Abstract： A new Geriatric Depression Scale（GDS）designed specifically for rating depression in the elderly was tested for reliability and validity and compared with the Hamilton Rating Scale for Depression（HRS-D）and the Zung Self-Rating Depression Scale（SDS）. In constructing the GDS a 100-item questionnaire was administered to normal and severely depressed subjects. The 30 questions most highly correlated with the total scores were then selected and readministered to new groups of elderly subjects. These subjects were classified as normal，mildly depressed or severely depressed on the basis of Research Diagnostic Criteria（RDC）for depression. The GDS，HRS-D and SDS were all found to be internally consistent measures，and each of the scales was correlated with the subject's number of RDC symptoms. However，the GDS and the HRS-D were significantly better correlated with RDC symptoms than was the SDS. The authors suggest that the GDS represents a reliable and valid self-rating depression screening scale for elderly populations.

來源出版物：Journal of Psychiatric Research，1983，17（1）： 37-49

被引頻次：4715

A self-rating depression scale

Zung WWK

Abstract： The fact that there is a need for assessing depression，whether as an affect，a symptom，or a disorder is obvious by the numerousscales and inventories available and in use today.The need to assess depression simply and specifically as a psychiatric disorder has not been met by most scales available today. We became acutely aware of this situation in a research project where we needed to correlate both the presence and severity of a depressive disorder in patients with other parameters such as arousal response during sleep and changes with treatment of the depressive disorder. It was felt that the general depression scales used were insufficient for our purpose and that the more specific scales were also inadequate. These inadequacies related to factors such as the length of a scale or inventory being too long and too time consuming，especially for a patient.

來源出版物：Archives of General Psychiatry，1965，12（1）： 63-70

被引頻次：3676

Influence of life stress on depression： Moderation by a polymorphism in the 5-HTT gene

Caspi A； Sugden K； Moffitt TE； et al.

Abstract： In a prospective-longitudinal study of a representative birth cohort，we tested why stressful experiences lead to depression in some people but not in others. A functional polymorphism in the promoter region of the serotonin transporter（5-HTT）gene was found to moderate the influence of stressful life events on depression. Individuals with one or two copies of the short allele of the 5-HTT promoter polymorphism exhibited more depressive symptoms，diagnosable depression，and suicidality in relation to stressful life events than individuals homozygous for the long allele. This epidemiological study thus provides evidence of a gene-by-environment interaction，in which an individual's response to environmental insults is moderated by his or her genetic makeup.

Keywords： serotonin transporter； major depression； mood disorders； events； history； perspectives； liability； genomics； onset

來源出版物：Science，2003，301（5631）： 386-389聯(lián)系郵箱：Caspi，A； t.moffitt@iop.kcl.ac.uk

被引頻次：3494

The PHQ-9 - Validity of a brief depression severity measure

Kroenke K； Spitzer RL； Williams JBW

Abstract： Objective： While considerable attention has focused on improving the detection of depression，assessment of severity Is also important in guiding treatment decisions. Therefore，we examined the validity of a brief，new measure of depression severity. Measurements： The Patient Health Questionnaire（PHQ）is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module，which scores each of the 9 DSM-IV criteria as "0"（not at all）to "3"（nearly every day）. The PHQ-9 was completed by 6，000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey，self-reported sick days and clinic visits. and symptom-related difficulty. Criterion validity was assessed against an Independent structured mental health professional（MHP）interview in a sample of 580 patients. Results： As PHQ-9 depression severity Increased，there was a substantial decrease in functional status on all 6 SF-20 subscales. Also，symptom-related difficulty，sick days，and health care utilization increased. Using the MHP reinterview as the criterion standard，a PHQ-9 score greater than or equal to 10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5. 10，15. and 20 represented mild，moderate，moderately severe，and severe depression，respectively. Results were similar in the primary care and obstetrics-gynecology samples. Conclusion： In addition to making criteria-based diagnoses of depressive disorders，the PHQ-9 Is also a reliable and valid measure of depression severity. These characteristics plus Its brevity make the PHQ-9 a useful clinical and research tool.

Keywords： depression； diagnosis； screening； psychological tests； health status

來源出版物：Journal of General Internal Medicine，2001，16（9）： 606-613

被引頻次：2884

The epidemiology of major depressive disorder - Results from the National Comorbidity Survey Replication（NCS-R）

Kessler RC； Berglund P； Demler O； et al.

Abstract： Context Uncertainties exist about prevalence and correlates of major depressive disorder（MDD）.

Objective： To present nationally representative data on prevalence and correlates of MDD by Diagnostic and Statistical Manual of Mental Disorders，F(xiàn)ourth Edition（DSM-IV）criteria，and on study patterns and correlates of treatment and treatment adequacy from the recently completed National Comorbidity Survey Replication（NCS-R）.

Design： Face-to-face household survey，conducted from February 2001 to December 2002.

Setting： The 48 contiguous United States.

Participants： Household residents ages 18 years or older（N=9090）who responded to the NCS-R survey.

Main： Outcome Measures Prevalence and correlates of MDD using the World Health Organization's（WHO）Composite International Diagnostic Interview（CIDI），12-month severity with the Quick Inventory of Depressive Symptomatology Self-Report（QIDS-SR），theSheehan Disability Scale（SDS），and the WHO disability assessment scale（WHO-DAS）. Clinical reinterviews used the Structured Clinical Interview for DSM-IV.

Results： The prevalence of CIDI MDD for lifetime was 16.2%（95% confidence interval ［CI］，15.1-17.3）（32.6-35.1 million US adults）and for 12-month was 6.6%（95% CI； 5.9-7.3）（13.1-14.2 million US adults）. Virtually all CIDI 12-month cases were independently classified as clinically significant using the QIDS-SR，with 10.4% mild，38.6% moderate，38.0% severe，and 12.9% very severe. Mean episode duration was 16 weeks（95% Cl，15.1-17.3）. Role impairment as measured by SIDS was substantial as indicated by 59.3% of 12-month cases with severe or very severe role impairment. Most lifetime（72.1%）and 12-month（78.5%）cases had comorbid CIDI/DSM-IV disorders，with MDD only rarely primary. Although 51.6%（95% Cl，46.1-57.2）of 12-month cases received health care treatment for MDD，treatment was adequate in only 41.9%（95% Cl，35.9-47.9）of these cases，resulting in 21.7%（95% Cl，18.1-25.2）of 12-month MDD being adequately treated. Sociodemographic correlates of treatment were far less numerous than those of prevalence.

Conclusions： Major depressive disorder is a common disorder，widely distributed in the population，and usually associated with substantial symptom severity and role impairment. While the recent increase in treatment is encouraging，inadequate treatment is a serious concern. Emphasis on screening and expansion of treatment needs to be accompanied by a parallel emphasis on treatment quality improvement.

Keywords： International Diagnostic Interview； Randomized Controlled Trial； Impulse-Control Disorders； United-tates； Primary-Care；

Psychiatric-Disorders； Mental-Disorders； Quality Improvement； Anxiety Disorders； Bipolar Disorder

來源出版物：JAMA-Journal of the Ameracan Medical Association，2003，289（23）： 3095-3105

被引頻次：2881

Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale

Cox JL； Holden JM； Sagovsky，R

Abstract： The development of a 10-item self-report scale（EPDS）to screen for Postnatal Depression in the community is described. After extensive pilot interviews a validation study was carried out on 84 mothers using the Research Diagnostic Criteria for depressive illness obtained from Goldberg's Standardised Psychiatric Interview. The EPDS was found to have satisfactory sensitivity and specificity，and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring. The use of the EPDS in the secondary prevention of Postnatal Depression is discussed.

來源出版物：British Journal of Psychiatry，1987，150（6）： 782-786

·推薦論文摘要·

功能MRI揭示抑郁癥腦結(jié)構(gòu)及功能變化的應(yīng)用及展望

房俊芳，王倩，王濱，等

摘要：抑郁癥是由多種因素導(dǎo)致的心境障礙性疾病，主要表現(xiàn)為情緒低落，悲觀，嚴(yán)重者甚至?xí)凶詺A向.有研究發(fā)現(xiàn)抑郁癥與腦部某些神經(jīng)聯(lián)系減低及神經(jīng)遞質(zhì)減少有關(guān).隨著功能MRI的發(fā)展，越來越多的人將功能MRI用于抑郁癥的研究，以期闡明其發(fā)病機制.與傳統(tǒng)的成像方式相比，它能反應(yīng)腦白質(zhì)微結(jié)構(gòu)的變化并將相應(yīng)腦區(qū)的功能狀態(tài)影像化，有利于更加直觀地分析研究腦結(jié)構(gòu)與功能之間的關(guān)系.

關(guān)鍵詞：抑郁癥；腦疾?。淮殴舱癯上?；擴散張量成像；磁共振波譜學(xué)

來源出版物：磁共振成像，2015，6（1）： 52-57聯(lián)系郵箱：王濱，binwang001@aliyun.com

老年腦卒中后抑郁與血管事件的相關(guān)性分析

梁晨，陳文權(quán)，高社榮

摘要：目的：探討老年腦卒中后抑郁（PSD）的相關(guān)因素及PSD與血管事件發(fā)生的相關(guān)性.方法：選擇2011年7月—2014年4月兵團七師醫(yī)院神經(jīng)內(nèi)科收治的326例老年腦卒中患者為研究對象，收集患者臨床資料，根據(jù)漢密爾頓抑郁量表進行評分，分為PSD組（83例）和非PSD組（243例），出院隨訪至2014年7月，分析老年P(guān)SD發(fā)病相關(guān)因素及其與血管事件的相關(guān)性.結(jié)果：PSD組高血壓、糖尿病、冠心病患病率高于非PSD組（χ2=6.374、6.481、7.096，P＜0.05），PSD組NIHSS評分高于非PSD組（u=3724，P＜0.001）.PSD組血管事件發(fā)生率為16.9%（14/83），高于非PSD組的8.2%（20/243）（χ2=4.374，P＜0.05）.Logistic回歸分析顯示，糖尿?。跲R=2.961，95%CI（1.192，7.358），P＜0.05］、血脂［OR=2.383，95%CI（1.134，5.007），P＜0.05］和PSD［OR=4.592，95%CI（1.823，11.567），P＜0.05］是血管事件發(fā)生的危險因素.結(jié)論：老年腦卒中患者合并高血壓、糖尿病、冠心病或神經(jīng)功能缺損嚴(yán)重易并發(fā)PSD，糖尿病、血脂、PSD是隨訪期發(fā)生血管事件的獨立危險因素.

關(guān)鍵詞：卒中；抑郁癥；血管疾?。焕夏耆?/p>

來源出版物：中國全科醫(yī)學(xué)，2015，18（5）： 513-516聯(lián)系郵箱：梁晨，liangc@ sina. cn

失眠與抑郁關(guān)系2008—2013年研究進展及存在問題

張繼輝，劉亞平，潘集陽

摘要：失眠障礙和抑郁癥是成人和兒童最常見的精神障礙之一.以前的觀點認(rèn)為，失眠癥狀是抑郁癥的一個常見伴隨癥狀，會隨著抑郁癥的緩解而消失.但逐漸積累的證據(jù)顯示，失眠癥狀不僅是抑郁癥起病及復(fù)發(fā)的危險因素，也是抑郁癥治療后的殘留癥狀.最新的《精神障礙診斷與統(tǒng)計手冊第5版》和《睡眠障礙國際分類第3版》將失眠障礙看作是與其他精神障礙共病的狀態(tài)，這將對未來失眠癥的診療和臨床研究產(chǎn)生重要的影響.本文主要就2008-2013年關(guān)于失眠（障礙或癥狀）和抑郁癥的研究進展，討論失眠與抑郁癥在疾病層面及癥狀層面上的關(guān)系.

關(guān)鍵詞：失眠；抑郁癥；共?。痪C述

來源出版物：中國心理衛(wèi)生雜志，2015，29（2）： 81-86聯(lián)系郵箱：張繼輝，jihui. zhang@ cuhk. edu. hk.

抑郁癥的腦網(wǎng)絡(luò)失調(diào)：來自圖論分析的證據(jù)

劉威，李海江，邱江

摘要：以腦成像數(shù)據(jù)為支撐，基于圖論的復(fù)雜腦網(wǎng)絡(luò)分析實現(xiàn)了在大尺度上對于大腦的整體定量分析，克服了傳統(tǒng)抑郁癥病理改變研究僅關(guān)注少數(shù)幾個腦區(qū)的缺點.本文主要總結(jié)了：（1）基于圖論的腦網(wǎng)絡(luò)分析的概念；（2）基于圖論的抑郁癥研究現(xiàn)狀；（3）以往傳統(tǒng)研究的不足，抑郁癥腦網(wǎng)絡(luò)研究的當(dāng)前總結(jié)和未來展望.總體來說：抑郁癥病人腦網(wǎng)絡(luò)的小世界屬性依舊存在，但在節(jié)點指標(biāo)上存在明顯的異常，且隨疾病發(fā)展呈線性變化，整個網(wǎng)絡(luò)趨向于隨機化.區(qū)域性的異常主要存在于默認(rèn)網(wǎng)絡(luò)和前額葉-邊緣系統(tǒng)環(huán)路.未來研究中，任務(wù)狀態(tài)下的腦網(wǎng)絡(luò)構(gòu)建和“最小生長樹”技術(shù)的應(yīng)用可能會為抑郁癥病人的腦網(wǎng)絡(luò)異常提供更多的信息.

關(guān)鍵詞：抑郁癥；復(fù)雜腦網(wǎng)絡(luò)；圖論；腦連接組

來源出版物：心理科學(xué)進展，2015，23（1）： 85-92聯(lián)系郵箱：邱江，qiuj318@swu.edu.cn

針刺聯(lián)合西藥治療輕中度抑郁癥患者88例臨床觀察

馬學(xué)紅，楊秀巖，許珂，等

摘要：目的：通過采用基于患者報告臨床結(jié)局的方式觀察針刺聯(lián)合西藥抗抑郁的療效.方法：將88例輕、中度抑郁癥患者隨機分為電針組28例，手針組25例，藥物組35例.藥物組患者給予鹽酸帕羅西汀片，治療第1、2天每日10 mg，每日1次，從第3天開始劑量增加到每日20 mg，每日1次，共服用6周.手針組在藥物組基礎(chǔ)上配合針刺治療，主穴：百會、印堂，基本配穴：風(fēng)府、風(fēng)池（雙側(cè)）、大椎、內(nèi)關(guān)（雙側(cè)）、三陰交（雙側(cè)）；電針組在藥物組基礎(chǔ)上配合電針治療，選穴同手針組，以百會和印堂、雙側(cè)風(fēng)池連接于電針儀正負(fù)極，刺激頻率選2/15Hz疏密交替波.手針組和電針組均隔天治療1次，每次針刺30 min，1周治療3次，療程6周.觀察各組治療前后漢密爾頓抑郁量表17項（HAMD-17）、基于患者報告的癥狀量表（MYMOP）評分變化情況，治療后評價臨床療效.結(jié)果：電針組臨床療效總有效率為89.28%、手針組為92.00%、藥物組為85.71%，電針組和手針組優(yōu)于藥物組（P＜0.05）.各組患者治療后MYMOP各項評分與本組治療前比較差異均有統(tǒng)計學(xué)意義（P＜0.05），并且電針組和手針組各項評分明顯低于藥物組（P＜0.05），而電針組和手針組各項評分比較差異無統(tǒng)計學(xué)意義（P＞0.05）.結(jié)論針刺聯(lián)合西藥可以顯著降低輕、中度抑郁癥患者HAMD-17及MYMOP評分，改善主要癥狀、總體健康狀況和活動情況，優(yōu)于單純西藥治療.

關(guān)鍵詞：抑郁癥；針刺療法；電針療法；漢密爾頓抑郁量表17項；患者報告的癥狀量表

來源出版物：中醫(yī)雜志，2014，55（6）： 493-496聯(lián)系郵箱：圖婭，tuyab@263.net

肝郁脾虛抑郁癥研究進展

董洪坦，韓剛，朱曉晨，等

摘要：肝郁脾虛證是抑郁癥常見證型之一，常由肝氣郁結(jié)證轉(zhuǎn)化而來.目前，對于抑郁癥肝郁脾虛證的基礎(chǔ)研究，一般認(rèn)為，肝郁脾虛時，機體存在神經(jīng)-內(nèi)分泌-免疫系統(tǒng)失調(diào)、腦腸軸異常、腦電生理功能紊亂.抑郁癥肝郁脾虛證臨床治療的效應(yīng)機制可能與神經(jīng)-內(nèi)分泌-免疫網(wǎng)絡(luò)、信號通路、基因表達(dá)關(guān)系密切.該文將近十年有關(guān)抑郁癥肝郁脾虛證臨床流行病學(xué)調(diào)查、證候標(biāo)準(zhǔn)化研究、病理生理學(xué)基礎(chǔ)、臨床效應(yīng)及效應(yīng)機制方面的研究成果及文獻(xiàn)進行綜述，并對研究中存在的一些問題進行討論，提出今后的研究思路與建議.

關(guān)鍵詞：抑郁癥；肝郁脾虛；綜述

來源出版物：環(huán)球中醫(yī)藥，2014，7（2）： 146-150聯(lián)系郵箱：郭蓉娟，dfguorongjuan@163.com

大型綜合醫(yī)院住院患者自殺引發(fā)的思考

胡德英，劉義蘭，鄧先鋒，等

摘要：回顧性分析某大型綜合醫(yī)院護理安全不良事件上報數(shù)據(jù)中的21例住院患者自殺的詳細(xì)資料，并訪談曾經(jīng)發(fā)生患者自殺事件的病房護士長或當(dāng)事人，發(fā)現(xiàn)自殺高危患者具有抑郁癥病史或家族史、有自殺病史或家族史、治療效果不好的癌癥患者、久治不愈的重病患者等特征；認(rèn)知因素、缺乏合適的心理評估、醫(yī)院管理存在薄弱環(huán)節(jié)等是影響患者自殺的重要因素.建議建立患者自殺評估及心理評估體系、加強患者心理健康教育與醫(yī)院管理等措施，以及時發(fā)現(xiàn)自殺患者，防止與減少患者自殺事件的發(fā)生.

關(guān)鍵詞：住院患者；自殺；心理護理；心理評估；抑郁癥

來源出版物：護理學(xué)雜志，2014，29（7）： 61-63聯(lián)系郵箱：胡德英，hude-ying2006@126.com

成都市中心城區(qū)社區(qū)中老年居民抑郁癥篩查及其危險因素研究

王偉文，廖曉陽，楊職藝，等

摘要：目的：調(diào)查成都市中心城區(qū)社區(qū)中老年居民抑郁癥患病狀況并探討相關(guān)危險因素.方法：采取多階段整群抽樣方法選取成都市2個城區(qū)社區(qū)，使用社區(qū)流行病學(xué)調(diào)查常用的患者健康問卷（PHQ-2）抑郁篩查量表和自行設(shè)計的一般資料調(diào)查問卷，對被選社區(qū)居住2年以上的35～70歲中老年居民進行入戶面對面調(diào)查.采用SPSS 18.0軟件計算患病率并使用logistic回歸模型對主要危險因素進行多因素分析.結(jié)果：共調(diào)查城區(qū)居民1015人，其中女性616人，男性399人，年齡58.90±9.48歲.35～70歲城區(qū)居民抑郁癥患病率為4.33%（44/1015），其中男性患病率（2.95%，10/339）低于女性（5.52%，34/616）；人口標(biāo)化后男、女患病率分別為3.41%和6.37%，且差異有統(tǒng)計學(xué)意義（χ2=6.021，P＜0.05）.多因素logistic回歸分析結(jié)果顯示：城區(qū)45～55歲人群較65歲以上人群患抑郁癥風(fēng)險增加［OR=3.465，95%CI（1.470，8.173）］；已婚較離婚人群患抑郁癥風(fēng)險降低［OR=0.174，95%CI（0.040，0.747）］；家庭收入每增加500元，其患抑郁癥風(fēng)險降低27.6%［OR=0.724，95%CI（0.583，0.898）］.結(jié)論：成都市城區(qū)社區(qū)中老年居民女性抑郁癥患病率高于男性，中年、離婚和低收入居民是罹患抑郁癥的主要危險因素.

關(guān)鍵詞：抑郁癥；城區(qū)社區(qū)；中老年居民；PHQ-2抑郁篩查量表；流行病學(xué)調(diào)查；危險因素

來源出版物：中國循證醫(yī)學(xué)雜志，2014，14（1）： 21-24聯(lián)系郵箱：王偉文，wangweiwen@sohu.com

昆明小鼠強迫游泳實驗與懸尾實驗抑郁模型相關(guān)性

孫世光，劉健，鹿巖，等

摘要：目的：探討強迫游泳實驗（FST）和懸尾實驗（TST）作為昆明小鼠抑郁動物模型的相關(guān)性.方法：成年雄性昆明小鼠先后進行TST和FST，攝像系統(tǒng)分別記錄6 min內(nèi)的行為變化，實驗間隔1周，實驗參數(shù)有不動狀態(tài)潛伏期和不動狀態(tài)持續(xù)時間百分率；采用因子分析、聚類分析、相關(guān)分析、一致性檢驗和生存分析等多種統(tǒng)計方法進行數(shù)據(jù)處理.結(jié)果：①因子分析提示，F(xiàn)ST與TST參數(shù)分別反映了FST與TST 2種不同抑郁模型維度.②聚類分析提示，不動狀態(tài)潛伏期參數(shù)反映了抗抑郁狀態(tài)，不動狀態(tài)持續(xù)時間百分率反映了抑郁樣絕望行為；經(jīng)過適當(dāng)數(shù)據(jù)轉(zhuǎn)換后，F(xiàn)ST與TST參數(shù)分別反映了FST與TST 2種不同抑郁模型維度.③相關(guān)分析結(jié)果提示，F(xiàn)ST與TST參數(shù)組內(nèi)具有較好相關(guān)性，而組間不動狀態(tài)潛伏期參數(shù)相關(guān)性尚可.④一致性檢驗ICC統(tǒng)計參數(shù)提示，F(xiàn)ST與TST參數(shù)評價抑郁樣絕望行為一致性均較差；Kappa統(tǒng)計參數(shù)提示，不動狀態(tài)潛伏期可作為FST與TST評價抑郁樣絕望行為一致性的穩(wěn)定參數(shù).⑤生存分析提示，F(xiàn)ST與TST的不動狀態(tài)潛伏期參數(shù)半數(shù)生存期差異有統(tǒng)計學(xué)意義，即FST與TST實驗操作對實驗動物首次產(chǎn)生抑郁樣絕望行為的效力不同，且FST＜TST.結(jié)論：FST與TST參數(shù)反映了2種不同抑郁模型維度；不動狀態(tài)潛伏期是FST與TST評價抑郁樣絕望行為一致性及首次產(chǎn)生抑郁樣絕望行為效力的穩(wěn)定參數(shù)；FST與TST聯(lián)合進行抗抑郁藥物評價時，應(yīng)注意動物模型異質(zhì)性問題.

關(guān)鍵詞：抑郁癥；動物模型；強迫游泳實驗；懸尾實驗；相關(guān)性

來源出版物：中國藥理學(xué)與毒理學(xué)雜志，2014，28（1）： 107-112聯(lián)系郵箱：孫世光，S.G.SUN@hotmail.com

團體心理治療對抑郁癥患者療效及生活質(zhì)量的影響

宋麗，余學(xué)，張慧芳

摘要：目的：探討團體心理治療對抑郁癥患者的療效及生活質(zhì)量的影響.方法：將符合CCMD-3抑郁癥診斷標(biāo)準(zhǔn)的122例住院患者，隨機分成研究組（60例）和對照組（62例），研究組給予團體心理治療聯(lián)合藥物治療，對照組僅接受藥物治療，觀察8周.采用漢密爾頓抑郁量表（HAMD）和世界衛(wèi)生組織生活質(zhì)量量表（WHO.QOL-100）于治療前和治療后8周進行量表評定.結(jié)果：治療后8周末，兩組HAMD總分均顯著下降，但研究組較對照組下降更明顯（t=4.82，P＜0.01）；兩組的生活質(zhì)量均有改善，但研究組在生活質(zhì)量總評（t=2.94，P＜0.01）、心理領(lǐng)域（t=2.44，P＜0.05）、獨立性領(lǐng)域（t=2.98，P＜0.01）及社會關(guān)系領(lǐng)域（t=2.25，P＜0.05）的改善顯著好于對照組.結(jié)論：團體心理治療能有效改善抑郁癥的精神癥狀，提高其生活質(zhì)量，有利于患者重返社會.

關(guān)鍵詞：團體心理治療；抑郁癥；療效；生活質(zhì)量

來源出版物：中國健康心理學(xué)雜志，2013，21（1）： 51-53聯(lián)系郵箱：宋麗，ZMDduqihang@126.com

音樂電針對慢性應(yīng)激抑郁模型大鼠海馬單胺類神經(jīng)遞質(zhì)表達(dá)的調(diào)節(jié)作用

唐銀杉，余仁鋒，紀(jì)倩，等

摘要：目的：觀察音樂電針對慢性應(yīng)激抑郁模型大鼠海馬單胺類神經(jīng)遞質(zhì)五羥色胺（5-HT）、多巴胺（DA）、去甲腎上腺素（NE）表達(dá)的影響，探討音樂電針治療抑郁癥的作用機制.方法：SD大鼠隨機分為4組：空白組、模型組、氟西汀組、音樂電針組，除空白組外，其余均采用慢性應(yīng)激結(jié)合孤養(yǎng)的方式造模.采用曠場實驗、糖水消耗量檢測和體重測量進行行為學(xué)評價；采用放射免疫法檢測大鼠海馬5-HT、NE、DA的表達(dá).結(jié)果與空白組比較，模型組大鼠水平穿越格數(shù)、豎立次數(shù)、糖水消耗量、體重明顯降低（P＜0.01）；與模型組比較，氟西汀組、音樂電針組水平穿越格數(shù)、豎立次數(shù)、糖水消耗量、體重均明顯升高（P＜0.05）.與空白組相比，模型組大鼠海馬組織5-HT、DA、NE 的含量明顯降低（P＜0.01）；與模型組相比，氟西汀組大鼠海馬組織的5-HT、DA、NE 的含量升高（P＜0.05）；音樂電針組大鼠海馬組織的5-HT、DA、NE 的含量升高（P＜0.01、P＜0.05）.與氟西汀組比較，音樂電針組大鼠海馬組織的5-HT的含量增加，有顯著性差異（P＜0.05）.結(jié)論：音樂電針可以改善慢性應(yīng)激抑郁大鼠的行為學(xué)癥狀，具有一定的抗抑郁作用；它能提高慢性應(yīng)激模型大鼠中樞單胺類神經(jīng)遞質(zhì)5-HT、DA、NE的水平，這可能是音樂電針發(fā)揮抗抑郁治療作用的途徑之一.

關(guān)鍵詞：音樂電針；慢性應(yīng)激；抑郁癥；五羥色胺；多巴胺；去甲腎上腺素；大鼠

來源出版物：北京中醫(yī)藥大學(xué)學(xué)報，2013，36（4）： 263-267聯(lián)系郵箱：李志剛，lizhigang620@126.com

Anxiety，Depression，and Cigarette Smoking： A Transdiagnostic Vulnerability Framework to Understanding Emotion-Smoking Comorbidity

Leventhal AM； Zvolensky MJ

Abstract： Research into the comorbidity between emotional psychopathology and cigarette smoking has often focused upon anxiety and depression's manifest symptoms and syndromes，with limited theoretical and clinical advancement. This article presents a novel framework to understanding emotion-smoking comorbidity. We propose that transdiagnostic emotional vulnerabilities-core biobehavioral traits reflecting maladaptive responses to emotional states that underpin multiple types of emotional psychopathology-link various anxiety and depressive psychopathologies to smoking. This framework is applied in a review and synthesis of the empirical literature on 3 transdiagnostic emotional vulnerabilities implicated in smoking：（a）anhedonia（Anh； diminished pleasure/interest in response to rewards），（b）anxiety sensitivity（AS； fear of anxiety-related sensations），and（c）distress tolerance（DT； ability to withstand distressing states）. We conclude that Anh，AS，and DT collectively（a）underpin multiple emotional psychopathologies，（b）amplify smoking's anticipated and actual affect-enhancing properties and other mechanisms underlying smoking，（c）promote progression across the smoking trajectory（i.e.，initiation，escalation/progression，maintenance，cessation/relapse），and（d）are promising targets for smoking intervention. After existing gaps are identified，an integrative model of transdiagnostic processes linking emotional psychopathology to smoking is proposed. The model's key premise is that Anh amplifies smoking's anticipated and actual pleasure-enhancing effects，AS amplifies smoking's anxiolytic effects，and poor DT amplifies smoking's distress terminating effects. Collectively，these processes augment the reinforcing properties of smoking for individuals with emotional psychopathology to heighten risk of smoking initiation，progression，maintenance，cessation avoidance，and relapse. We conclude by drawing clinical and scientific implications from this framework that may generalize to other comorbidities.

Keywords： anxiety； depression； smoking； comorbidity； nicotine dependence

來源出版物：Psychological Bulletin，2015，141（1）： 176-212聯(lián)系郵箱：Leventhal AM； adam.leventhal@usc.edu

Treatment-Resistant Bipolar Depression： A Randomized Controlled Trial of Electroconvulsive Therapy Versus Algorithm-Based Pharmacological Treatment

Schoeyen HK； Kessler U； Andreassen OA； et al.

Abstract： Objective： Electroconvulsive therapy（ECT）is regarded by many clinicians as the most effective treatment for treatment-resistant bipolar depression，but no randomized controlled trials have been conducted，to the authors' knowledge. They compared efficacy measures of ECT and algorithm-based pharmacological treatment in treatment-resistant bipolar depression.

Method： This multicenter，randomized controlled trial was carried out at seven acute-care psychiatric inpatient clinics throughout Norway and included 73 bipolar disorder patients with treatment-resistant depression. The patients were randomly assigned to receive either ECT or algorithm-based pharmacological treatment. ECT included three sessions per week for up to 6 weeks，right unilateral placement of stimulus electrodes，and brief pulse stimulation.

Results： Linear mixed-effects modeling analysis revealed that ECT was significantly more effective than algorithm-based pharmacological treatment. The mean scores at the end of the 6-week treatment period were lower for the ECT group than for the pharmacological treatment group： by 6.6 points on the Montgomery-Asberg Depression Rating Scale（SE=2.05，95% CI=2.5-10.6），by 9.4 points on the 30-item version of the Inventory of Depressive Symptomatology-Clinician-Rated（SE=2.49，95% CI=4.6-14.3），and by 0.7 points on the Clinical Global Impression for Bipolar Disorder（SE=0.31，95% CI=0.13-1.36）. The response rate was significantly higher in the ECT group than in the group that received algorithm-based pharmacological treatment（73.9% versus 35.0%），but the remission rate did not differ between the groups（34.8% versus 30.0%）.

Conclusion： Remission rates remained modest regardless of treatment choice for this challenging clinical condition.

Keywords： rating-scale；disorder；metaanalysis；unipolar；efficacy；ECT；recommendations；guidelines；inpatients；episode

來源出版物：American Journal of Psychiatry，2015，172（1）： 41-51聯(lián)系郵箱：Schoeyen HK； hsc@sus.no

Efficacy and safety of deep transcranial magnetic stimulation for major depression：a prospective multicenter randomized controlled trial

Levkovitz Y； Isserles M； Padberg F； et al.

Abstract： Major depressive disorder（MDD）is a prevalent and disabling condition，and many patients do not respond to available treatments. Deep transcranial magnetic stimulation（dTMS）is a new technology allowing non-surgical stimulation of relatively deep brain areas. This is the first double-blind randomized controlled multicenter study evaluating the efficacy and safety of dTMS in MDD. We recruited 212 MDD outpatients，aged 22-68 years，who had either failed one to four antidepressant trials or not tolerated at least two antidepressant treatments during the current episode. They were randomly assigned to monotherapy with active or sham dTMS. Twenty sessions of dTMS（18 Hz over the prefrontal cortex）were applied during 4 weeks acutely，and then biweekly for 12 weeks. Primary andsecondary efficacy endpoints were the change in the Hamilton Depression Rating Scale（HDRS-21）score and response/remission rates at week 5，respectively. dTMS induced a 6.39 point improvement in HDRS-21 scores，while a 3.28 point improvement was observed in the sham group（p=0.008），resulting in a 0.76 effect size. Response and remission rates were higher in the dTMS than in the sham group（response： 38.4 vs. 21.4%，p=0.013； remission： 32.6 vs. 14.6%，p=0.005）. These differences between active and sham treatment were stable during the 12-week maintenance phase. dTMS was associated with few and minor side effects apart from one seizure in a patient where a protocol violation occurred. These results suggest that dTMS constitutes a novel intervention in MDD，which is efficacious and safe in patients not responding to antidepressant medications，and whose effect remains stable over 3 months of maintenance treatment.

Keywords： deep transcranial magnetic stimulation； major depressive disorder； treatment resistance； response； remission； maintenance treatment

來源出版物：World Psychiatry，2015，14（1）： 64-73

Metabotropic glutamate receptor 3 activation is required for long-term depression in medial prefrontal cortex and fear extinction

Walker AG； Wenthur CJ； Xiang ZX； et al.

Abstract： Clinical studies have revealed that genetic variations in metabotropic glutamate receptor 3（mGlu3）affect performance on cognitive tasks dependent upon the prefrontal cortex（PFC）and may be linked to psychiatric conditions such as schizophrenia，bipolar disorder，and addiction. We have performed a series of studies aimed at understanding how mGlu3 influences PFC function and cognitive behaviors. In the present study，we found that activation of mGlu3 can induce long-term depression in the mouse medial PFC（mPFC）in vitro. Furthermore，in vivo administration of a selective mGlu3 negative allosteric modulator impaired learning in the mPFC-dependent fear extinction task. The results of these studies implicate mGlu3 as a major regulator of PFC function and cognition. Additionally，potentiators of mGlu3 may be useful in alleviating prefrontal impairments associated with several CNS disorders.

Keywords： GRM3； medial prefrontal cortex； fear extinction； long-term depression； group II mGlu receptors

來源出版物：Proceedings of the National Academy of Sciences of the United States of America，2015，112（4）： 1196-1201

聯(lián)系郵箱：Conn，PJ； jeff.conn@vanderbilt.edu

Enhancing Depression Mechanisms in Midbrain Dopamine Neurons Achieves Homeostatic Resilience

Friedman AK； Walsh JJ； Juarez B； et al.

Abstract： Typical therapies try to reverse pathogenic mechanisms. Here，we describe treatment effects achieved by enhancing depression-causing mechanisms in ventral tegmental area（VTA）dopamine（DA）neurons. In a social defeat stress model of depression，depressed（susceptible）mice display hyperactivity of VTA DA neurons，caused by an up-regulated hyperpolarization-activated current（I-h）. Mice resilient to social defeat stress，however，exhibit stable normal firing of these neurons. Unexpectedly，resilient mice had an even larger Ih，which was observed in parallel with increased potassium（K+）channel currents. Experimentally further enhancing Ih or optogenetically increasing the hyperactivity of VTA DA neurons in susceptible mice completely reversed depression-related behaviors，an antidepressant effect achieved through resilience-like，projection-specific homeostatic plasticity. These results indicate a potential therapeutic path of promoting natural resilience for depression treatment.

Keywords： ventral tegmental area；social defeat stress；reward circuit；I-H；channels；susceptibility；inhibition；BDNF

來源出版物：Science，2014，344（6181）： 313-319聯(lián)系郵箱：Han MH； ming-hu.han@mssm.edu

The association between low vitamin D and depressive disorders

Milaneschi Y； Hoogendijk W； Lips P； et al.

Abstract： It has been hypothesized that hypovitaminosis D is associated with depression but epidemiological evidence is limited. We investigated the association between depressive disorders and related clinical characteristics with blood concentrations of 25-hydroxyvitamin D ［25（OH）D］ in a large cohort. The sample consisted of participants（aged 18-65 years）from the Netherlands Study of Depression and Anxiety（NESDA）with a current（N=1102）or remitted（N=790）depressive disorder（major depressive disorder，dysthymia）defined according to DSM-IV criteria，and healthy controls（N=494）. Serum levels of 25（OH）D measured and analyzed in multivariate analyses adjusting for sociodemographics，sunlight，urbanization，lifestyle and health. Of the sample，33.6% had deficient or insufficient serum 25（OH）D（＜50 nmol l-1）. As compared with controls，lower 25（OH）D levels were found in participants with current depression（P=0.001，Cohen's d=0.21），particularly in those with the most severe symptoms（P=0.001，Cohen's d=0.44）. In currently depressed persons，25（OH）D was inversely associated with symptom severity（beta=-0.19，s.e. -0.07，P=0.003）suggesting a dose-response gradient，and with risk（relative risk =0.90，95% confidence interval =0.82-0.99，P=0.03）of having a depressive disorders at 2-year follow-up. This large cohort study indicates that low levels of 25（OH）D were associated to the presence and severity of depressive disorder suggesting that hypovitaminosis D may represent an underlying biological vulnerability for depression. Future studies should elucidate whether-the highly prevalent-hypovitaminosis D could be cost-effectively treated as part of preventive or treatment interventions for depression.

Keywords： vitamin D； parathyroid hormone； depressive disorder

來源出版物：Molecular Psychiatry，2014，19（4）： 444-451聯(lián)系郵箱：Milaneschi Y ； y.milaneschi@ggzingeest.nl

From Stress to Inflammation and Major Depressive Disorder：A Social Signal Transduction Theory of Depression

Slavich GM； Irwin MR

Abstract： Major life stressors，especially those involving interpersonal stress and social rejection，are among the strongest proximal risk factors for depression. In this review，we propose a biologically plausible，multilevel theory that describes neural，physiologic，molecular，and genomic mechanisms that link experiences of social-environmental stress with internal biological processes that drive depression pathogenesis. Central to this social signal transduction theory of depression is the hypothesis that experiences of social threat and adversity up-regulate components of the immune system involved in inflammation. The key mediators of this response，called proinflammatory cytokines，can in turn elicit profound changes in behavior，which include the initiation of depressive symptoms such as sad mood，anhedonia，fatigue，psychomotor retardation，and social-behavioral withdrawal. This highly conserved biological response to adversity is critical for survival during times of actual physical threat or injury. However，this response can also be activated by modern-day social，symbolic，or imagined threats，leading to an increasingly proinflammatory phenotype that may be a key phenomenon driving depression pathogenesis and recurrence，as well as the overlap of depression with several somatic conditions including asthma，rheumatoid arthritis，chronic pain，metabolic syndrome，cardiovascular disease，obesity，and neurodegeneration. Insights from this theory may thus shed light on several important questions including how depression develops，why it frequently recurs，why it is strongly predicted by early life stress，and why it often co-occurs with symptoms of anxiety and with certain physical disease conditions. This work may also suggest new opportunities for preventing and treating depression by targeting inflammation.

Keywords： early life stress； social threat； cytokines； mechanisms； disease

來源出版物：Psychological Bulletin，2014，140（3）： 774-815聯(lián)系郵箱：Slavich GM ； gslavich@mednet.ucla.edu

Rapid regulation of depression-related behaviours by control of midbrain dopamine neurons

Chaudhury D； Walsh JJ； Friedman AK； et al.

Abstract： Ventral tegmental area（VTA）dopamine neurons in the brain's reward circuit have a crucial role in mediating stress responses（1-4），including determining susceptibility versus resilience to social-stress-induced behavioural abnormalities（5）. VTA dopamine neurons show two in vivo patterns of firing： low frequency tonic firing and high frequency phasic firing（6-8）. Phasic firing of the neurons，which is well known to encode reward signals（6，7，9），is upregulated by repeated social-defeat stress，a highly validated mouse model of depression（5，8，10-13）. Surprisingly，this pathophysiological effect is seen in susceptible mice only，with no apparent change in firing rate in resilient individuals（5，8）. However，direct evidence-in real time-linking dopamine neuron phasic firing in promoting the susceptible（depression-like）phenotype is lacking. Here we took advantage of the temporal precision and cell-type and projection-pathway specificity of optogenetics to show that enhanced phasic firing of these neurons mediates susceptibility to social-defeat stress in freely behaving mice. We show that optogenetic induction of phasic，but not tonic，firing in VTA dopamine neurons of mice undergoing a subthreshold social-defeat paradigm rapidly induced a susceptible phenotype as measured by social avoidance and decreased sucrose preference. Optogenetic phasic stimulation of these neurons also quickly induced a susceptible phenotype in previously resilient mice that had been subjected to repeated social-defeat stress. Furthermore，we show differences in projection-pathway specificity in promoting stress susceptibility： phasic activation of VTA neurons projecting to the nucleus accumbens（NAc），but not to the medial prefrontal cortex（mPFC），induced susceptibility to social-defeat stress. Conversely，optogenetic inhibition of the VTA-NAc projection induced resilience，whereas inhibition of the VTA-mPFC projection promoted susceptibility. Overall，these studies reveal novel firing-pattern-and neural-circuitspecific mechanisms of depression.

Keywords： ventral tegmental area； social defeat stress； antidepressant action； reward circuit； IN-VIVO； susceptibility； stimulation；inhibition； expression； responses

來源出版物：Nature，2013，493（7433）： 532-538聯(lián)系郵箱：Han MH； ming-hu.han@mssm.edu

Dopamine neurons modulate neural encoding and expression of depression-related behaviour

Tye KM； Mirzabeko，JJ； Warde，MR； et al.

Abstract： Major depression is characterized by diverse debilitating symptoms that include hopelessness and anhedonia（1）. Dopamine neurons involved in reward and motivation（2-9）are among many neural populations that have been hypothesized to be relevant（10），and certain antidepressant treatments，including medications and brain stimulation therapies，can influence the complex dopamine system. Until now it has not been possible to test this hypothesis directly，even in animal models，as existing therapeutic interventions are unable to specifically target dopamine neurons. Here we investigated directly the causal contributions of defined dopamine neurons to multidimensional depression-like phenotypes induced by chronic mild stress，by integrating behavioural，pharmacological，optogenetic andelectrophysiological methods in freely moving rodents. We found that bidirectional control（inhibition or excitation）of specified midbrain dopamine neurons immediately and bidirectionally modulates（induces or relieves）multiple independent depression symptoms caused by chronic stress. By probing the circuit implementation of these effects，we observed that optogenetic recruitment of these dopamine neurons potently alters the neural encoding of depression-related behaviours in the downstream nucleus accumbens of freely moving rodents，suggesting that processes affecting depression symptoms may involve alterations in the neural encoding of action in limbic circuitry.

Keywords： stress-induced anhedonia； ventral tegmental area； social defeat； animal-model； aversive stimuli； reward circuit； gaba neurons；susceptibility； mice； inhibition

來源出版物：Nature，2013，493（7433）： 537-541聯(lián)系郵箱：Tye KM ； kaytye@mit.edu

The neuroprogressive nature of major depressive disorder： pathways to disease evolution and resistance，and therapeutic implications

Moylan S； Maes M； Wray NR； et al.

Abstract： In some patients with major depressive disorder（MDD），individual illness characteristics appear consistent with those of a neuroprogressive illness. Features of neuroprogression include poorer symptomatic，treatment and functional outcomes in patients with earlier disease onset and increased number and length of depressive episodes. In such patients，longer and more frequent depressive episodes appear to increase vulnerability for further episodes，precipitating an accelerating and progressive illness course leading to functional decline. Evidence from clinical，biochemical and neuroimaging studies appear to support this model and are informing novel therapeutic approaches. This paper reviews current knowledge of the neuroprogressive processes that may occur in MDD，including structural brain consequences and potential molecular mechanisms including the role of neurotransmitter systems，inflammatory，oxidative and nitrosative stress pathways，neurotrophins and regulation of neurogenesis，cortisol and the hypothalamic-pituitary-adrenal axis modulation，mitochondrial dysfunction and epigenetic and dietary influences. Evidence-based novel treatments informed by this knowledge are discussed.

Keywords： cytokines； depression； inflammation； neuroprogression； nitrosative stress； oxidative stress

來源出版物：Molecular Psychiatry，2013，18（5）： 595-606聯(lián)系郵箱：Moylan S； steven.moylan@deakin.edu.au

Burden of Depressive Disorders by Country，Sex，Age，and Year： Findings from the Global Burden of Disease Study 2010

Ferrari AJ； Charlson FJ； Norman RE； et al.

Abstract： Background： Depressive disorders were a leading cause of burden in the Global Burden of Disease（GBD）1990 and 2000 studies. Here，we analyze the burden of depressive disorders in GBD 2010 and present severity proportions，burden by country，region，age，sex，and year，as well as burden of depressive disorders as a risk factor for suicide and ischemic heart disease.

Methods and Findings： Burden was calculated for major depressive disorder（MDD）and dysthymia. A systematic review of epidemiological data was conducted. The data were pooled using a Bayesian meta-regression. Disability weights from population survey data quantified the severity of health loss from depressive disorders. These weights were used to calculate years lived with disability（YLDs）and disability adjusted life years（DALYs）. Separate DALYs were estimated for suicide and ischemic heart disease attributable to depressive disorders. Depressive disorders were the second leading cause of YLDs in 2010. MDD accounted for 8.2%（5.9%-10.8%）of global YLDs and dysthymia for 1.4%（0.9%-2.0%）. Depressive disorders were a leading cause of DALYs even though no mortality was attributed to them as the underlying cause. MDD accounted for 2.5%（1.9%-3.2%）of global DALYs and dysthymia for 0.5%（0.3%-0.6%）. There was more regional variation in burden for MDD than for dysthymia； with higher estimates in females，and adults of working age. Whilst burden increased by 37.5% between 1990 and 2010，this was due to population growth and ageing. MDD explained 16 million suicide DALYs and almost 4 million ischemic heart disease DALYs. This attributable burden would increase the overall burden of depressive disorders from 3.0%（2.2%-3.8%）to 3.8%（3.0%-4.7%）of global DALYs.

Conclusions： GBD 2010 identified depressive disorders as a leading cause of burden. MDD was also a contributor of burden allocated to suicide and ischemic heart disease. These findings emphasize the importance of including depressive disorders as a public-health priority and implementing cost-effective interventions to reduce its burden.

Keywords： systematic analysis； lifetime prevalence； major depression； 21 regions； disability； health； injuries； recall； common

來源出版物：Plos Medicine，2013，10（11）： 331-343聯(lián)系郵箱：Ferrari AJ； alize_ferrari@qcmhr.uq.edu.au

（責(zé)任編輯王帥帥王微（實習(xí)生））

The appearance of yet another rating scale for measuring symptoms of mental disorder may seem unnecessary，since there are so many already in existence and many of them have been extensively used. Unfortunately，it cannot be said that per-fection has been achieved，and indeed，there is considerable room for improvement.

Psychiatric status rating scales； anxiety disorders； depressive disorders

文獻(xiàn)編號文章題目第一作者來源出版物1A Rating Scale for DepressionHamilton MJournal of Neurology Neurosurgery and Psychiatry 1960（230）2An Inventory for Measuring DepressionBeck ATArch Gen Psychiat 1961（4）3Collaborative Management to Achieve Treatment Guidelines - Impact On Depression in Primary-Care Katon WJAMA-Journal of the American Medical Association 1995（273）4Depression Following Myocardial-Infarction - Impact On 6-Month Survival Frasuresmith NJAMA-Journal of the American Medical Association 1993（270）5Reduction of Prefrontal Cortex Glucose-Metabolism Common to 3 Types Of Depression Baxter LRArchives of General Psychiatry 1989（46）

A rating scale for depression

Hamilton M