Post Robert M, Denicoff Kirk D, Leverich Gabriele S, Altshuler Lori L, Frye Mark A, Suppes Trisha M, Rush A John, Keck Paul E, McElroy Susan L, Luckenbaugh David A, Pollio Chad, Kupka Ralph, Nolen Willem A
Stanley Foundation Bipolar Network and Biological Psychiatry Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD 20892-12723, USA.
J Clin Psychiatry. 2003 Jun;64(6):680-90; quiz 738-9. doi: 10.4088/jcp.v64n0610.
A number of recent longitudinal outcome studies have found substantial long-term morbidity in patients with bipolar disorder. The detailed course and pattern of illness emerging despite comprehensive treatment with mood stabilizers and adjunctive agents have previously not been well delineated.
258 consecutive outpatients admitted from 1996 to 1999 to the Stanley Foundation Bipolar Network who had a full year of prospective daily clinician ratings on the National Institute of Mental Health-Life Chart Method were included in the analysis. Patients were diagnosed by the Structured Clinical Interview for DSM-IV, with the majority (76%) having bipolar I disorder. They completed a questionnaire on demographics and prior illness course, and variables associated with outcome were examined in a hierarchical multinomial logistic regression analysis. Patients were treated naturalistically with a mean of 4.1 psychotropic medications during the year.
Despite comprehensive pharmacologic treatment, mean time depressed (33.2% of the year) was 3-fold higher than time manic (10.8%); 62.8% of patients had 4 or more mood episodes per year. Two thirds of the patients were substantially impacted by their illness; 26.4% were ill for more than three fourths of the year, and 40.7% were intermittently ill with major affective episodes. After logistic regression analysis, those who were ill most of the year, compared with the largely well group, had a significantly greater family history of substance abuse, 10 or more depressive episodes, and limited occupational functioning prior to Network entry.
A majority of outpatients with bipolar illness, even with intense monitoring and treatment in specialty clinics, have a considerable degree of residual illness-related morbidity, including a 3-fold greater amount of time spent depressed versus time spent manic. A personal or family history of substance abuse, 10 or more prior depressions, and limited occupational functioning predicted the poorest outcomes. Additional interventions, particularly those targeted at treating depressive phases of bipolar illness, are greatly needed.
近期多项纵向结局研究发现，双相情感障碍患者存在大量长期发病情况。尽管使用心境稳定剂及辅助药物进行了全面治疗，但此前疾病的详细病程及模式尚未得到很好的描述。
对1996年至1999年连续入住斯坦利基金会双相情感障碍网络的258名门诊患者进行分析，这些患者依据美国国立精神卫生研究所生命图表法接受了为期一整年的每日临床医生前瞻性评估。通过《精神疾病诊断与统计手册》第四版（DSM-IV）结构化临床访谈对患者进行诊断，大多数患者（76%）患有双相I型障碍。他们完成了一份关于人口统计学和既往病程的问卷，并在分层多项逻辑回归分析中检查了与结局相关的变量。患者在这一年中接受自然疗法，平均使用4.1种精神药物。
尽管进行了全面的药物治疗，但平均抑郁时间（占一年的33.2%）比躁狂时间（10.8%）高出3倍；62.8%的患者每年有4次或更多次情绪发作。三分之二的患者受到疾病的严重影响；26.4%的患者一年中患病时间超过四分之三，40.7%的患者间歇性患有重度情感发作。经过逻辑回归分析，与大部分时间病情良好的组相比，一年中大部分时间患病的患者有明显更多的药物滥用家族史、10次或更多次抑郁发作，且在进入该网络之前职业功能受限。
大多数双相情感障碍门诊患者，即使在专科诊所接受密切监测和治疗，仍有相当程度与疾病相关的残留发病情况，包括抑郁时间比躁狂时间多3倍。个人或家族药物滥用史、10次或更多次既往抑郁发作以及有限的职业功能预示着最差的结局。迫切需要额外的干预措施，尤其是针对双相情感障碍抑郁阶段的治疗措施。
