Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy, so they are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.
BACKGROUND: In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD). METHODS: The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles. RESULTS: Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009. LIMITATIONS: Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes. CONCLUSIONS: There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.

是由两种非常有效的化合物组成的合剂。三氟噻吨是一种神经阻滞剂,根据不同剂量具有不同药理作用。大剂量的三氟噻吨主要拮抗突触后膜的多巴胺受体,降低多巴胺能活性 ;而小剂量三氟噻吨主要作用于突触前膜多巴胺自身调节受体(D2受体),促进多巴胺的合成和释放,使突触间隙中多巴胺的含量增加,而发挥抗焦虑和抗抑郁作用。四甲蒽丙胺是一种双相抗抑郁剂,可以抑制突触前膜对去甲肾上腺素及5-羟色胺的再摄取作用,提高了突触间隙的单胺类递质的含量。两种成分的合剂具有协同的调整中枢神经系统的功能,抗抑郁、抗焦虑和兴奋特性。另一方面,本药中的四甲蒽丙胺可以对抗大剂量时三氟噻吨可能产生的锥体外系症状。三氟噻吨和四甲蒽丙胺相互拮抗的结果使本药的抗胆碱能作用较四甲蒽丙胺弱。本药对上述中枢神经递质的影响,临床上也相应表现为两种成分在治疗作用方面的协同效应和副作用的拮抗效应。此外,体内及体外试验表明,本药对组胺受体有一定的拮抗作用。并且还具有镇痛、抗惊厥作用,但无抗精神病作用。
抑郁症以往被划分为情感性精神病、其它类型的疾病均被划分为神经 症。抑郁症是一种持久的心境低落状态,常伴有焦虑、躯体不适感和睡眠障 碍,患者有治疗要求,而无明显的运动障碍、以及幻觉、幻想、思维和行为 紊乱等精神特征,生活能力无明显影响;神经症是一組表现心情抑郁、烦恼、 紧张、恐怖、疑病、强迫症状、分离和转换症状等,除意症表现为短的发作 性症状外, 一般病程迁延可达数年或数十年,可分为恐怖性神经症、焦虑性 神经症、强迫性神经症、抑郁性神经症、癔症、疑病性神经症、神经哀弱、 其它神经症(人格解体神经症、躯体化障碍、职业性如书写痉挛)等。依据中 医理论,抑郁症、焦虑症统称为精神和心理障碍性疾病,是由于植物神经功 能紊乱而导致心境低落、焦虑、失眠多梦,幻觉、妄想、思维和行为紊乱等 精神病特征。中医认为这些症状是因情志不遂,忧思悲怒,起居不慎,饮食 不节而造成。西医治疗多采取化学药物治疗,其疗效不稳定,副作用大;而中药以其毒性小,长期服用安全,越来越多的被人们认识用于治疗精神方面 的疾病。
人的心情低落就像感冒一样经常会来干扰一下,普通的心情低落也像感冒一样会不药而自愈。但是抑郁症却不同了,它是长期的精神和情绪的失调,有先天性格的原因,更有后天长期自身不良习惯、外在压力的累计造成的,现代社会生活和工作的压力增大,因此患抑郁症的人群也越来越多。目前市场上抗抑郁药物的种类主要有:特异性血清素(5羟色胺)再摄取抑制剂(SSRIs),血清素和去甲肾上腺素再摄取抑制剂(SNRIs),三环抗抑郁剂(TCAs),单胺氧化酶抑制剂(MAOIs)等,其中最常见的是SSRIs和SNRIs这两类。血清素与去甲肾上腺素都是能够传递兴奋信号、产生愉悦感的神经递质,而抑郁症患者的中枢神经系统内的这些物质含量较少,抗抑郁药物通过提高它们在神经突触中的浓度来发挥作用。人类对自身的神经系统和情绪调控系统了解的并不深入,受制于人们对这个疾病的认识,抗抑郁药物的发展最近几年处于比较缓慢的阶段,销售额前10名的药物从10年前的总销量接近100亿美元,下降到如今的不到40亿美元,这主要是因为重磅药物的专利到期,而新上市的药物在机制上又没有突破性创新。
×