12.9% 21.7% 6.2% 6.8% 15.5% 2003 ( G e r i a t r i c Depression Scales, GDS) % 29.5%(GDS ) 75% 危險因子及自殺議題 WHO ( WHO ) 65

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0 1 高雄榮民總醫院精神部住院醫師 2 國軍左營總醫院家庭醫學科主任 depressive disorder, psychotic depressive

1 朱哲生 1 葉慶輝 2 前言 WHO 1998 ( m a j o r depressive disorder) 21 ( DSM-IV-TR ) 2005 WHO Global Burden of Disease, GBD D i s a b i l i t y Adjusted Life Years, DALYs 高雄榮民總醫院精神部住院醫師 2 國軍左營總醫院家庭醫學科主任 depressive disorder, psychotic depressive (depressive disorder) 流行病學 7% % % 家庭醫學與基層醫療第二十五卷第六期

2 12.9% 21.7% 6.2% 6.8% 15.5% 2003 ( G e r i a t r i c Depression Scales, GDS) % 29.5%(GDS ) 75% 危險因子及自殺議題 WHO ( WHO ) % 老人憂鬱性疾患評估及鑑別診斷 (psychotic depression) B12 家庭醫學與基層醫療第二十五卷第六期 227

3 25~50% (8~44%) (1~40%) (40%) (20~40%) (17~31%) 憂鬱性疾患 The 10th International Classifications of Disease, ICD-10 ICD-10 ( I C D F32 F33 F34.1 F38.1) 1994 ( T h e Diagnostic and Statistical Manual of Mental Disorders, DSM-IV) D S M - I V- T R ( T e x t Revision of the DSM-IV) DSM-IV-TR DSM-IV-TR D S M - I V- T R (d y s t h y m i a) (single episode) (recurrent) (mild) (moderate) 表一 : 可能導致憂鬱性疾患的藥物及內科疾病藥物心血管藥物 beta-blocker, clonidine, digitalis, hydralazine methyldopa, reserpine, thiazide diuretic 化療藥物 6-azauridine, asparaginase, azathioprine, bleomycin, cisplatin, cyclophosphamide, doxorubicin, vinblastine, vincristine 抗精神病藥物 fluphenazine, haloperidol 安定及抗焦慮藥物 barbiturates, benzodiazepines, chloral hydrate, ethanol 抗帕金森氏病藥物類固醇非類固醇抗發炎藥物疾病癌病 ( 特別是胰臟癌 ) 神經系統疾病老化性及血管性失智症帕金森氏病阿茲海默氏病多發性硬化症心血管疾病心肌梗塞心臟衰竭心肌病變代謝性疾病糖尿病葉酸及維他命 B12 不足電解質不平衡內分泌疾病甲狀腺功能亢進或低下 Addison 氏病 Cushing 氏症腦下垂體低下症病毒感染病毒性肝炎 HIV 感染病毒性肺炎流行性感冒風濕性免疫疾病紅斑性狼瘡類風濕性關節炎本圖修改自 Depression in Later Life: A Diagnostic and Therapeutic Challenge, Am Fam Physician 2004;69: 家庭醫學與基層醫療第二十五卷第六期

4 ( s e v e r e w i t h o u t psychotic features) (severe with psychotic features) (major depressive episode) ( 5%) ( ) (1) ( ) (2) (3) ( 4 ) (mood disorder) (1) ( ) (2) 2 (3) 2 ( 4 ) (5) ( ) (1) ( ) (2) (3) 2001 ICF ( I n t e r n a t i o n a l C l a s s i f i c a t i o n o f Functioning, Disability, and Health) ICF ICF 評估工具家庭醫學與基層醫療第二十五卷第六期 229

5 ( T a i w a n G e r i a t r i c Depression Scales, TGDS-30 ) [ / ] G D S (1) Hamilton 1960 (Hamilton Depression Rating Scale, HAMD) (2)Beck 1967 (Beck Depression Inventory) (BDI-II) (3) ( C e n t e r f o r Epidemiological Studies Depression Scale, CES-D) 病因 ( ) ( b r a i n a t r o p h y a n d w h i t e m a t t e r hyperintensities) 治療 65%~75% 40% 2 6~12 6 藥物治療 selective serotonin-reuptake inhibitors: S S R I t r i c y c l e antidepressants, TCA 70%~75% TCA 230 家庭醫學與基層醫療第二十五卷第六期

6 SNRI(serotonin-norepinephrine reuptake inhibitor), venlafaxine (efexor); NDRI(norepinephrine-dopamine reuptake i n h i b i t o r ), b u p r o p i o n ; N a S S A ( n o r a d r e n e r g i c a n d s p e c i f i c s e r o t o n e r g i c a n t i d e p r e s s a n t s ), m i r t a z a p i n e ( R e m e r o n ) venlafaxine mirtazapine 2009 Lancet 表二抗憂鬱劑選擇及使用劑量 e s c i t a l o p r a m sertraline mirtazapine venlafaxine C A N M AT ( C a n a d i a n N e t w o r k f o r M o o d a n d A n x i e t y Treatments) 第一線治療 * 抗憂鬱劑作用機轉劑量 ( daily) 副作用 ( 詳述如表三 ) bupropion[wellbutrin] citalopram[celexa] fluoxetine[prozac] sertraline[zoloft] fluvoxamine[luvox] paroxetine[seroxat] venlafaxine[efexor] duloxetine[cymbalta] escitalopram[lexapro] 第二線治療 amitriptyline, clomipramine and others selegiline transdermal[emsam] trazodone[desyrel]# NDRI SNRI SNRI 抑制突觸前 serotonin and norepinephrine 回收 ( 主要機轉 ) Irreversible MAO-B inhibitor SARI mg mg mg mg mg mg mg mg mg Various 6-12 mg transdermal mg 癲癇 (dose-dependent) S S R I S N R I 併用 M A O I 使用時會引起 serotonin syndrome 危險口乾便秘小便困難視力模糊體重增加嗜睡心搏過速血壓降低等併用提升血清素藥物如 TCAs s 等會引起 serotonin syndrome 危險嗜睡及姿勢性低血壓 * 第一線藥物在 CANMAT 所作的 systemic review 文章中定義為有 level 1 或 level 2 證據加上臨床運用的支持 ; 第二線藥物為 level 3 證據加上臨床運用支持 (level 1: 至少兩篇 RCTs 文章證據 ;level 2: 至少一篇 RCT 文章 ;level 3: 非隨機取樣 case series 回顧性文章證據支持 ) * 患者對於第一線治療藥物的耐受性和副作用小, 接受度也較高, 因此使用上優於第二線藥物如 TCA MAOI, 但研究也指出第一線和第二線藥物對於患者的療效大致相同 #trazodone 在治療劑量下 sedative effect( 鎮定效果 ) 很強, 因此放在第二線治療資料來源 :Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy 家庭醫學與基層醫療第二十五卷第六期 231

7 表三第二代抗憂鬱劑藥物常見副作用嗜睡失眠頭痛口乾視力模糊解尿困難腸胃不適噁心便秘性功能障礙 citalopram b * * b * * a b * 10-30% escitalopram a a * a * * a b a 10-30% fluoxetine b b * b * * a b * >30% fluvoxamine c b c b * a a c b >30% paroxetine b b b b a a a b b >30% sertraline b b c b a a a c a >30% bupropion * b * b a * a b b <10% duloxetine a b a b a a a c b 10-30% selegiline a b b a a * a * * <10% trazodoe c a a b a a b * a ( 未註明 ) a=9% or lower, b=10-29%, c=30-49%, d=50% or higher, *=usually 5% or less 資料來源 :Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy (major depression in old age) 978 ( 11%) 9 (1) ( 2 ) (start low, go slow) (3) BZD ( ) 心理治療 232 家庭醫學與基層醫療第二十五卷第六期

8 電痙攣療法 (ECT, electroconvulsive therapy) ECT ECT 結語參考資料 1. Cipriani A, Furukawa TA, Salanti G et al: Comparative efficacy and acceptability of 12 new-generation antidepressants: amultipletreatmentsmeta-analysis. Lancet 2009; 373: A l e x o p o u l o s G S, K a t z I R, R e y n o l d s C F, Carpenter D, Docherty JP: The expert consensus guideline series. Pharmacotherapy of depressive disorders in older patients. Postgrad Med Accessed April Carota A, Berney A, Aybek S et al: A prospective study of predictors of post stroke depression Neurology 2005; 64: Birrer RB, Vemuri SP: Depression in Later Life: A Diagnostic and Therapeutic Challenge, Am Fam Physician 2004; 69: Ryan J, Carriere I, Ritchiek, et al: Late-life depression and mortality: influence of gender and antidepressant use, The Bri J Psychiatry. 2008; 192: Charney DS, Reynolds CF III, Lewis L, et al: Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch Gen Psychiatry 2003; 60: Reynolds CF 3rd, Dew MA, Pollock BG, et al: Maintenance Treatment of Major Depression in Old Age N Engl J Med 2006; 354: Fitch K, Molnar FJ, Power B, Wilkins D, Man- San-Hing M: Antidepressant use in older people Family physicians knowledge, attitudes, and practices Can Fam Physician 2005; 51: Givens JL, Datto CJ, Ruckdeschel K et al: Older Patients Aversion to Antidepressants. A Qualitative Study. J Gen Intern Med 2006; 21: 家庭醫學與基層醫療第二十五卷第六期 233

8% 13% 40% ( P a r k i n s o n s d i s e a s e - a s s o c i a t e d psychosis, PDAP) (NINDS-NIMH criteria ) UK Brain Bank ( ) () 病理生理 (PDAP) A. - (Il

8% 13% 40% ( P a r k i n s o n s d i s e a s e - a s s o c i a t e d psychosis, PDAP) (NINDS-NIMH criteria ) UK Brain Bank ( ) () 病理生理 (PDAP) A. - (Il 1 2 3 臨床案例 77 69 1 Madopar(250mg) 1 tab q4h Entacapone 1 tab tid 1 10 9 5 2 1 2 1 1 彰化基督教醫院家庭醫學科住院醫師 2 彰化基督教醫院家庭醫學科主任 3 彰化基督教醫院家庭醫學科主治醫師 Parkinson's disease, psychosis, hallucinations, delusions (CASI)