Greden John F
Department of Psychiatry and University of Michigan Depression Center, Ann Arbor, MI 48109, USA.
J Clin Psychiatry. 2003;64 Suppl 7:5-11.
The burden of depression on society is sizable. Innate to this burden are underdiagnosis and under-treatment of unipolar and bipolar major depressive disorder in all parts of the health care system in part due to underrecognition of the physical symptoms that commonly are core components of major depressive disorder. Physical pains especially complicate the diagnosis of depression. Many patients de-emphasize psychosocial symptoms while emphasizing pains as their primary or sole complaints. There is a high correlation between the number of physical symptoms reported and the presence of depression. Additionally, patients with residual physical and emotional symptoms following treatment for depression appear to be at higher risk of relapse compared with those who have no residual symptoms. Complex genetic vulnerabilities underlie the depressive diathesis, and stress appears to be an accentuation for the gene expression that sets off episodes of depression in persons with these predispositions. If underdiagnosis interferes and acute treatment is not implemented early and effectively for initial episodes of depression and maintained after remission, individuals with genetic vulnerabilities may experience a pattern of recurrences, cycle acceleration, and increased severity. Serotonin and norepinephrine may be shared neurochemical links that tie depression and physical symptoms together. Thus, it is reasonable to hypothesize that antidepressants that incorporate both serotonin and norepinephrine reuptake inhibition might be a more efficacious treatment approach for patients with physical symptoms of depression.
抑郁症给社会带来的负担相当大。在整个医疗保健系统中，单相和双相重度抑郁症的诊断不足和治疗不足是这一负担的内在因素，部分原因是对通常作为重度抑郁症核心组成部分的躯体症状认识不足。身体疼痛尤其使抑郁症的诊断复杂化。许多患者在强调疼痛是其主要或唯一症状时，淡化了心理社会症状。报告的躯体症状数量与抑郁症的存在之间存在高度相关性。此外，与没有残留症状的患者相比，抑郁症治疗后仍有残留躯体和情绪症状的患者复发风险似乎更高。复杂的基因易感性是抑郁素质的基础，压力似乎是引发有这些易感性的人抑郁发作的基因表达的加剧因素。如果诊断不足产生干扰，且对抑郁症的初始发作没有早期有效地实施急性治疗并在缓解后维持治疗，具有基因易感性的个体可能会经历复发、发作周期加速和病情加重的模式。血清素和去甲肾上腺素可能是将抑郁症和躯体症状联系在一起的共同神经化学纽带。因此，有理由假设，对有抑郁症躯体症状的患者而言，同时抑制血清素和去甲肾上腺素再摄取的抗抑郁药可能是一种更有效的治疗方法。
