432 重度憂鬱症的最新治療策略文 / 郭約瑟林式榖 * 唐子俊 ** 陳紹祖 *** 賴建翰 **** 洪曜 ***** 羅東聖母醫院精神科台北市立聯合醫院松德院區一般精神科 * 高雄市唐子俊診所 ** 慈濟醫學大學暨花蓮慈濟醫院一般精神科 *** 台北振興醫院身心內科 **** 花蓮門諾醫院身心科 ***** (major depressive disorder) 16.1%(4.4-18%) 5-10% 10% 25% 30% (1) 20 366 (2) (disability adjusted life years, DALY) 1990 2004 2030 (2) 2006 (remission rate) 36.8% 30.6% 13.7% 13.0% 67% (3) (repeated transcranial magnetic stimulation, r-tms) (dialectical behavior therapy, DBT) 重度憂鬱症的治療目標 (remission) 1 2 20% 20% 2-4 8-10 (hippocampus) (4) functional recovery (response) Greer TL (5) 1. 2. 3. 4. 5. 2014, Vol.57, No.9 9
433 6. 一般抗憂鬱劑治療無效的可能原因 (6) 1. 假性無效因素 :(1) (2) (3) 2. 確實無效因素 : 33% 25% 2-3 (7) 合併用藥或換藥的治療趨勢 (1) 1. 2. (switch) (selective serotonin reuptake inhibitor, SSRI) (tricyclic antidepressants, TCA) (serotonin-norepinephrine reuptake inhibitor, SNRI) 3. 4. (combination) SSRI mirtazapine 5. augmentation add-on 6. 7. 2013 (1) 1. 2. 3. SSRI mirtazapine lithium 0.6-0.8 mmol/l aripiprazole 5-10mg quetiapine 150-300mg T3 T4 olanzapine(5-20mg) fluoxetine(20-50mg) 非典型抗精神病劑 (8) 16 3480 44.2% 29.9%(OR:1.69; p<0.00001) 30.7% 17.2%(OR:2.00; p<0.00001) (FDA) aripiprazole quetiapine olanzapine fluoxetine aripiprazole(or:2.07)> quetiapine(or:1.60)>olanzapine(or:1.39) aripiprazole(or:2.09)> quetiapine(or:1.89)> olanzapine(or:1.83) (number need to treat, NNT) (9) quetiapine 300mg (NNT:7) > aripiprazole (NNT:8) > quetiapine 150mg (NNT:11) >olanzapine (NNT:13) aripiprazole quetiapine 300mg aripiprazole (akathisia) 10 2014, Vol.57, No.9
434 quetiapine olanzapine aripiprazole (2-5mg) (5-10mg) quetiapine 300mg 作用機轉 1. (mesocortical pathway) (cingulate gyrus) (10) 5HT1A (partial agonist) 5HT2A 5HT2C 5HT6 (antagonist) Adrenergic -2 aripiprazole quetiapine norquetiapine 5HT1A (brainderived neurotrophic growth factor, BDNF) cortisol 2. (reward system) (11) (12) (rumination) (13) (repetitive thoughts) (14) (15) 3. ( 1 6 ) (dorsolateral prefrontal cortex, DLPFC) (anterior cingulate cortex, ACC) (17) DLPFC ACC executive function ACC DLPFC ACC ACC (frontocingulate dysfunction) (18) default mode 2014, Vol.57, No.9 11
435 network, DMN DLPFC ACC DLPFC ACC (aripiprazole quetiapine) 重複穿顱磁刺激 (r-tms) DLPFC (19) DLPFC ACC (hypercortisolemia) DLPFC ACC (neurodegeneration) DLPFC DLPFC BDNF 30-40 3-6 20-30 30-40% 辯證行為治療 Serenity Prayer 16 mindfulness (20) 1. (mindfulness) 2. 12 2014, Vol.57, No.9
436 3. 4. 結語 2030 60% aripiprazole quetiapine 5HT1A DLPFC 參考文獻 1. Bauer M, Pfennig A, Severu E, et al.: World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1:Update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013; 14: 334 385. 2. Lépine JP, Briley M: The increasing burden of depression. Neuropsychiatr Dis Treat 2011; 7: 3-7. 3. Rush AJ, Trivedi MH, Wisniewski SR, et al.:acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STARD Report. Am J Psychiatry 2006; 163: 1905-1917. 4. Sheline YI, Gado MH, Kraemer HC:Untreated depression and hippocampal volume loss. Am J Psychiatry 2003; 160: 1516-1518. 5. Greer TL, Kurian BT, Trivedi MH:Defining and measuring functional recovery from depression. CNS Drugs 2010; 24: 267-284. 6. Kornstein SG, Schneider RK:Clinical features of treatmentresistant depression. J Clin Psychiatry 2001; 62: 18-25. 7. Li CT, Bai YM, Huang YL, et al.:association between antidepressant resistance in unipolar depression and subsequent bipolar disorder:cohort study. Br J Psychiatry 2012; 200: 45-51. 8. Nelson JC,Papakostas G:Atypical antipsychotic augmentation in major depressive disorder:a metaanalysis of placebo-controlled randomized trialsam J Psychiatry 2009; 166: 980-991. 9. Citrome L:Adjunctive aripiprazole, olanzapine, or quetiapine for major depressive disorder:an analysis of number needed to treat, number needed to harm, and likelihood to be helped or harmed. Postgrad Med 2010; 2014, Vol.57, No.9 13
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