16 PSD 1 3 6 PSD 33 34

流行病学 脑血管病和卒中后抑郁焦虑障碍1~6 各研究报道的卒中后抑郁（PSD）发病率和患病率 变异很大 有研究认为卒中后1个月是发病的高峰, 但也有研究 认为卒中后3～ 6月是发病高峰 社区研究： PSD在卒中急性期为 33％，慢性期为 34％ 医院研究：PSD在卒中急性期为 36％、 恢复期为 32％， 慢性期为 34％ 我国研究发现，PSD在卒中后1月为 39%、3～ 6个 月为 53%、1年为 24% l l l 1． 2． 3． 4． 5． 6． Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. Pohjasvaara T, Leppavuori A，Siira I，et al. Frequency and clinical determinants of poststroke depression. Stroke，1998，29: 2311 -2317. Hackett ML, Yapa C, Parag V, et al. Frequency of depression after stroke：A systematic review of observational studies. Stroke，2005，36: 1330 -1340.

流行病学 帕金森病（PD）伴抑郁焦虑障碍1~7 l PD患者的抑郁障碍患病率为 8%～ 76%， 平均25%～ 40% l 约 40%患者有焦虑障碍 l 有研究认为抑郁和焦虑障碍可能先于患者 的运动症状出现 1． Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. 2． Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. 3． Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. 4． Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. 5. Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia. J Neurol Neurosurg Psychiatry，2002，72: 12– 21. 6. Okun MS, Watts RL. Depression associated with Parkinson’s disease：. Neurology, 2002，58(Suppl 1): S 63–S 70. 7. Ehrt U，Aarsland D. Psychiatric aspects of Parkinson's disease. Curr Opin Psychiatry，2005，18: 335 -341.

流行病学 多发性硬化（MS）伴抑郁焦虑障碍1~7 l 终身患病率近 50%，是普通人群的3倍 l 社区问卷调查研究发现 41%患者有抑郁，其 中 29%为中-重度抑郁 l 对 3000例16岁以上MS患者的死因调查显示， 15%的患者死于自杀 l 流行病学调查结果显示 35. 7%的患者合并各种 焦虑，其中 18. 6%为广泛性焦虑、10%为惊 恐发作 1． 2． 3． 4． 5. 6. 7. Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: JAMA 2003，289: 3095– 3105. Janssens AC, Buljevac D, van Doorn PA. Prediction of anxiety and distress following diagnosis. Mult Scler，2006 ，12: 794 -801. Siegert RJ，Abernethy DA. Depression in multiple sclerosis: a review. J Neurol Neurosurg Psychiatry，2005，76; 469 -475.

流行病学 癫痫伴抑郁焦虑障碍1~6 抑郁症的患病率为 50%～ 55% 住院患者中，控制良好者的抑郁发病率为 10%、 患病率为 20%，控制不良者则分别为 20%和 60% l 癫痫患者发作间期的焦虑症的患病率为 10%～ 25% l l 1． 2． 3． 4． 5. 6. Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. Lambert M, Robertson M. Depression in epilepsy: etiology, phenomenology and treatment. Epilepsia，1999，40(suppl 10): S 21–S 47. Gaitatzis A，Trimble MR，Sander JW. The psychiatric comorbidity of epilepsy. Acta Neurologica Scandinavica，2004，110: 207 -220.

目前主要神经生物学假设/发现-2（形态学） 海马体积和未治疗的抑郁之间的关系 38 Female Outpatients With Recurrent Depression in Remission 海马总体积( mm 3) 6, 000 R 2=0. 28 P=0. 0006* 5, 500 R 2=0. 28 P=0. 0006* 5, 000 4, 500 4, 000 3, 500 3, 000 0 1, 000 2, 000 3, 000 4, 000 未治疗的抑郁 *Significant inverse relationship between total hippocampal volume and the length of time depression went untreated. Sheline YI, et al. Am J Psychiatry. 2003; 160: 1516 -1518.

目前主要神经生物学假设/发现-3（形态学） 抑郁症与细胞凋亡 应激2 糖皮质激素 树突分支 1 BDNF 正常存活和生长 BDNF=brain-derived neurotrophic factor. 1. Sapolsky RM. Arch Gen Psychiatry. 2000; 57: 925 -935. 2. Duman RS, et al. Biol Psychiatry. 2000; 48: 732 -739. 神经元的萎缩/死亡

目前主要神经生物学假设/发现-4（形态学） 治疗能预防或逆转损伤吗？ 2 应激 糖皮质激素 树突分支 1 ? ? 神经元萎缩/死亡 增加存活和生长 BDNF 正常存活和生长 糖皮质激素 5 -HT and NE，DA 药物治疗, ECT, 心理治疗 2 5 -HT=serotonin; NE=norepinephrine; ECT=electroconvulsive therapy. 1. Sapolsky RM. Arch Gen Psychiatry. 2000; 57: 925 -935. 2. Duman RS, et al. Biol Psychiatry. 2000; 48: 732 -739.

卒中伴发抑郁焦虑障碍的特点 1~6 PSD虽然常见，但由于患者常有失语、忽略或认知损害 而不被诉说或识别 研究认为PSD为直接的脑损害所致，并提示优势半 球和前部半球损害更容易发生PSD，但meta分析未 见部位相关性 l “血管性抑郁”是老年期抑郁的重要病因，约占 1/3， 主要与额叶和底节部位的白质病变、小血管病变及“ 无症状卒中”有关 l 1． Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. 2． Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. 3． Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. 4． Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. 5. Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia. J Neurol Neurosurg Psychiatry，2002，72: 12– 21. 6. Okun MS, Watts RL. Depression associated with Parkinson’s disease：. Neurology, 2002，58(Suppl 1): S 63–S 70.

痴呆伴发抑郁焦虑障碍的特点 1~6 皮质下小血管病性Va. D或VCI患者的抑郁障 碍持续时间长、难治. 突出表现：始动性差、 精神运动迟缓和易伴执行功能障碍 l. AD伴发的抑郁障碍有随病程延长而逐渐减 少的趋势 l 1． Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. 2． Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. 3． Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. 4． Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. 5. Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia. J Neurol Neurosurg Psychiatry，2002，72: 12– 21. 6. Okun MS, Watts RL. Depression associated with Parkinson’s disease：. Neurology, 2002，58(Suppl 1): S 63–S 70.

PD伴发抑郁焦虑障碍的特点 1~6 PD患者的情感障碍与脑内多种神经递质的改变有关 常见的精神运动迟缓、淡漠、兴致缺乏、身体语言减 少、自主神经症状容易与抑郁混淆 l 常见的失眠、注意差、疲乏、震颤、不安和自主神经 症状又容易与焦虑混淆。过多担心可能是重要鉴别 点 l PD患者可有明显的情感波动，持续数分钟，每天多 次。晚期患者出现治疗的“开关”现象，有抑郁焦虑情 绪，使得诊断困难。 l 1． Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. 2． Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. 3． Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. 4． Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. 5. Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia. J Neurol Neurosurg Psychiatry，2002，72: 12– 21. 6. Okun MS, Watts RL. Depression associated with Parkinson’s disease：. Neurology, 2002，58(Suppl 1): S 63–S 70.

MS及癫痫伴发抑郁焦虑障碍的特点 1~6 MS患者的抑郁可能与病灶部位（额叶、颞叶）及炎症 有关 精神运动迟缓、睡眠异常、认知改变和疲乏是MS和 抑郁共有的表现 l 抑郁多见于复发和用激素治疗期间 l 抑郁与癫痫的关系是双向的，病因多重而复杂 l 抑郁可为癫痫发作和发作后表现，但更多见于发作间 期。 l 颞叶癫痫和左侧痫灶者容易发生抑郁。 1． Benedetti F, Bernasconi A，Pontiggia A. Depression and neurological disorders. Curr Opin Psychiatry，2006，19: 14– 18. 2． Tucker GJ. Neurological disorders and depression. Seminars Clinical Neuropsychiatry，2002，7: 213 -220. 3． Rickards H. Depression in neurological disorders: an update. Curr Opin Psychiatry，2006，19: 294– 298. 4． Rickards H. Depression in neurological disorders: Parkinson’s disease, multiple sclerosis, and stroke. J Neurol Neurosurg Psychiatry，2005，76; 48 -52. 5. Ring HA, Serra-Mestres J. Neuropsychiatry of the basal ganglia. J Neurol Neurosurg Psychiatry，2002，72: 12– 21. 6. Okun MS, Watts RL. Depression associated with Parkinson’s disease：. Neurology, 2002，58(Suppl 1): S 63–S 70.

Table The Frequency of Symptoms in Hysteria Neurosis Symptom % l l l l l l l l l Dyspnea Palpitation Chest pain Dizziness Headache Anxiety attacks Fatigue Blindness Paralysis Anesthesia Aphonia Lump in throat Fits or convulsions Faints Unconsciousness Amnesia Visual blurring Visual hallucination Deafness Olfatory hallucination Weakness Sudden fluctuations In weight Extremity pain Other bodily pain Phobias Nervous Had to quit working Because felt bad Always sickly (most of life) Thought of suicide 72 60 72 84 80 64 84 20 12 32 44 28 20 56 16 8 64 12 4 16 84 36 48 92 44 40 28 Weight loss Anorexia Nausea Vomiting Abdominal pain Abdominal bloating Food intolerances Diarrhea Constipation Dysuria Urinary retention Dysmenorrhea (premarital only) Dysmenorrhea (prepregnancy only) Dysmenorrhea(other) Menstrual irregularity Excessive menstrual bleeding Sexual indifference Frigidity(absence of orgasm) Dyspareunia Back pain Joint pain Burning pains in rectum, vagina, mouth Depressed feelings Vomiting all nine months of pregnancy Cried a lot Felt life was hopeless Thought of dying Wanted to die Attempted suicide 28 60 80 32 80 68 48 20 64 44 8 48 48 48 44 24 52 88 84 28 64 20 60 28 48 36 12

慢性原发性头痛主要分类 IHS国际头痛疾病分类第二版（ICHD－Ⅱ） ICHDⅡ编码 WHO ICD －10编码 1. [G 43] 2. [G 44. 2] 紧张型头痛(Tension-type Headache, TTH) 3. [G 44. 0] 丛集性头痛和其他三叉自主神经性头痛 （Cluster headache and other trigeminal autonomic Cephalalgrias） 4. [G 44. 80] 其他原发性头痛(Other primary headaches): 新症每日持续性头痛(New daily-persistent headache, NDPH) 12. [R 51] 头痛由于精神疾病(Headaches attributed to psychiatric disorder) 诊断 （英文原名，缩写） 偏头痛（Migranine）

慢性原发性头痛是成年最常见疾病之一 地区 紧张性头痛 偏头痛 非洲 1. 7 (1 study) 4. 0 (2 studies) 亚洲 2. 2 (3 studies) 10. 6 (6 studies) 欧洲 3. 4 (6 studies) 13. 8 (9 studies) 北美 2. 2 (1 study) 12. 6 (8 studies) 南美 5. 0 (2 studies) 9. 6 (10 studies) 平均 11. 2 3. 2

临床治愈是急性期治疗的目标 l 抑郁症的临床治愈是抗抑郁治疗的根本目标1 -4 l 包括情感和躯体症状完全缓解 5, 6 l 各种功能的完全恢复5, 6 –重新投入 作 –恢复兴趣和爱好 –恢复人际关系 1. Clinical Practice Guideline No. 5: Depression in 4. Primary Care, 2: Treatment of Major Depression; 1993. 5. AHCPR publication 93 -0551. 2. American Psychiatric Association. Am J Psychiatry. 6. 2000; 157(suppl 4): 1 -45. 3. Anderson IM, et al. J Psychopharmacol. 2000; 14: 3 -20. Reesal RT, Lam RW. Can J Psychiatry. 2001; 46(suppl 1): 21 S-28 S. DSM-IV-TR™. 4 th ed. Washington, DC: American Psychiatric Association; 2000. Rush AJ, Trivedi MH. Psychiatr Ann. 1995; 25: 704 -705, 709.

作、社会功能只在“临床治愈”后完全正常 化* 自评社会适应量表 (平均 标准差) † † 无疗效 (n=299) 改善 (n=122) 临床治愈 (n=202) Remission=Psychiatric Status Rating (PSR) 1 or 2. *Psychosocial functioning after treatment with sertraline or imipramine. †P<0. 05 compared with the remission group. Miller IW, et al. J Clin Psychiatry. 1998; 59: 608 -619. 健康对照 (n=482)