作者：Marlene Busko
出處：WebMD醫學新聞
September 22, 2008 — 新研究顯示，長期血液透析且診斷有憂鬱的病患，相較於沒有憂鬱的血液透析患者，住院內一年死亡的比率達兩倍。
研究者指出，這是首次關於透析病患有憂鬱診斷者其預後較差的研究，憂鬱診斷是根據正式的精神疾病診斷與統計手冊第四版(DSM-IV)的結構式評估，而非病患自述。
第一作者、德州大學西南醫學中心與達拉斯退伍軍人醫學中心的S. Susan Hedayati醫師向Medscape Psychiatry表示，本研究顯示，當出現其他共病症，如糖尿病、高血壓或者冠狀動脈疾病時，憂鬱是不佳預後的一大風險因素。
她指出，治療透析病患的腎臟科醫師花許多時間注意病患的檢驗數據，來監控其貧血、副甲狀腺亢進、與透析的適當性，但是他們有時候忽略了病患的憂鬱症篩檢。
本研究發表在10月1日的國際腎臟期刊。
【診斷黃金標準】
研究者寫道，因為末期腎臟病患者有相當高的心血管死亡比率，而憂鬱會增加心血管事件，探究憂鬱與透析病患結果的關係有其重要性。
之前的研究顯示，自我報告的憂鬱症狀(根據貝克憂鬱量表等問卷的回覆)和透析患者的不佳結果有關；不過，缺乏食慾、體力不佳、疲勞與睡眠障礙等症狀常見於末期腎臟病患者，這些身體症狀可能被誤認為憂鬱。
研究者藉由醫師使用DSM結構式臨床訪談(SCID)診斷透析病患之憂鬱以及後續病患的死亡或住院來檢視之間的關聯。
他們研究98名病患，其中44名女性，主要是非洲裔美國人，就診於三個門診透析機構，研究對象平均年紀為57歲，平均接受透析4.1年(範圍從4個月-8年)，病患平均有3.1個共病症，追蹤他們最多達一年，平均追蹤9個月。
根據研究開始時的醫師評估SCID，26名病患(26.5%)診斷有憂鬱症；追蹤期間，26名憂鬱病患中，有21(81%)人住院或死亡，而無憂鬱的72名病患中，有31人(43%)住院或死亡；大部份都是住院而非死亡：死亡的有9 人。心血管原因佔所有住院的20%。
校正年紀、種族、性別、接受透析年數、共病症數之後，相較於沒有憂鬱的病患，那些有SCID診斷憂鬱的患者，發生住院或死亡的比率達兩倍(風險比，2.07; 95% CI, 1.10 – 3.90)。
Hedayati醫師表示，平均而言，每位病患在透析的第一年住院兩次，五分之一的新病患在一年內死亡。
她表示，我們需要確認會導致不佳結果的風險因素，例如憂鬱，並確認處置和/或治療後能否有所改善。
【不可以再忽視憂鬱】
康乃迪克紐哈分聖拉斐爾醫院的Fredric O. Finkelstein醫師等人在評論中寫道，Hedayati醫師等人的初步研究指出超過四分之一的末期腎病患者有臨床憂鬱症狀，這代表我們要開始行動。
他們寫道，我們不再忽視憂鬱對於末期腎病患者的影響，需要研究適當的治療處方與試驗。
Hedayati醫師的研究接受照護研究與品質中心、John A. Hartford基金會、Claude D. Pepper Older Americans Independence Center等資金贊助；其他研究作者的資金列於報告中。
Dialysis Patients Diagnosed With Depression Have Poorer Outcomes
By Marlene Busko
Medscape Medical News
September 22, 2008 — Patients on chronic hemodialysis and diagnosed with depression are twice as likely as their nondepressed counterparts to die or be hospitalized within a year, new research suggests.
According to investigators, this is the first study in dialysis patients to report that physician-diagnosed depression — based on a formal Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV) structured interview rather than a self-report — is associated with poor outcomes.
"This study shows that depression could be as big a risk factor for poor outcomes as the presence of another comorbidity such as diabetes, high blood pressure, or coronary artery disease," first author S. Susan Hedayati, MD, from University of Texas Southwestern Medical Center and the Dallas Veterans Affairs Medical Center, told Medscape Psychiatry.
Nephrologists who treat dialysis patients spend a lot of time looking at their patients' laboratory values to monitor them for anemia, hyperparathyroidism, and adequacy of dialysis, but they sometimes neglect to screen patients for depression, she added.
The study is published in the October 1 issue of Kidney International.
Gold-Standard Diagnosis
Given the excessive rate of cardiovascular death in patients with end-stage renal disease and the correlation of depression with increased cardiovascular events, it is important to investigate the link between depression and outcomes in dialysis patients, the group writes.
Previous studies have shown an association between self-reported depressive symptoms — based on replies to questionnaires such as the Beck Depression Inventory — and poor outcomes in patients receiving dialysis.
However, symptoms such as lack of appetite, poor energy, fatigue, and sleep disturbances are common in patients with advanced kidney disease, and somatic symptoms can be misclassified as depression.
The investigators examined whether there was an association between depression diagnosed in dialysis patients by physicians using the Structured Clinical Interview for DSM (SCID) and subsequent patient death or hospitalization.
They investigated 98 consecutive patients, including 44 women, who were mainly African American and who were seen in 3 outpatient dialysis units. Subjects had a mean age of 57 years and had been on dialysis for an average of 4.1 years (range, 4 months to 8 years). Patients had an average of 3.1 comorbid conditions. They were followed for up to 1 year, with a median follow-up of 9 months.
Based on a physician-administered SCID at study entry, 26 patients (26.5%) were diagnosed with depression.
At follow-up, 21 of the 26 depressed patients (81%) vs 31 of the 72 nondepressed patients (43%) had been hospitalized or had died.
Most of these outcomes were hospitalizations rather than death: 9 patients died. Cardiovascular causes accounted for 20% of the hospitalization.
Compared with patients without depression, those with a SCID diagnosis of depression were twice as likely to have subsequent hospitalization or death, even after corrections for age, race, sex, years on dialysis, and number of comorbidities (hazard ratio, 2.07; 95% CI, 1.10 – 3.90).
On average, each patient who starts dialysis is hospitalized twice in the first year, and one-fifth of new patients on dialysis die within a year, said Dr. Hedayati.
"We need to identify risk factors, such as depression, that can lead to poor outcomes and determine whether modifying and/or treating them makes a difference," she said.
"We Can No Longer Ignore Depression"
In an accompanying commentary, Fredric O. Finkelstein, MD, at the Hospital of St. Raphael, in New Haven, Connecticut, and colleagues write that this initial study by Hedayati et al documented that more than one-quarter of end-stage renal disease patients had clinical depression, a prevalence rate that calls for action.
"We can no longer ignore the impact of depression on end-stage-renal-disease patients. Appropriate therapeutic regimens and trials need to be explored," they write.
Dr. Hedayati's research was supported by grants from the Agency for Health Care, Research, and Quality; the John A. Hartford Foundation; and the Claude D. Pepper Older Americans Independence Center. The grants for the other study authors are listed in the paper.
Kidney Int 2008;74:930-936 Abstract, 843-845. Abstract
[ 本帖最後由 goodcat1111 於 2008-10-3 11:24 編輯 ] |
|
