本帖最後由 lsc0019 於 2009-8-23 22:09 編輯
短期和長期介入都有效果
作者：Caroline Cassels
出處：WebMD醫學新聞
August 6, 2009 — 新研究顯示，簡短的心理社會/行為治療(psychosocial/behavioral therapy)合併抗憂鬱藥物，對於治療恢復中中風病患的憂鬱症比單用藥物更有效，且短期和長期介入都有效。
中風病患之憂鬱症心理社會/行為治療的第一個長期研究顯示，與同樣包括抗憂鬱劑的一般照護相比，包括抗憂鬱劑的合併治療，可顯著改善憂鬱分數。此外，短期和持續一年時都可以觀察到這些改善。特別的是，以心理社會/行為治療法合併抗憂鬱藥物治療八週之病患的憂鬱分數降低47%，接受一般照護者則降低32%。
研究者表示，這些發現有臨床和統計上的顯著意義。憂鬱改善之病患覺得自己的恢復情況顯著較佳，也覺得自己的生理狀況和社會參與度比那些憂鬱改善不佳者更好。
研究作者、華盛頓大學醫學院精神和行為科學教授Richard C. Veith醫師在聲明中表示，中風之後憂鬱是一個重要的公共衛生問題。三分之一的中風病患發生臨床憂鬱症，使他們更難以恢復、惡化認知功能、社會功能也不佳，且與其他不良後遺症有關。
此研究線上發表於8月6日的中風(Stroke)期刊。
根據該研究，憂鬱是各類中風的一個嚴重後遺症，且至少有33%的中風存活者受到影響。作者指出，中風後的憂鬱與不佳的恢復和復健反應、降低社交功能、延後返回工作崗位、使用更多健康照護服務、增加後續心血管事件風險以及各種原因的死亡率有關。
雖然抗憂鬱藥物在短期追蹤研究中顯示不同程度的效果，但是並無短期或長期之緩解或反應的明顯證據。相對的，作者們指出，2006年一篇對16個隨機控制試驗進行的後設分析顯示，相較於安慰劑，各種的抗憂鬱劑對中風後憂鬱有明確的整體改善(An Pharmacother.2006;40:2115-2122)。
不過，作者們指出，並沒有短期行為治療輔助抗憂鬱劑治療的良好研究。
他們寫道，最近才有一些設計完整的非藥物治療的試驗，顯示在短期(三個月)時，對於中風後的憂鬱有重要的改善。我們相信，我們是首次提出在長期時，臨床和統計上都有顯著改善的研究。
該研究包括101名臨床憂鬱的非住院中風病患(59%是男性，年紀在25至88歲之間)。每個人在過去四個月內都發生過中度的缺血性中風。這些參與者被隨機分成兩組：心理社會/行為治療合併藥物治療八週，或一般照護合併選擇性血清素再吸收抑制劑，如sertraline。
研究護士在這八週期間內九次訪視病患時提供心理社會/行為治療介入方式。護士提供一小時的憂鬱與正向行為的教育課程。課程內容包括增加歡樂事件的方法、分辨與修正負向思考、解決問題、照護者支持等。
研究開始時，研究者發現，在作為標準的Hamilton憂鬱評分量表(Hamilton Rating Scale for Depression)中，所有病患都屬於中度嚴重憂鬱。兩組的平均分數幾乎相同—大約20。
第九週時，相較於一般照護組，心理社會/行為治療組的憂鬱分數顯著降低。
一般照護組的病患在第一年的憂鬱也降低。不過，研究者指出，他們的緩解程度較少也較慢。
作者們結論表示，簡短的心理社會/行為治療介入輔助抗憂鬱劑治療，在短期內可高度有效降低憂鬱和達到緩解，且效果甚至可持續達兩年。
國家護士研究中心部份資助本研究。研究者皆宣告沒有相關財務關係。
Stroke-Related Depression: Behavioral Therapy Plus Antidepressants More Effective Than Medication Alone
By Caroline Cassels
Medscape Medical News
August 6, 2009?— Brief psychosocial/behavioral therapy combined with antidepressant medication is a more effective treatment for depression in recovering stroke patients than medication alone — both in the short and long term, new research shows.
The first long-term study of psychosocial/behavioral therapy in depressed stroke patients showed that combination therapy, which included antidepressants, significantly improved depression scores, compared with usual care, which also included antidepressants. In addition, these improvements were observed in the short term and were sustained at 1 year. Specifically, depression scores dropped 47% in patients treated with 8 weeks of psychosocial/behavioral therapy and antidepressants and 32% in those who received usual care.
These findings, researchers say, are clinically and statistically significant. Patients with improved depression perceived their recovery as significantly greater, and also felt that their physical condition and social participation were better than those with less improvement in depression.
"Depression following stroke is an important public-health problem. One third of patients who have strokes develop clinical depression, which makes them less able to recover from the stroke, worsens cognitive functioning, impairs social functioning, and is associated with other adverse consequences," study investigator Richard C. Veith, MD, professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle, said in a statement.
The study is published online August 6 in Stroke.
According to the study, depression is a serious sequela of strokes of all types and affects at least 33% of survivors. The authors note that poststroke depression has been linked to poor recovery and rehabilitation response, reduced social functioning, delayed return to work, greater use of healthcare services, and increased risk for subsequent cardiovascular events and all-cause mortality.
Although antidepressants have shown varying degrees of efficacy in studies with short follow-up periods, there is no clear evidence of remission or response in the short or long term. In contrast, the authors point out that a 2006 meta-analysis of 16 randomized controlled trials showed a definite overall improvement in poststroke depression in a variety of antidepressants, compared with placebo (Ann Pharmacother. 2006;40:2115-2122).
However, the authors note, brief behavioral therapy as an adjunct to treatment with antidepressants has not been well studied.
"Only recently have there been well-designed trials of nonpharmacologic treatments, both showing important reductions in [poststroke depression in the] short term (3 months). We believe ours is the first study to report a clinically and statistically important reduction in depression over the long term," they write.
The study included 101 clinically depressed nonhospitalized stroke patients (59% men, aged 25 to 88 years). Each had suffered a modest ischemic stroke in the previous 4 months. Participants were randomized to 1 of 2 groups: psychosocial/behavior therapy combined with medication for 8 weeks, or usual care combined with a selective serotonin reuptake inhibitor, such as sertraline.
The psychosocial/behavioral intervention was delivered by research nurses who visited the patients 9 times over an 8-week period. The nurses conducted 1-hour sessions that focused on education about depression and positive behaviors. The sessions covered ways to increase pleasant events and to identify and modify negative thoughts, problem solving, and caregiver support.
At the beginning of the study, researchers found that all patients had a moderately severe depression rating on a standard rating scale (the Hamilton Rating Scale for Depression). The average scores for both groups were essentially the same — about 20.
At 9 weeks, the psychosocial/behavioral-treatment group had a highly significant reduction in depression score, compared with the usual-care group.
Participants in the usual-care group also reduced their depression over the first year. However, it was slower and they experienced a lesser degree of remission, the researchers note.
"A brief psychosocial/behavioral intervention adjunctive to antidepressant therapy is highly effective in reducing depression and achieving remission in the short term, with the effect sustained for up to 2 years," the authors conclude.
The National Institutes of Nursing Research partially funded the study. The researchers have disclosed no relevant financial relationships.
Stroke. 2009;12:95-97. |
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