中国科技论文统计源期刊　中文核心期刊  
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医药导报
医药导报, 2017, 36(10): 1137-1142
doi: 10.3870/j.issn.1004-0781.2017.10.012
精神疾病治疗进展(二):抑郁症*
Therapeutic Progress of Mental Diseases (Second): Depression
周晓丽, 林燕, 郑国庆
温州医科大学附属第二医院神经精神学科,温州 325027
ZHOU Xiaoli,, LIN Yan, ZHENG Guoqing,
Department of Neurology, the Second Affiliated Hospital of Wenzhou Medical University,Wenzhou 325027, China
通信作者 郑国庆(1975-),男,浙江温岭人,教授,博士,主要研究方向:精神神经疾病的临床和基础。E-mail:gq_zheng@sina.com。

作者简介 周晓丽(1992-),女,浙江丽水人,医师,硕士,从事神经精神疾病的临床诊治工作。电话:0577-88002064,E-mail:108398028@qq.com。
基金资助: 浙江省高等学校中青年学科带头人项目(浙教办高科201360277)
中图分类号: R971.43     文献标识码: A     文章编号: 1004-0781(2017)10-1137-06
摘要:

抑郁症是一种常见的心境障碍,具有较高的发病率及患病率,但总体诊断率及治疗率偏低。抑郁症即使初发治愈,仍有较高复发可能,自残自杀风险大。目前,国内外多个临床治疗指南推荐抗抑郁症药物作为中重度抑郁症治疗首选。同时,抑郁症的治疗理念也逐步从最初的单纯依靠药物控制症状向综合性、个体化、量化的治疗模式转变。心理治疗、物理治疗及替代补充治疗等辅助治疗也在不断发展。
关键词: 抗抑郁症药物 ; 抑郁症 ; 综合治疗

Abstract:

Depression is a common mood disorder, with a high incidence and prevalence, while the overall diagnosis and treatment rate are low.Even if patients attained the initial clinical cure, there is still a high risk of depression recurrence, of which a great part may turn into self-mutilation or even suicide.Taking antidepressants as the most preferred treatment of moderate and major depression is recommended by almost all clinical treatment guidelines at home and abroad currently.At the same time, the concept of depression treatment is changing gradually from the initial single-mode drug therapy for symptom control to a comprehensive, individualized, quantitative treatment model.Promising psychological treatment, physical therapy and other alternative and complementary treatments are developing quickly.
Key words: Antidepressants ; Depression ; Comprehensive therapy

抑郁症是一种常见的心境障碍,可由多种原因引起,以显著而持久的情绪低落、愉快感缺失为核心症状。目前抑郁症的病因、发病机制尚不明确。一般认为,抑郁症的发病主要与生物化学因素如去甲肾上腺素(norepinephrine,NE)、5-羟色胺(5-hydroxytryptamine,5-HT)和多巴胺(dopamine,DA),遗传因素,社会与环境因素有关。多数病例有反复发作倾向,每次发作大部分可以缓解,部分患者可有残留症状或进展为慢性抑郁[1]。抑郁症除导致一系列生理、心理、社会功能障碍外,还存在潜在的高自杀风险,加重患者、家属及社会的负担。世界卫生组织(WHO)调查发现,全球抑郁症患者估计为3.22亿例,占世界人口的4.4%[2]。研究表明,抑郁症已经成为全世界最大的致残性疾病[3]。在全球疾病负担过重的疾病中,抑郁症疾病负担占社会总体经济成本的三分之一,预计到2030年将上升至世界疾病负担首位[4]。流行病学资料显示,中国人中有20%存在抑郁症状,其中7%为重度抑郁; 抑郁症占中国疾病负担的第2位,其中仅有不足10%抑郁症患者得到正规治疗[5]。 现就抑郁症的治疗进展综述如下。

1 抑郁症的诊断

抑郁症的诊断主要根据WHO制定的《疾病和有关健康问题的国际统计分类》第10次修订本(International Classification of Diseases,ICD-10)[6]及美国精神病学会(American Psychiatric Association,APA)制定的《精神疾病的诊断和统计手册》第5次修订本(Diagnostic and Statistical Manual of Mental Disorders-5,DSM-5)[7]标准。抑郁症诊断的核心标准为抑郁发作持续至少2周,既往不存在轻躁狂或躁狂发作且除外精神活性物质或器质性精神障碍。目前抑郁症的诊断仍主要基于临床症状主诉,尚无特异性较好的实验室及辅助检查确诊方法。ICD-10及DSM-5中抑郁症的诊断标准主要包括[6-7]:①相对固定的不合乎个体实际情况的抑郁心境,且存在于一天中大多数时间,持续至少2周;②对平时感兴趣的事情丧失兴趣或愉快感;③常感疲惫,精力不足;④其他:自信心丧失、自卑、无价值感、无理由的过分自责、不适当的罪恶感、失眠、食欲减退、体质量减轻、思维分散、注意力降低、反复出现自杀观念或自杀行为等。根据符合的症状条款数目,ICD-10和DSM-5分别界定抑郁的轻、中、重严重程度。英国国家临床最优化研究所(National Institute for Health and Care Excellence,NICE)首次提出阈下抑郁这一新亚型[8],系指低于轻度抑郁症诊断标准,以长期存在1或2项抑郁症状为主要特征,如失眠、疲惫、注意力分散、效率下降、躯体不适等,临床常易忽视。NICE指出,阈下抑郁在英国的患病率高,为30%~40%,与抑郁症造成同样严重的自残、自杀影响及经济损失,值得重视。

2 抑郁症的治疗原则

抑郁症治疗的目标是提高显效率和临床治愈率,最大限度减少病残率和自杀率,预防复发,最终达到提高生存质量,恢复社会功能的目的。目前抑郁症的治疗主要包括药物治疗、心理治疗、物理治疗、替代与补充治疗。受本身疾病严重程度、患者个体情况差异影响,抑郁症的治疗选择较为复杂。一般认为,阈下抑郁及轻度抑郁建议采取非药物治疗。中重度抑郁推荐抗抑郁症药作为一线治疗选择,可考虑联合心理治疗、物理治疗及替代与补充治疗以达到最佳治疗效果。抗抑郁治疗原则主要有:①综合评估,个体化治疗;②患者开始治疗前知情同意;③尽可能单一用药,剂量逐步递增,达到最小有效量后足量足疗程治疗;④治疗期间密切观察病情变化和不良反应并及时处理,尽可能采用量表形式定期评估;⑤治疗效果不佳时重新评估,可考虑换药、增药或联合治疗,但需要注意药物之间的相互作用;⑥可联合心理治疗、物理治疗及替代与补充治疗等;⑦积极治疗原发病与共发病[9]。近年来提出量化治疗(measurement based care, MBC)的理念,2015年APA多伦多会议重申抑郁症治疗中MBC的重要性。MBC基于循证医学实践发展,可为临床治疗方案选择及制定提供参考依据,目前已在高血压、糖尿病等慢性疾病中广泛使用。抑郁症中MBC主要包括[10]:①准确评估症状严重程度;②确保足够的抗抑郁症药物剂量;③评估药物的耐受性;④监测和增加治疗依从性;⑤确保治疗的安全性。APA更新的指南中已纳入MBC理念。

3 抑郁症的常用药物治疗

抗抑郁症药物近年来发展迅速,其品种已超过20多种。目前,除三环类(tricyclic antidepressants,TCAs)作为经典抗抑郁症药仍保留TCAs这个名称外,国内外较多按作用机制划分命名,主要包括[9]:①5-HT再摄取抑制药(selective serotonin reuptake inhibitor,SSRIs),如氟西汀、帕罗西汀、舍曲林、氟伏沙明、西酞普兰和艾司西酞普兰;②选择性5-HT及NE再摄取抑制药(selective serotonin-norepinephrine reuptake inhibitors,SNRIs),如文拉法辛、度洛西汀;③NE及特异性5-HT能抗抑郁症药(noradrenergic and specific serotonergic antidepressant,NaSSA) ,如米氮平;④NE及DA再摄取抑制药(norepinephrine-dopamine reuptake inhibitors,NDRIs),如安非他酮;⑤5-HT2A受体拮抗药及5-HT再摄取抑制药(serotonin receptor antagonists reuptake inhibitor,SARIs),如曲唑酮、奈法唑酮;⑥单胺氧化酶抑制药(monoamine oxidase inhibitors,MAOIs),如苯乙肼、环苯丙胺及新一代可逆性MAOIs吗氯贝胺。除TCAs和MAOIs作为经典的第一代抗抑郁症药,上述药物多属于新一代抗抑郁症药。

根据目前国内外抑郁症药物治疗指南,一般推荐SSRIs、SNRIs、NaSSAs等新一代抗抑郁症药作为首选药物。在我国部分地区,由于经济限制,TCAs如阿米替林、氯米帕明、麦普替林等仍作为一线治疗药物[9]。抗抑郁症药物具有不同的作用机制及不良反应,对每个人的治疗应答也不尽相同,合理选择与应用药物尤为重要。英国精神药理协会(British Association for Psychopharmacology,BAP)对目前一线抗抑郁症药物治疗疗效进行进一步文献荟萃分析,在其更新的循证医学指南 [11] 中指出,相比于SSRIs,双通道阻断药SNRIs(如文拉法辛)可能具有更高的特异性及更好的疗效;而在SSRIs中,艾司西酞普兰的疗效可能优于其他SSRIs;综合考虑治疗应答率、疗效、耐受性等因素时,选择舍曲林及艾司西酞普兰可能治疗效果最佳。

4 抑郁症的治疗策略

APA指南[12]指出,在接诊初期,医生即需对患者进行详尽的诊断学量化评估,识别其他需要关注的精神或躯体疾病状态,明确抑郁症的诊断、严重程度及危险分层,从而制定全面的治疗计划。抑郁症目前多为定性诊断,其轻重程度通常较难把握,国内外多个指南推荐使用量表进行综合评估,做到使诊断定量或半定量化,在后续的治疗选择及疗效监测中具有重大意义。其次,抑郁症患者通常有较高的自杀、自残风险,接诊初期需要综合评估患者的安全性,包括自杀观念、暴力冲动及家属的照顾能力。最后,与患者及家属有效沟通,如了解患者的治疗期望、纠正错误的治疗观念及建立治疗联盟等,对于提高患者后续治疗依从性意义重大。

对于成人中重度抑郁及持续时间超过2年的任何程度抑郁,药物治疗应作为首选治疗方式,这一点国内外多个指南已达成共识。对于成年短期发作性中重度抑郁,抑郁症状持续超过2~3个月,既往曾有抑郁发作史患者,BAP更新的指南[11]中指出,建议采用抗抑郁症药物治疗。欧洲精神病学协会(European Psychiatric Association,EPA)指出,对于慢性抑郁患者,建议其联合药物、心理及其他辅助治疗以达到最佳治疗效果[13]。对于阈下抑郁及轻度抑郁,多个国家临床治疗指南一致认为,排除过去中、重度抑郁史或初次出现长期存在的阈下抑郁症状(通常至少2年)或其他干预后持续存在的轻度抑郁,不推荐经常性使用抗抑郁症药治疗[8,11-14]。

4.1 中重度抑郁症的治疗

4.1.1 急性期 急性期治疗原则是迅速控制症状,尽可能达到临床治愈。药物治疗是中重度抑郁急性期治疗首选,可考虑联合物理治疗、心理治疗及替代与补充治疗等。在抑郁危重状态或多种治疗效果不佳时可紧急采取电休克治疗(electroconvulsive therapy,ECT)。急性期治疗,特别是首发抑郁症的初始治疗,药物的合理选择十分重要,关系到疾病转归及后续治疗预后。合理选药可根据Preskorn教授提出 “STEPS”原则综合考虑,即用药的安全性(safety)、耐受性(tolerance)、疗效(efficacy)、价格(payment)、服用简便性(simplicity)。确定治疗药物后,需根据患者病情、年龄及耐受性,以适当速度增加药物剂量。抗抑郁症药物起效一般较慢,常需2~4周。治疗期间建议定期以量表形式对病情及治疗效果进行评估。如果经4~8周足量治疗,症状仍无明显改善,需要进行重新评估并相应调整治疗计划。可以考虑联合心理治疗、物理治疗,或者更换其他治疗药物。药物更换可以是同类药物内(如从一种SSRIs到另一种SSRIs),或不同类药物间(如从SSRIs到SNRIs)。抗抑郁症药物通常作用机制相近,不良反应常常类似,且药物间相互作用大,故不建议多药联合治疗。例如,5-HT综合征是SSRIs并发症,可在单独或合并使用SSRIs或与其他具有5-HT能特性药物联用时发生,故后两种药物合用情况应尽量避免[9]。由于MAOIs需要进行严格的饮食药物限制,有潜在致命性的药物间相互作用,用药应更加谨慎。

4.1.2 巩固期 此期抑郁症状较前明显缓解,仍有较高复燃风险。为了减少复燃,建议继续使用前期药物,巩固治疗时间一般为4~9个月。在此期间,需进行严密监测,及时发现复燃征兆,并建议定期对患者的症状、药物不良反应、治疗依从性和功能状态进行量化评估。多个指南建议巩固期加强心理治疗,其中认知行为治疗得到最多证据支持,重复经颅磁刺激亦可有效降低患者复燃风险。

4.1.3 维持期 抑郁症具有高复发性,尤其是≥3次抑郁发作及慢性抑郁患者,多个指南明确提出应该继续进行维持期治疗。如合并抑郁症家族史、起病早、症状残存、持续应激等危险因素时,需考虑进行维持治疗。WHO建议对单次发作、症状轻、间歇期长(≥5年)者,一般可不维持治疗,但也有较多专家认为首次抑郁症发作也应维持6~8个月的治疗[9]。维持治疗的时间长短各指南论述不一,差异较大,应根据患者的综合情况个体化考虑。一般倾向至少持续2~3年,多次复发者主张长期维持治疗。维持治疗期间应定期进行病情及疗效评估,关注早期复发征象,监测药物不良反应。长期维持治疗,如病情稳定,各方面评估良好者,可考虑缓慢减药直至停药。减药期间应加强监测,一旦发现早期复发征象,应立即恢复原先治疗剂量。国内外多个指南推荐,维持期建议加强心理治疗,如认知行为治疗、团体自助模式等,纠正错误的观点及认知,建立积极的自助、社交心态,可有效降低抑郁症复发率,改善疾病预后。

4.2 特殊情况的抑郁症

4.2.1 老年期抑郁症 老年期常面临生活方式改变、共患病、多药治疗、居丧等情况,此期抑郁患病率较高,且常常伴随较高的自杀风险。老年期抑郁总体识别率及诊断率较低,可能原因包括:①老年人常常身体机能减退,易患各种疾病,抑郁症状常常被忽视误诊;②老年人多有不同程度的认知功能减退,使老年患者在病情认知、重视、表达等都存在缺陷,使得就诊率、诊断率偏低;③老年人怕麻烦子女,心态节约,常有淡化症状严重性倾向,不愿承认患病,否认情绪低落、兴趣下降是心境障碍。因此,疾病的早期识别和诊断尤为重要。老年期抑郁合并躯体疾病者所占比例大,常有较明显的焦虑,躯体不适主诉多,伴有一定的认知损害及偏执,失眠和食欲减退较明显。老年期抑郁治疗药物选择与一般人群大致相同,但老年人肝肾功能减退,对药物不良反应特别敏感(如低血压、抗胆碱作用),需要适当调整药物剂量,必要时可选择进行治疗药物监测。如果合并明显焦虑、失眠,可以选择抗焦虑及镇静催眠药物,包括苯二氮、丁螺环酮、佐匹克隆、艾司佐匹克隆等。

4.2.2 青少年抑郁症 研究表明,约有2.8%的13岁以下儿童及5.6%的13~18岁青少年患抑郁症,且多数具有阳性家族史[15]。早期识别和有效治疗可以减少青少年抑郁症对家庭、社会和学习功能的影响,并可降低抑郁症持续进展、自杀及药物滥用风险。多个指南[16-17]均推荐对青少年抑郁症进行综合治疗干预,并强调了诊治初期对患者进行全面综合评估、建立治疗联盟(包括患者、家长、学校及相关医疗机构等)及心理干预与动态随访管理的重要性。目前尚无绝对安全有效的青少年抗抑郁症药物。NICE指南指出,青少年轻度抑郁症不建议药物初始治疗;中重度抑郁症患者,如病情允许,建议先进行3~4个月心理治疗,效果不佳时可联合药物治疗,不建议单独药物治疗[16]。美国预防服务工作组(U.S.Preventive Services Task Force,USPSTF)指出,8岁以上儿童推荐使用氟西汀,12~17岁青少年可使用艾司西酞普兰。作为美国食品药品管理局(FDA)通过的儿童及青少年抑郁治疗药物,氟西汀可能是最优选择,但服药期间仍应密切关注患者症状及行为改变,警惕病情反复或加重,尤其需警惕自杀风险[17]。青少年抑郁症通常病程较长,复发风险高,向双向障碍发展可能性大,且处于生理、心理不断发展期,治疗期间应动态监测,及时调整治疗方案。

4.3.3 妊娠期及产后抑郁 妊娠期及产后女性处于激素水平波动期,抑郁症发生率高。此期抑郁症危害较大,对孕产妇、(胎)婴儿以及整个家庭都造成严重影响。我国学者对现有临床资料及诊疗指南进行研究,提出妊娠期及产后抑郁治疗5项基本原则[18]:①综合治疗,包括药物治疗、心理治疗、物理治疗等;②全程治疗,同样分为急性期、巩固期、维持期;③分级治疗,分级治疗的原则基本如前,若为重度抑郁症并伴精神病性症状、极端想法及行为时,务必进行精神专科治疗;④以孕产妇安全为前提;⑤保证(胎)婴儿安全。目前FDA和我国国家食品药品监督管理总局均未正式批准任何一种抗抑郁症药用于妊娠及哺乳期。所有的抗抑郁症药均会渗入乳汁,对发育的远期影响尚不明确,故原则上应尽量避免在哺乳期用药。如病情需要必须在哺乳期用药,建议采取最小有效剂量,必要时可考虑终止哺乳。目前尚无确切证据表明何种抗抑郁症药对孕产妇抑郁更有效,故药物选择主要参考既往用药史及耐受性。SSRIs常作为一线用药选择,其中舍曲林临床应用较多,被证明具有较高安全性,但尚缺乏远期影响资料。

4.3.4 共病性抑郁 综合医院患者躯体疾病伴发或共病焦虑、抑郁较为常见,如脑卒中、帕金森综合征、老年性痴呆、冠心病、糖尿病、慢性阻塞性肺疾病、恶性肿瘤等。部分心血管药物(如可乐定、利舍平、β受体阻断药)、中枢神经系统药物(如巴比妥类、苯二氮类、苯妥英)、激素类药物(如皮质醇激素、雌激素、黄体酮)及吲哚美辛、干扰素、麻醉剂等在治疗过程中也可引起抑郁症。原发疾病或药物可导致抑郁症,反之,持续存在的抑郁症又影响原发疾病的预后与转归,二者相互促进,关系复杂。临床工作中应注意识别和区分原发疾病本身表现和共病性抑郁,积极应用量表综合评估,这点已成为国内专家共识[19]。症状较轻者可给予健康教育和心理支持治疗;中重度抑郁症建议精神科会诊或转诊。共病性抑郁症治疗关键在于早期识别和介入,积极治疗原发病及去除可能心理、药物因素。抗抑郁症药物共病性抑郁症患者与一般抑郁人群无明显差别,但应注意药物相互作用及不良反应。我国专家共识[19]建议,卒中后抑郁症可考虑选择西酞普兰、舍曲林、艾司西酞普兰等SSRIs类及TCAs中的阿米替林等药物;痴呆患者可选择抗胆碱能作用小的药物,如安非他酮、氟西汀、舍曲林、曲唑酮;帕金森综合征患者可考虑选择帕罗西汀及文拉法辛,不加重帕金森综合征的运动症状;合并心血管疾病可选择SSRIs、SNRIs、安非他酮等,但需注意QT间期延长风险;合并糖尿病患者可选择能减少对胰岛素抵抗的SSRIs;癌症患者可以选择疗效较肯定的SSRIs和SNRIs;躯体疼痛症状明显者,建议优先选择对疼痛疗效好且不良反应小的SNRIs。

5 心理治疗

认知行为治疗(cognitive behavioral therapy,CBT)是一大类包括认知治疗和行为治疗的心理治疗方法,是通过改变个人思维行为模式来纠正失调情绪和行为,改善心理问题的一系列心理治疗方法总和。它着眼于患者不合理的认知问题,通过改变患者的看法与态度来解决心理问题,对抑郁症、焦虑症等具有较好疗效。BAP指南提出,对于严重抑郁患者,虽不建议将CBT作为唯一治疗手段,但应在药物治疗中考虑联合使用;对于老年期重度抑郁,CBT的整体效果可能高于药物治疗疗效;对于药物治疗困难的青少年重度抑郁,可选择CBT作为治疗手段之一[10]。

团体心理咨询是一种同时对多人进行治疗的咨询形式,可极大提高治疗效率,节约经济成本。由团体心理咨询发展演变的团体互助模式近年来受到较大关注。团体互助模式中,强调积极参与与自助互助,拟通过学习掌握新的认知、行为技巧来增强自我对症状的控制能力和情绪稳定性。其作用机制可能是通过模拟的社会环境和交往,加强组员间的情感联系与支持,打破自我封闭恶性循环[20]。这可能也是团体互助模式近年来被国内外研究者极力推崇的原因。

其他心理治疗方式,如人际关系疗法、精神动力心理治疗、问题焦点治疗、婚姻治疗和家庭治疗等,亦可选择应用。

6 物理治疗

ECT亦称电抽搐治疗,拟短时间内适量电流通过患者头部致全身抽搐,而达到治疗疾病目的的一种有效疗法。自1930年问世,ECT拟人工诱导癫痫发作的方法来改善精神分裂症的症状,却在治疗实践中被发现对抑郁症状有明显改善作用。随着技术的发展与成熟,近年来又出现附加简单麻醉和应用肌肉松弛剂的改良ECT(无抽搐ECT),使得治疗更为安全和可接受。ECT具有起效快、效果好等优点,多个临床治疗指南推荐其作为严重抑郁症紧急情况下(如高危自杀风险、极度痛苦、流体摄入不足)的治疗首选[8-9,12-14]。需注意,ECT可能存在一定的脑血管意外、认知功能损害等风险,故治疗前应充分评估风险收益,且治疗后应继续进行抗抑郁症药物治疗,以降低复发风险。ECT治疗抑郁症机制仍待进一步研究,其机制可能涉及激活GABA通路、突触重塑、减少谷氨酸、上调NMDA-NR2B表达等[21]。

经颅磁刺激技术(transcranial magnetic stimulation,TMS)即以磁信号刺激颅脑神经方式达到神经功能改善目的。TMS在1985应用于临床治疗,随着技术的发展与革新,出现具有连续可调功能的重复TMS(repetitive transcranial magnetic stimulation,rTMS),并在临床精神病、神经疾病及康复领域获得越来越多的认可。低频和高频rTMS均能有效治疗抑郁症,二者效果相当,但前者耐受性更好,适应人群更广泛,故目前抑郁症治疗中主要采用低频rTMS。2016年美国临床经颅刺激学会发布的TMS治疗重度抑郁症共识[22]指出,每日左前额TMS治疗急性期抑郁症患者安全有效。该共识认为,对于临床诊断符合DSM-5定义的抑郁症,单次发作或复发性抑郁症、抗抑郁症药物治疗效果不佳或不耐受的患者,应考虑单独或合并TMS治疗。TMS在急性期及急性期后治疗中均有良好效果,并且急性期后持续TMS治疗可降低抑郁症复发风险。

7 替代与补充治疗

贯叶连翘(hypericum perforatom L.)为藤黄科金丝桃属植物,广泛分布于北美、欧洲和亚洲,具有抗抑郁、抗病毒、抗菌、镇痛等作用。药理学研究表明,其抗抑郁有效成分主要为苯并二蒽酮类、黄酮类和间苯三酚类化合物[23]。欧美国家将其应用于抑郁症治疗,取得很好疗效。文献荟萃分析表明,相比于标准抗抑郁症药,贯叶连翘可能具有相近的临床疗效,且不良反应较小[24]。由于目前研究只给出初步中期数据,缺乏长期和预防复发数据,BAP指南未推荐其作为抑郁症一线治疗,但建议在一线治疗不能耐受或效果不佳的情况下可以考虑使用[10]。值得指出的是,中医药治疗抑郁症在我国有数千年的历史,有较多的专题研究发表和一定的循证医学证据,可配合使用。

The authors have declared that no competing interests exist.
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Abstract DESCRIPTION: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for major depressive disorder (MDD) in children and adolescents. METHODS: The USPSTF reviewed the evidence on the benefits and harms of screening; the accuracy of primary care-feasible screening tests; and the benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years. POPULATION: This recommendation applies to children and adolescents aged 18 years or younger who do not have a diagnosis of MDD. RECOMMENDATION: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger. (I statement).
DOI:10.7326/M15-2957      PMID:26858097      URL    
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[18] 丁辉,陈林,邸晓兰.产后抑郁症防治指南的专家共识(基于产科和社区医生)[J].中国妇产科临床杂志,2014,15(6):572-576.
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[19] 中华医学会神经病学分会神经心理学与行为神经病学组.综合医院焦虑、抑郁与躯体化症状诊断治疗的专家共识[J].中华神经科杂志,2016,49(12):908-917.
失眠、疼痛、乏力、全身不适、异常感觉及心血管、消化、呼吸、泌尿生殖系统自主神经功能失调症状是焦虑、抑郁与躯体化患者的常见躯体症状和主要就诊原因，情感症状往往被躯体症状掩盖，难以引起重视。综合医院医生不能正确识别处理，造成患者病情迁延，辗转各处就诊，大量消耗医疗资源，损害社会功能，甚至加剧医患矛盾。如何快速识别焦虑、抑郁与躯体化症状并运用有效手段进行干预成为综合医院医生必须面对和迫切需要解决的问题。为此，中华医学会神经病学分会神经心理学与行为神经病学组组织相关专家按照循证医学原则，参考美国精神病联合会、加拿大焦虑障碍协会、美国临床肿瘤学会等专业学会制定的最新指南，结合我国综合医院焦虑、抑郁与躯体化症状诊断治疗的临床实践，形成本共识，以期为广大综合医院临床医生提供借鉴与帮助。
DOI:10.3760/cma.j.issn.1006-7876.2016.12.002      URL    
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[20] 黄天宝. 抑郁的团体认知行为治疗[M].北京:人民卫生出版社,2012.
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[21] 董军,闵苏,魏珂,等.无抽搐电休克治疗大鼠抑郁症的谷氨酸能机制研究[J].中国神经精神疾病杂志,2008,34(5):310-312.
目的观察抑郁大鼠电休克治疗后海马内谷氨酸含量以及N-甲基-D天门冬氨酸（NMDA）受体 的表达，探讨电休克治疗抑郁症的谷氨酸能神经机制。方法36只SD大鼠随机分为无抽搐电休克组（电休克组）、抑郁模型对照组（抑郁组）、对照组，每组12 只。前两组采用孤养加慢性不可预见性应激建立抑郁模型，建模后电休克组在丙泊酚麻醉下行无抽搐电休克治疗，隔天1次共2周。检测各组海马谷氨酸含量和海马 CA1区、CA3区NMDA受体2B亚单位（NMDA-NP,2B）的表达。结果①电休克治疗后电休克组大鼠水平移动格数、垂直竖立次数和糖水消耗量都高 于抑郁组（P〈0．01）。②电休克组大鼠海马内谷氨酸含量低于抑郁组（P〈0．01），而抑郁组高于正常组（P〈0．01）。③电休克组大鼠海马CAI 区和CA3区NMDA．NP,2B的表达量高于正常组（P〈0．05），而抑郁组低于正常组（P〈0．01）。结论无抽搐电休克治疗可抑制抑郁症模型大鼠 海马内谷氨酸含量的升高并使NMDA—NR2B的表达量上调，这可能是其抗抑郁机制之一。
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[22] PERERA T,GEORGE M S,GRAMMER G,et al.The clini-cal TMS society consensus review and treatment recommendations for TMS therapy for major depressive disorder[J].Brain Stimul,2016,9(3):336-346.
Abstract BACKGROUND: Prefrontal Transcranial Magnetic Stimulation (TMS) therapy repeated daily over 4-6 weeks (20-30 sessions) is US Food and Drug Administration (FDA) approved for treating Major Depressive Disorder in adults who have not responded to prior antidepressant medications. In 2011, leading TMS clinical providers and researchers created the Clinical TMS Society (cTMSs) (www.clinicaltmssociety.org, Greenwich, CT, USA), incorporated in 2013. METHODS: This consensus review was written by cTMSs leaders, informed by membership polls, and approved by the governing board. It summarizes current evidence for the safety and efficacy of the use of TMS therapy for treating depression in routine clinical practice. Authors systematically reviewed the published TMS antidepressant therapy clinical trials. Studies were then assessed and graded on their strength of evidence using the Levels of Evidence framework published by the University of Oxford Centre for Evidence Based Medicine. The authors then summarize essentials for using TMS therapy in routine clinical practice settings derived from discussions and polls of cTMSs members. Finally, each summary clinical recommendation is presented with the substantiating peer-reviewed, published evidence supporting that recommendation. When the current published clinical trial evidence was insufficient or incomplete, expert opinion was included when sufficient consensus was available from experienced clinician users among the membership of the cTMSs, who were polled at the Annual Meetings in 2014 and 2015. CONCLUSIONS: Daily left prefrontal TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Following the clinical recommendations in this document should result in continued safe and effective use of this exciting new treatment modality. Copyright 脗漏 2016 The Authors. Published by Elsevier Inc. All rights reserved.
DOI:10.1016/j.brs.2016.03.010      PMID:27090022      URL    
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[23] 瞿发林,张理义,余海鹰,等.贯叶连翘抗抑郁作用机制的研究进展[J].中国神经精神疾病杂志,2003,29(1):80-82.
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[24] LINDE K,BERNER M M,KRISTON L.St John's wort for major depression[J].Cochrane Database Syst Rev,2008,(4):CD000448.
To investigate whether extracts of hypericum are more effective than placebo and as effective as standard antidepressants in the treatment of major depression; and whether they have fewer adverse effects than standard antidepressant drugs.
DOI:10.1002/14651858.CD000448.pub3      PMID:18843608      URL    
[本文引用:1]
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关键词（key words）
抗抑郁症药物
抑郁症
综合治疗
Antidepressants
Depression
Comprehensive therapy
作者
周晓丽
林燕
郑国庆
ZHOU Xiaoli
LIN Yan
ZHENG Guoqing