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。
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.能坐得久一点。站着的时候必须找东西靠着,有时候靠墙上,有时候靠着桌子,否则就会开始烦躁不安,感觉自己马上就会晕过去或者突然猝死一样。另外,我还特别怕吵闹,如果身边的人说话稍微大声一些,就会觉得很烦躁,很想逃离出去。感觉所有的噪声在拼命地往我脑子里钻。那段时间我非常抵触跟别人交谈,不必要的社交也都尽可能推掉,甚至上司请吃饭我都不想去。我开始越来越少说话,因为说多了会累,气接不上(这再次让我怀疑我肾虚)。因此,一整天,如非必要,我绝不开口说话。对于刚换了新工作的我来说,这等于是将自己与所有同事都隔绝开了。因此,每天一上班,我就觉得周围的气氛异常的压抑,大家都很陌生,即使我已经在那里上班超过两个月了,可是,依然无法跟身边的同事好好交流。上班成了一件非常痛苦的事情。
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。
也是这时候,大概是2015年10月的时候吧,我开始觉得自己非常不
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。

问•举痛论》中说:"百病皆生于气。"《医方论-越鞠丸》中亦说:"凡 郁病必先气病,气得流通,郁于何有。"抑郁症,焦虑症的病变机制关键在 于情志不舒,气郁发于始,终于末,贯穿于本病始终。而情志不遂,气机不畅 乃始发于肝,明•赵献可《医贯•郁病论》中认为五郁以木郁为先导。《丹 溪心法》云:"郁者,结聚而不得发越也,当升者不升,当降者不得降,当变 化者不得变化也。此为传化失常,六郁之病见矣。,,肝主疏泄,喜条达,肝之 疏泄功能正常,则全身气机升降出入运动疏通畅达,通而不滞,气血调和, 经络通利,脏腑器官活动正常协调,情志舒畅。由于各脏腑间存在相生相克的 关系,故肝之疏泄功能失常,可以累及心、脾、肾,演变为多种病证,出现神 志功能失调的不同性质的各类郁证症候群。肝气郁结,血行不畅可致血瘀; 肝失疏泄,水津停滞,聚湿为痰;肝气不畅,郁久化火;肝郁化火,灼伤肝阴, 导致肾阴亏虚;肝郁气滞,木不疏土,导致脾失健运;脾伤而致食少纳呆,营 血渐耗,心失所养,神失所藏而心慌不安、情绪低落、懒言少动、反应緩慢 等;痰火互结,扰乱心神出现烦躁、失眠等。根据《证治汇补'郁证》:"郁 病虽多,皆因气不周流,法当顺气为先。"及《素问.'六元正纪大论》:"木 郁达之",以疏通气机为总的治则,并依据瘀、血、痰、火以及虚、实之病 理演变机制与实际辨证相结合,以疏肝活血、养心安神、化痰开窍为主。


A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.
And finally one day, I woke up and I thought perhaps I'd had a stroke, because I lay in bed completely frozen, looking at the telephone, thinking, "Something is wrong and I should call for help," and I couldn't reach out my arm and pick up the phone and dial. And finally, after four full hours of my lying and staring at it, the phone rang, and somehow I managed to pick it up, and it was my father, and I said, "I'm in serious trouble. We need to do something."

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。

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