Psychiatry (Abingdon, England)最新文献

The symptoms and epidemiology of seasonal affective disorder (SAD) are summarized. The management of recurrent winter depression with self-help, psychotropic medication, and psychological therapy is described briefly. The use and effectiveness of light therapy (in its various forms) in SAD are discussed. Other uses of light therapy (non-seasonal depression, bulimia nervosa, antepartum depression, jet lag, sleep/wake disorders, dementia, and attention deficit hyperactivity disorder) are outlined.

Evidence-based psychological treatments for adults with unipolar depressive disorder and bipolar disorder are reviewed. There is most empirical evidence for cognitive behavioural therapy (CBT), which is examined in terms of what it is and its evidence base in unipolar depression, including severe, chronic, and treatment-resistant cases. The evidence base for the combination of CBT plus antidepressant treatment, including where continuation CBT may be usefully employed, reveals greater effectiveness than antidepressant treatment with continuing clinical support or other forms of psychotherapy in patients with severe, chronic, and treatment-resistant depression or depression with co-morbid personality disorder. Briefer descriptions and evidence for the role of mindfulness-based cognitive therapy, behaviour therapy, problem-solving, interpersonal therapy, psychodynamic therapy and cognitive analytical therapy are reviewed. All of these have some evidence for effectiveness and the roles of some of these treatments are starting to become clearer. Simple psychological treatments for bipolar disorder, such as medication adherence and early warning symptoms interventions, can improve some types of clinical outcome, but longer psychological interventions delivered by highly skilled therapists such as CBT and group psycho-education may have more comprehensive evidence of effectiveness. There is some preliminary evidence for the effectiveness of some psychological treatments in bipolar depression. Overall, the effectiveness of psychological treatments for unipolar depressive disorder and bipolar disorder is now well established and an understanding is starting to be obtained as to when they may be employed most usefully.

Advanced treatment options are available from a few tertiary centres for patients with the most severe and treatment-refractory forms of depression and obsessive–compulsive disorder. These treatments include ablative neurosurgery and electrical stimulation procedures directed against different neural targets. They include vagus nerve stimulation (VNS) and deep brain stimulation (DBS). Ablative procedures, such as anterior cingulotomy, are the best established of these alternatives, although the newer electrical stimulation procedures confer potential advantages with respect to surgical morbidity and reversibility. Whilst evidence for VNS as an effective therapy for depression is accruing, DBS remains an experimental treatment, with definitive evidence of efficacy awaited. All neurosurgical procedures used to treat psychiatric disorder should be provided by specialist multidisciplinary teams with expertise in the management of psychiatric disorder by pharmacological and psychological treatment methods. All psychiatric neurosurgical procedures should be subject to detailed long-term clinical audit to determine efficacy and adverse effect burden.

Depression has an annual prevalence of 1–6% in the community; 50–60% of depressed individuals might not respond to conventional pharmacotherapy. Transcranial magnetic stimulation (TMS) non-invasively stimulates superficial cortex in patients, for investigative and therapeutic purposes. It is usually applied over the prefrontal cortex at frequencies of 1–20 Hz at motor threshold intensity. We present a meta-analysis of 24 studies evaluating the antidepressant effect of TMS for major depressive or bipolar disorder in treatment groups ≥10 patients. Out of 617 patients receiving active rTMS, 218 (35.3%) were classified as ‘responders’, whereas only 71 (13.1%) of 543 patients undergoing sham rTMS met the criteria for clinical response. The Peto odds ratio meta-analysis indicated that this difference is statistically significant, with an odds ratio of 3.88 (95%-CI: 2.94–5.13). Heterogeneity between studies did not exceed that expected by chance and there was no significant publication bias. Based on these data, five patients (95% CI = 4–6) need to be treated in order to obtain a clinical response attributable to rTMS, a respectable effect size among psychiatric (add-on) treatments. Unfortunately, there is no compelling evidence regarding the most effective combination of rTMS parameters. The literature indicates that future trials should employ a greater number of rTMS sessions, adequate concealment allocation and an individualized approach to locating the DLPFC using neuroimaging. Also, more knowledge is needed regarding the characteristics of patients who benefit from this treatment and the size and persistence of clinical effects.

Unipolar affective disorder, or depression, is the one of the leading causes of disability worldwide and its effective management is a high priority. Treatment is required whether or not the illness is seen as ‘reactive’ to circumstances or understandable. Guidelines for its management have been produced by the National Institute for Health and Clinical Excellence (NICE) and the British Association for Psychopharmacology (BAP). These recommend rating the severity of the illness and using this as a guide for treatment. For less severe depression, antidepressants are recommended only when a patient fails to respond to other interventions or there is a history of more severe depression. For moderate-to-severe depression, antidepressants such as citalopram or fluoxetine are recommended as first-line treatments. The management of treatment-resistant depression (failure to respond to two adequate courses of antidepressants) is complex. NICE includes recommendations to consider augmentation of an antidepressant with cognitive behavioural therapy or lithium, monotherapy with venlafaxine or phenelzine (the latter particularly for atypical depression), and the combination of mirtazapine plus a selective serotonin reuptake inhibitor. BAP guidelines also include consideration of atypical antipsychotic or tri-iodothyronine augmentation of antidepressants. Other strategies have limited data supporting them and are not recommended, or are for use only in specialist centres.

Cultures invariably affect the way emotional distress and psychiatric disorders present to the clinicians. Mood is a subjective feeling and its expressions are highly likely to be influenced by the way the culture expects the individual to behave and express this. In mood disorders, although hypomanic symptoms may be easily identified, the symptoms of depression may be more difficult because these can be seen as both a clinical syndrome and an emotional expression. Here, some epidemiological studies are described with suggestions for managing affective disorders with patients from different cultures.

In this review, we discuss the importance of neuropsychological deficits in unipolar and bipolar affective disorder. Cognitive impairments are a key component of both disorders and, although a number of deficits exist in the depressed state, many of these disappear on remission. We propose that state-dependent deficits in unipolar depression may be explicable in terms of alterations in emotion-dependent, or ‘hot’, processing, particularly in tasks that utilize feedback. In bipolar disorder, where impairments are also common in the euthymic state, cognitive deficits may provide putative endophenotypes, which may aid research into the biological underpinnings of mood disorders.

Functional imaging studies report activation differences between healthy controls and patients with mood disorders within prefrontal and anterior limbic regions. Existing evidence supports a model of mood disorders involving reduced modulation of limbic regions by prefrontal networks, but also suggests a degree of diagnostic specificity with regard to the direction of change. For example, patients with major depressive disorder show greater and more consistent increases in prefrontal and anterior cingulate activity in working memory tasks than those with bipolar disorder, irrespective of symptomatic state. Increased activation of the amygdala during emotional processing seems to be common In both disorders. The relationship of these findings to disease severity and prognosis remains to be elucidated.