Wuerth Diane, Finkelstein Susan H, Kliger Alan S, Finkelstein Fredric O
New Haven CAPD, Renal Research Institute, New Haven, Connecticut, USA.
Semin Dial. 2003 Nov-Dec;16(6):424-7. doi: 10.1046/j.1525-139x.2003.16094.x.
Depression has been documented as the most frequently encountered psychological problem in end-stage renal disease (ESRD) patients and has been correlated with both mortality and morbidity in these patients. Previous work by our group has shown that clinical depression is treatable with psychotropic medications in these patients, but that only a limited number of ESRD patients with depression will successfully complete a course of pharmacologic therapy. From July 1997 to October 2002, all chronic peritoneal dialysis (PD) patients in our facility were encouraged to be screened for depression utilizing the self-administered Beck Depression Inventory (BDI) questionnaire. Based on previous work, a score > or =11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores > or =11 were encouraged to complete a more formal evaluation for the presence of clinical depression. A total of 320 BDI questionnaires were completed during the study period: 134 patients. (42%) scored > or =11 on the BDI, 69 of the 134 patients (51%) with BDI scores > or =11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores > or =18 on the Hamilton Depression Scale and standard Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Forty-four patients with clinical depression agreed to pharmacologic treatment. However, only 23 of the 44 patients (52%) successfully completed a 12-week course of drug therapy. Two unit social work reviewers systematically reviewed the records of these 21 patients who did not complete therapy and assessed the reasons for their inability to complete treatment. Reasons identified included eight patients who experienced acute medical problems, three who were active substance abusers, and two who reported medication side effects. The remaining eight patients who did not complete the 12 weeks of therapy were examined by applying the axis 1 and axis 2 DSM-IV criteria. Axis 1 is used to diagnose clinical disorders and axis 2 is used to diagnose personality disorders. While all these patients met the DSM-IV axis 1 criteria for clinical depression, eight of these patients met axis 2 criteria for personality disorders; five patients had borderline personality disorders, one had a narcissistic personality disorder, one had a factitious disorder, and one had features of avoidant personality disorder. While some chronic PD patients can be successfully treated for clinical depression with psychotropic medication prescribed by the dialysis medical team, not all patients will agree to be evaluated for clinical depression and accept pharmacologic treatment. Others cannot or will not complete treatment when additional psychiatric disorders exist. These patients may require additional intervention when diagnosed with clinical depression and a personality disorder. Further trials are warranted.
抑郁症已被证明是终末期肾病（ESRD）患者中最常见的心理问题，并且与这些患者的死亡率和发病率都相关。我们团队之前的研究表明，临床抑郁症在这些患者中可用精神药物治疗，但只有少数患有抑郁症的ESRD患者能成功完成一个药物治疗疗程。从1997年7月到2002年10月，我们机构鼓励所有慢性腹膜透析（PD）患者使用自行填写的贝克抑郁量表（BDI）问卷进行抑郁症筛查。根据之前的研究，该问卷得分≥11分被用来表明可能患有临床抑郁症；BDI得分≥11分的患者被鼓励完成更正式的临床抑郁症评估。在研究期间共完成了320份BDI问卷：134名患者。（42%）在BDI上得分≥11分，134名BDI得分≥11分的患者中有69名（51%）同意进一步评估。这69名患者中有60名（87%）根据汉密尔顿抑郁量表得分≥18分以及《精神疾病诊断与统计手册》第4版（DSM-IV）标准被诊断为临床抑郁症。44名患有临床抑郁症的患者同意接受药物治疗。然而，44名患者中只有23名（52%）成功完成了为期12周的药物治疗疗程。两名科室社会工作审查员系统地审查了这21名未完成治疗患者的记录，并评估了他们未能完成治疗的原因。确定的原因包括8名出现急性医疗问题的患者、3名活跃的药物滥用者以及2名报告有药物副作用的患者。其余8名未完成12周治疗的患者通过应用DSM-IV标准的轴I和轴II进行检查。轴I用于诊断临床疾病，轴II用于诊断人格障碍。虽然所有这些患者都符合DSM-IV轴I临床抑郁症标准，但其中8名患者符合轴II人格障碍标准；5名患者患有边缘型人格障碍，1名患有自恋型人格障碍，1名患有做作性障碍，1名具有回避型人格障碍特征。虽然一些慢性PD患者可以通过透析医疗团队开的精神药物成功治疗临床抑郁症，但并非所有患者都会同意接受临床抑郁症评估并接受药物治疗。当存在其他精神疾病时，其他患者无法或不愿完成治疗。这些患者在被诊断为临床抑郁症和人格障碍时可能需要额外的干预。有必要进行进一步的试验。
