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Somatic Symptoms & Depression in General Practice 情緒障 碍 躯体化

David Wong 王大 卫 MB.,BS, PDip.Com.Psy Med HONG KONG. 9 th Beijing/ Hong Kong Medical Exchange 第九届京港 医学交流会议 Psychological medicine in Community 社 区心理医学 3 - 4 November 2007 Presidential, Plaza Hotel, Beijing, China. Somatic Symptoms & Depression in General Practice 情緒障 碍 躯体化. S.1.

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Somatic Symptoms & Depression in General Practice 情緒障 碍 躯体化

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  1. David Wong 王大卫 MB.,BS, PDip.Com.Psy Med HONG KONG 9th Beijing/ Hong Kong Medical Exchange 第九届京港医学交流会议 Psychological medicine in Community社区心理医学 3 - 4 November 2007 Presidential, Plaza Hotel, Beijing, China Somatic Symptoms & Depression in General Practice情緒障碍躯体化 S.1

  2. What is this & what do you see ? 猜猜这是什么? S.2

  3. Somatic symptoms & depression Review of patients’ record in General Practice 病人纪录在全科医学中的覆检 Somatic symptoms躯体症狀 • Associated with medical causes and now found increasingly so with psychiatric disorders as well. 一向被认以为是躯体的疾病, 现在我们知道精神障碍也可以引起同样症状. • Some medically unexplainable symptoms may be listed under well defined psychiatric disorders, the rest is grouped loosely as medically `unexplained` symptoms (MUS). 部份躯体症状不能以身体疾病解释, 原来是精神障碍症侯一类. 目前还有一些躯体症状未能(起码暂时)有合理的解释, 有些学者就冠上一个名词”医学未能解释的症状” (MUS). • Management of MUS, also not explainable by the present system of psychiatry, remains a challenge. 对临床和做研究的医学界MUS都是一个挑战. S.3

  4. Somatic symptoms & depression Somatic symptoms(躯体症狀) in DSM IV & HAM-D S.4

  5. Somatic symptoms & depression Somatic symptoms(躯体症狀) in DSM IV & HAM-D S.5

  6. Somatic symptoms & depression Significance of somatic symptoms 躯体症狀的重要性 • Prevalent in depression忧郁病中很普遍 • Number of published articles found in PubMed: 文献里越来越多关于情绪障碍躯体化的文章: • Up to 2000: 1498 (2000年以前:1498) • Up to 2007 Jan:2718 (2007年一月以前:2718) • Diagnosis Implications对診斷影响 • higher no. of somatic symptoms predict depression. 越多症状,患忧郁的机会起大。 • Medically unexplained symptoms associate more frequently with depression. 越多医学未能解释的症状,患忧郁症的机会越大。 S.6

  7. Somatic symptoms & depression Significance of somatic symptoms 躯体症狀的重要性 • Treatment implications-higher no of SS delays: 对治療的影响: • response, 越多症状,越可能延誤,对藥物物的反應 • remission,復原的時間 • increases recurrence 增加復發的可能機會 S.7

  8. Somatic symptoms & depression Percentage of depressed patients presenting with predominantly physical symptoms 抑鬱病人有躯体问题的比率 • 70-75% (Gps`家庭科医生) 60-65% (psychiatrist精神專科医生) (Partners in Research,SA,04 南非Mitchell们做的研究) • 45% to 95% (Gps`) 69% (psychiatrist) present only with somatic symptoms純粹躯体症状 (Simon GE et al, N.Eng.J Med 1999;341:1329-1335) • >65% depressed patients report somatic symptoms 忧郁病人有躯体症状 (Bair MJ et al, Arch Intern Med. 2003;163:2433-2445. Bair MJ et al, Psychosom Med. 2004; 66: 17-22.) S.8

  9. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Analysis of total 437 patients 437病者的分析 S.9

  10. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Analysis of 429 patients presenting with somatic symptoms 429位带躯体症状病者的分析 S.10

  11. Somatic symptoms & depression Unexplained Somatic Symptoms & Mood Disorders 医学上末能解释的症状与情绪障碍 • ~ 32% to 62% of such patients are depressive ~ 32% to 62%病者有忧郁症 • ~ 24% to 50% have anxiety disorders ~ 24% to 50%病者有焦虑症 (Kroenke K et al Arch Fam Med 1994;3-774-9) • More frequent association with anxiety disorders and depression MUS 跟焦虑和忧郁有密切出现的关系 (Katon W et al. Ann Intern Med 2001;134-971-925) S.11

  12. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Analysis of 91 patients with medically unexplained symptoms (MUS) 91位带有医学上末能解释症状的患者分析 Mood dominant somatic symptoms (m++ss+) 大部分情绪障碍症状 小部分躯体症状 Somatic symptoms dominant, some mood symptoms (m+ss++) 大部分躯体症状 小部分情绪障碍症状 Somatic symptoms only (ss+++) 纯躯体症状 A 7 (7.7%) B 30 (33%) C 54 (59%) S.12

  13. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Analysis of 99 patients (91 patients with MUS & 8 patients with mood symptoms) 99 位病者（91 位未能解释 + 8 位情绪障碍）的分析 S.13

  14. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Diagnosis of “depressed group” of patients (53 patients) 53 位忧郁病者的分析 S.14

  15. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Prevalence of somatic symptoms in 53 “depressed group of patients” (depression, depression comorbid with anxiety, low mood with MUS) S.15

  16. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Conclusion I 小结 (I) • 12.1% of 437 patients suffer from depression. 437到诊病人中12%患有忧郁症 • 21% of 429 patients with somatic symptoms present with medically unexplained symptoms. 429带有躯体各式各样的症状的病人中有 21% 人属于医学解释不了的例子 • 58.2% of patients presenting with medically unexplained symptoms suffer from depression. 当中有分58.2%患有忧郁症 • All depressed patients have somatic symptoms. 所有忧郁的患者都有躯体的问题 S.16

  17. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Treatment for the “depressed group” of patients (53 patients) 53位抑郁病者的治疗 • All patients were receiving antidepressant drugs when surveyed (with or without atypical antipsychotics) 所有患者在统计时正服用SSRls • 4 patients discontinued subsequently. 4位停止疗程 • 49 patients remained on antidepressant treatment 49人正继续服用SSRls • Number of somatic symptoms per patient : between 1 to 9. 每一位患者平均拥用一至九种躯体症体 S.17

  18. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Outcome of treatment in “depressed group”patients (53 patients) 治疗结果 S.18

  19. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Outcome of treatment in “depressed group” patients (53 patients)痊愈结果 Number of patients S.19

  20. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Conclusion II结果二 • Antidepressants are useful in the treatment of somatic symptoms associated with depression. 抗忧郁药可有效治疗忧郁引起的躯体症状 • Antidepressants are useful in the treatment of somatic symptoms in the patients with medically unexplained symptoms(MUS). 对MUS,目前未能解释的躯体症状,抗忧郁药可能有效 • A systemic review of 96 randomized trials found antidepressants to be moderately effective. Odd Ratio comparing with placebo 3.4 (O’Malley, PG et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999;48:980-990). 奥马(O‘Malley)重复检视了96个随机对照试验发现抗忧郁药用于治疗MUS有中度效用。 S.20

  21. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Review of records of patients for January 07 Analysis of somatic symptoms in 53 patients with depression 53位忧郁人位的躯体症状分析 S.21

  22. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Analysis of 41 depressed patients with pain 痛楚类别分折(4l人) S.22

  23. Somatic symptoms & depression Review of records of patients for January 07 复查2007年一月份病人的记录 Analysis of 35 patients with GI upset 肠胃常见的问题(35人) S.23

  24. Somatic symptoms & depression Questions to be answered 有待回答的问题 Why & How are antidepressants effective in the treatment of somatic symptoms? 为何抗忧郁药物对躯体病微有疗效 Are all patients with medically unexplained symptoms psychiatric? 一部分患者的躯体症状， 我们目前不能解释，他们是否都有精神上的问题呢？ S.24

  25. Somatic symptoms & depression Questions to be answered 有待回答的问题 How does the mind generate symptoms of the body? 精神（尤其是情绪障碍）如何导致身体不适呢？ Is the pathophysiology producing the psychiatric & medical somatic symptoms the same biological mechanism? 同是躯体不适，情绪障碍和肉体病症引起的不适是不是一样？它们是否共用同一机制呢? S.25

  26. Somatic symptoms & depression The body and the mind精神与身体 Are doctors feeling different parts of the same depressed elephant? 不同科目的医生可能正在摸着同一只大象不同的部位? S.26

  27. Psychiatrists, researchers & GPs seeing different parts of a depressed elephant Non-psychiatric doctors in general practice & other specialities e.g. Dr. David Wong • 家庭及其它非精神科医生，例如王大卫 The Body身体: 一只忧郁的大象 A depressed elephant S.27

  28. Psychiatrists精神科医生 Psychiatrists: e.g. Prof. S W TANG 精神科医生: e.g. 邓兆华教授 一只忧郁的大象 A depressed elephant S.28

  29. Researchers研究者 一只忧郁的大象 A depressed elephant Researchers & Psychopharmacologists: e.g. Prof. Brian Leonard e.g.自烂尼教授 S.29

  30. Mind & Body is One精神与身体是共为一体 A depressed elephant 一只忧郁的大象 S.30

  31. Acknowledgment鸣谢 I would like to thank Professor SW Tang & Professor Brian Leonard for their encouragement and inspiration to make this project possible. 香港大学的邓兆华教授及爱尔兰大学的自烂尼教授启发了我对精神学的热情及兴趣。在此容许我表达对他们永远的尊敬及谢意 S.31

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