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治疗强迫症的疗效和安全性课件

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治疗强迫症ppt课件 的疗效和安全性 强迫症ppt课件 强迫症的ppt 强迫症的治疗PPT PPTppt 治疗 强迫症的效果 强迫症治疗效果
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Click to edit Master title style Click to edit Master subtitle style SSRI治疗强迫症的疗效和安全性 北京大学精神卫生研究所 崔玉华 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD的流行病学 •以前认为强迫症十分罕见,终生患病率仅为 0.05%1 – 我国(1982)(15~59岁)(0.03%) •现在:心理卫生的重要关注点 – 美国5个研究中心得出的患病率: 1.9% - 3.3% 2(1984) – 国际7个中心得出的终生患病率 2.5%a 3 – 20世纪90年代以来发现其很常见,仅次于恐怖 症、药物依赖、重症抑郁 1 1 Rudin (1953); Rudin (1953); 2 2 Karno et al (1988);Karno et al (1988); 3 3 Weissman et al (1994)Weissman et al (1994) a a Excluding Taiwan (0.7%)Excluding Taiwan (0.7%) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1 1 Flament et al (1988); Flament et al (1988); 2 2 Valeni-Basile et al (1994);Valeni-Basile et al (1994); 3 3 Swedo et al (1989)Swedo et al (1989) 多在青少年发病,成人的发病率仍然不减多在青少年发病,成人的发病率仍然不减 1.9% - 3.0% 1.9% - 3.0%1,2 1,2 平均发病年龄为平均发病年龄为19-2019-20岁,男女发病比例近似岁,男女发病比例近似 ,大约一半病人对药物及心理治疗效果不理想,大约一半病人对药物及心理治疗效果不理想 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 强迫症:儿童和青少年的发病率 a=DSM-III or DSM-III-Ra=DSM-III or DSM-III-R诊断标准诊断标准 作者作者国家国家n (n (年龄年龄, ,年年) ) 患病率患病率 (%) (%) 当前当前终生终生 (1–12 (1–12月月) ) 930 (18) 930 (18) 356 (8 – 356 (8 – 13)13) 5108 (14–18)5108 (14–18) 386 (18) 386 (18) 1032 (11–17) 1032 (11–17) 3283 (12–15)3283 (12–15) 562 (16–17) 562 (16–17) 4.04.0 2.8–4.6 (8 2.8–4.6 (8 yr olds)yr olds) b b 2.3–3.4 (13 yr olds) 2.3–3.4 (13 yr olds) b b 1.01.0 1.9 1.9 1.31.3 2.1 2.1 4.1 4.1 b b 3.03.0 1.81.8 c c –3.6–3.6 d d Douglass et al (1995)Douglass et al (1995)新西兰新西兰 Esser et al (1990)Esser et al (1990)德国德国 Flament et al (1988)Flament et al (1988)美国美国 Reinherz et al (1993)Reinherz et al (1993)美国美国 Thomsen (1993)Thomsen (1993)丹麦丹麦 Valleni-Basile et al (1994)Valleni-Basile et al (1994)美国美国 Zohar et al (1992)Zohar et al (1992)以色列以色列 b=b=强迫症状;强迫症状;c=c=试图抗拒,摆脱不了试图抗拒,摆脱不了; ; d=d=各种困扰,和各种困扰,和/ /或强迫性冲动或强迫性冲动 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD: 横向国家间流行病学比较 终生 (%) 始发年龄 (Years) 女/男 比率 韩国1.929.81.2 美国 2.326.21.6 Weissman et al: J Clin Psychiatry 55:(3 suppl) 5-10, 1994 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD综合征 67%-79% 67%-79% 伴发抑郁伴发抑郁1,2 1,2 ³ ³ 40% 40% 伴有人格障伴有人格障 碍碍 3 3 50% 50% 具有轴具有轴1 1的精神障碍的精神障碍 3 3 1 1 Rasmussen and Eisen (1992);Rasmussen and Eisen (1992); 2 2 Demal et al (1993);Demal et al (1993); 3 3 Pigott et al (1994)Pigott et al (1994) OCD OCD共患的疾病共患的疾病 惊恐发作,躯体形式障碍,进食障碍 抽动,冲动控制学所谓的强迫谱系 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD 谱系 心境恶劣 欣快症 躯体化障碍 畸形恐怖 社交恐怖 性变态 赌博 偷窃狂 嗜甲癖 拔毛癖 进食障碍 创伤性应激障碍 癔病 伤害 习惯 冲动控制 人格分裂 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD 及共病情况流行病学统计 重症抑郁 67% 酒精及其他物质滥用 33% 社交恐怖18% 进食障碍 17% 惊恐 12% 图雷特综合征 7% 双相障碍 4% Modified from Rasmussen SA, Eisen JL: Psychiatric Ann 19:67, 1989 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 丘脑 额叶 尾状核 Fronto-striato-thalamo-frontal Circuit With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 强迫症 • 反复出现并且令人不快 • 意识到源自于自己头脑 • 试图抗拒 (从不成功) • 显著的痛苦/功能损害 强迫观念强迫观念强迫行为强迫行为和和/ /或或 OCDOCD With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 强迫症的治疗 年龄年龄 (years) (years) 0 0 5 5 101015152020252530303535 症状出现症状出现 14–15 14–15诊断诊断OCDOCD 30 30岁岁 找专业人员找专业人员 咨询咨询 24 24岁岁 接受治疗平接受治疗平 均均 31.5 31.5岁岁 Hollander et al (1996)Hollander et al (1996) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD 的治疗 • 行为治疗 • 药物治疗 • 神经外科手术 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD的行为治疗 • 暴露疗法与反应预防 • 60-80% 可以改进为 50-60% • 单独或联合药物 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD的行为治疗 Schwartz et al: AGP 53:109, 1996 治疗前治疗后 丘脑 rCd rCd With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 强迫症治疗的药物 •氯丙咪嗪 (Clomipramine Collaborative Study Group, 1991) •氟西汀 (Tollefson et al, 1994; Montgomery et al, 1993) •氟伏沙明 (Koran et al, 1996; Goodman et al, 1996; Greist et al, 1995; Freeman et al, 1994; Chouinard et al, 1990) •帕罗西汀 (Zohar and Judge, 1996; Wheadon et al, 1993) •左洛复 (Bisserbe et al, 1997; Rasmussen et al, 1997; Greist et al, 1995a,b; Chouinard et al, 1990) FDAFDA::批准用于儿童批准用于儿童OCDOCD用量用量 50-200 50-200mg/dmg/d With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society • •左洛复左洛复100 100 ~~200 200 mg mg //天天 (( 线性量效关系)线性量效关系) • •氯丙咪嗪氯丙咪嗪 150150~~250 250 mg /mg /天天 • •氟西汀氟西汀40 40 ~~ 60 60 mg mg //天天 • •氟伏沙明氟伏沙明100 100 ~~300 300 mg mg //天天 • •帕罗西汀帕罗西汀40 40 ~~ 60 60 mg mg //天天 SSRISSRI治疗治疗OCDOCD的常用剂量的常用剂量 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society SSRI治疗强迫症 SSRIs 促使对强迫症的理解促使对强迫症的理解 n n 临床病程临床病程 n n 精神病理学精神病理学 治疗的革命治疗的革命 n n 成人治疗成人治疗 n n 长期治疗长期治疗 n n儿童治疗儿童治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Y-BOCS Y-BOCS 评分评分 -8 -7 -6 -5 -4 -3 -2 -1 0 0123456789101112 Greist et al (1995) 治疗周数治疗周数 安慰剂安慰剂 舍曲林舍曲林 50 50 mg/daymg/day 舍曲林舍曲林 100 100 mg/daymg/day 舍曲林舍曲林 200 200 mg/daymg/day p p=0.0063=0.0063 左洛复:左洛复:1212周固定剂量治疗的疗效周固定剂量治疗的疗效 Y-BOCSY-BOCS评分的变化评分的变化 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氯丙咪嗪治疗强迫症的比较采用双盲法、设有平行组、可变 剂量的研究 经过1周的清洗期之后进入为时16周的双盲法治疗期 168例患者、年龄≥18岁 OCD≥1年,Y-BOCS≥20 舍曲林50-200mg (n=86) 氯丙咪嗪50-200mg (n=82) 评价方法:Y-BOCS、NIMH-OC、CGI、HAM-D、CAS 舍曲林对强迫症的疗效 Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氯丙咪嗪疗效的比较:治疗16周时疗效优于氯丙咪嗪 随机分组的对照研究:ITT人群(LOCF) 0 -2 -4 -6 -8 -10 -12 -14 -16 0124681216 Y-BOCS评分:与基线改变的平均改变 氯丙咪嗪50-200mg(n=81) 舍曲林50-200mg(n=86) 周 数 *p=0.04 * Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 对强迫观念与强迫行为的临床疗效: 强迫性思想 (Y-BOCS项目1) 强迫性行为 (Y-BOCS项目6) 所占用的时间 Y-BOCS评分:最后一次就诊时与基线相比的平均改变(%) p=0.002 P0.01 Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氯丙咪嗪疗效的比较 随机分组的对照研究:ITT人群 p=0.02 p=0.01 p=0.04 最后一次就诊时与基线相比的平均变化(%) Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氯丙咪嗪耐受性的比较 每组发生率>10%的不良反应事件 患者% Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 由于不良反应事件而中断治疗 舍曲林与氯丙咪嗪治疗OCD的比较 由于不良反应事件而退出治疗患者% p=0.015 Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 总结: 舍曲林与氯丙咪嗪治疗OCD的比较 治疗疗效 –终点(LOCF)分析:舍曲林>氯丙 咪嗪(p=0.04) –完成治疗者分析:舍曲林=氯丙咪嗪 耐受性 由于不良反应事件而退出治疗患者%:氯丙咪嗪>舍曲林 (p=0.015) ■ ■ Bisserbe et al (1997)Bisserbe et al (1997) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 强迫症长期治疗的研究 Katz et al (1990)Katz et al (1990) 氯米帕明 1101106262 Koran (1995)Koran (1995) 氟伏沙明 39394040 Tollefson et al (1994)Tollefson et al (1994) 氟西汀 70703737 Dunbar et al (1995)Dunbar et al (1995) 帕罗西汀 a a 10410412+5212+52 Greist et al (1995)Greist et al (1995) 舍曲林 962405252 Rasmussen et al (1997)Rasmussen et al (1997) 舍曲林 383852+5252+52 与安慰剂比较对复发的预防 治疗时间研究药物n (周数) a With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society左洛复治疗强迫症的长期疗效 5252周、双盲随机安慰剂对照的临床研究周、双盲随机安慰剂对照的临床研究 Greist et al (1995)Greist et al (1995) 左洛复的不良反应与安慰剂相比无显著性差异左洛复的不良反应与安慰剂相比无显著性差异 -6-6 -4-4 -2-2 0 0 Y-BOCS Y-BOCS 评分评分 治疗后的变化治疗后的变化 Sertraline 50-200mg (n=240)Sertraline 50-200mg (n=240) Placebo (n=84)Placebo (n=84) p p0.0010.001左洛复与安慰剂比较左洛复与安慰剂比较 * *p p=0.046=0.046 0 0 4 4 8 8 1212161620202424282832323636404044444848 治疗周数治疗周数 * With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 不良反应 0-120-12周周 舍曲林舍曲林安慰剂安慰剂 3838 3434 2929 2929 1515 1313 2626 1818 1616 1010 0 0 2 2 12-5212-52周周 舍曲林舍曲林安慰剂安慰剂 4141 1616 1010 1515 8 8 1 1 2727 1414 9 9 9 9 5 5 5 5 事件事件 发生率发生率(%)(%) 头痛头痛 失眠失眠 恶心恶心 腹泻腹泻 性欲性欲 厌食厌食 Greist et al (1995)Greist et al (1995) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 左洛复治疗OCD的长期疗效 完成完成2 2年治疗的分析年治疗的分析 Rasmussen et al (1997)Rasmussen et al (1997) 治疗周数治疗周数 Sertraline 50-200mg (n=38)Sertraline 50-200mg (n=38) 0 0 8 8 1616 2424 3232 40404848 5656 6464 7272 8080 8888 9696 104104 -16-16 -14-14 -12-12 -10-10 -8-8 -6-6 -4-4 -2-2 0 0 Y-BOCS Y-BOCS 评分评分 8个月 一年 2年 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氟西汀在治疗 OCD中的比较 (24周, 双盲, n-150) • 剂量: 舍曲林 50-200 mg - 开始剂量 50 mg, 平均剂 量 140 mg 氟西汀 20-80 mg - 开始剂量 20 mg, 平均剂 量 57 mg • 24周疗效相同 (Y-BOCS, NIMH-OC, CGI) • 耐受性相等 Bergeron et al: J Clin Psychopharmacology 22:148-154, 2002 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氟西汀在治疗 OCD中的比较 Bergeron et al: J Clin Psychopharmacol 22:148-154, 2002 痊愈 有效 舍曲林 舍曲林氟西汀 氟西汀 12周24周 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与氟西汀在治疗 OCD中的比较 Bergeron et al: J Clin Psychopharmacol 22:148-154, 2002 舍曲林氟西汀 12周12周 24周 24周 CGI-严重性CGI-改善 (Percent rated as normal-to mildly ill) (Percent rated as much-to-very-much improved) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与去甲丙咪嗪在伴有重性抑郁的OCD中的应用( 12周, 双盲, n=164) • 舍曲林对 OCD 和抑郁均更加有效 • 舍曲林耐受性更好 – 副反应脱落率 (10% vs. 26%) • 平均终点剂量 舍曲林160 mg/d 去甲丙咪嗪194 mg/d Hoehn-Saric et al: Arch Gen Psychiatry 57:76-82, 2000 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 舍曲林与去甲丙咪嗪在伴有重性抑郁的OCD中的应用 Hoehn-Saric et al: Arch Gen Psychiatry 57:76-82, 2000 有几份研究报告显示:提高舍曲林有效剂量为有几份研究报告显示:提高舍曲林有效剂量为50-20050-200mg/dmg/d,,第第3 3周有效,第周有效,第8 8周疗效周疗效 最明显。一份多中心研究提示:治疗年龄在最明显。一份多中心研究提示:治疗年龄在7-177-17岁儿童为岁儿童为200200mg/dmg/d,,开始出现疗效为开始出现疗效为 第第3 3周,大约周,大约42%42%的儿童的儿童1212周时疗效显著周时疗效显著 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 当单一治疗失败 • 核查诊断,剂量,疗程 • 换药 • 其他治疗 • 尝试行为治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society OCD: 氯丙咪嗪无效者 (150 mg/day, n=33, 开放研究) • 增加剂量至 250 mg 无益,脱落增加 • 加舍曲林 (50 mg) 改善,耐受性更好 • 加维思通 (3 mg) 2组均有改善 Ravizza et al: Psychopharmacol Bull 32:677-682, 1996 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 左洛复治疗的安全性 • 舍曲林对认知功能的影响 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 左洛复:改善患者部分认知功能 显著提高认知功能(不困倦,不影响注意力和记忆力) •左洛复治疗后显著改 善某些认知功能 – 视觉追踪 – 编码 – 动作操作 •购物清单试验 – 语言学习 – 回忆 *p=0.019 vs fluoxetine, **p=0.037 vs fluoxetine 数字符号替换试验 **** 治疗后平均改善 双盲治疗周数 Fluoxetine (n=119) Sertraline (n=117) * * 24681012 8 8 7 7 6 6 5 5 4 4 3 3 2 2 1 1 0 0 43.1%试验终点左洛复剂量 100 mg/day sertraline 45.8%试验终点氟西汀剂量 of 40 mg/day fluoxetine Newhouse PA et al (2000). J Clin Psychiatry With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society与帕罗西汀不同,左洛复不影响认知功能 Schmitt et al J Psychopharm 2002 Zoloft Paxil 警觉操作综合评分 治疗天数 0714 -1.2 -0.8 -0.4 0.0 0.4 0.8 * * *P0.01 左洛复: 1-7天 50 mg/d; 8-14天 100 mg/d 帕罗西汀:1-7天 20 mg/d;8-14天 40 mg/d N = 21 交叉对照实验 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (F1,20=3.4, p=.041). 17 19 21 23 25 1815 治疗天数 侦察警觉性 安慰剂 舍曲林 西酞普兰 与舍曲林和安
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