右单侧超短脉冲电惊厥疗法联合文拉法辛治疗对老年抑郁症患者失眠症状的影响。
Effects of a Course of Right Unilateral Ultrabrief Pulse Electroconvulsive Therapy Combined With Venlafaxine on Insomnia Symptoms in Elderly Depressed Patients.
机构信息
Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, 997 St Sebastian Way, Augusta, GA 30912.
Department of Psychiatry and Health Behavior, Augusta University/Medical College of Georgia, Augusta.
出版信息
J Clin Psychiatry. 2018 Mar/Apr;79(2). doi: 10.4088/JCP.16m11089.
OBJECTIVE
Antidepressant medications have a variety of effects on sleep, apart from their antidepressant effects. It is unknown whether electroconvulsive therapy (ECT) has effects on perceived sleep in depressed patients. This secondary analysis examines the effects of ECT on perceived sleep, separate from its antidepressant effects.
METHODS
Elderly patients with major depressive disorder, as defined by DSM-IV, received open-label high-dose, right unilateral ultrabrief pulse ECT, combined with venlafaxine, as part of participating in phase 1 of the National Institute of Mental Health-supported study Prolonging Remission in Depressed Elderly (PRIDE). Phase 1 of PRIDE participant enrollment period extended from February 2009 to August 2014. Depression severity was measured with the Hamilton Depression Rating Scale-24 item (HDRS₂₄), and measures of insomnia severity were extracted from the HDRS₂₄. Participants were characterized at baseline as either "high-insomnia" or "low-insomnia" subtypes, based upon the sum of the 3 HDRS₂₄ sleep items as either 4-6 or 0-3, respectively. Insomnia scores were followed during ECT and were adjusted for the sum of all the HDRS₂₄ non-sleep items. Generalized linear models were used for longitudinal analysis of insomnia scores.
RESULTS
Two hundred forty patients participated, with 48.3% in the high-insomnia and 51.7% in the low-insomnia group. Although there was a reduction in the insomnia scores in the high-insomnia group, only 12.4% of them experienced remission of insomnia after a course of ECT, despite an increase in utilization of sleep aids across the course of ECT, from 8.6% to 23.2%. The degree of improvement in insomnia symptoms paralleled the degree of improvement in non-insomnia symptoms. A "low" amount of improvement on the sum of the HDRS non-insomnia items (HDRS-sleep) was accompanied by a "low" amount of improvement in insomnia scores (change of -1.6 ± 1.2, P < .0001), while a "high" amount of improvement on the sum of the HDRS non-insomnia items was accompanied by a "higher" amount of improvement in insomnia scores (change of -3.1 ± 1.6, P < .0001). After adjustment for non-insomnia symptoms, there was no change in insomnia in the low-insomnia group.
CONCLUSIONS
We found that ECT, combined with venlafaxine, has a modest anti-insomnia effect that is linked to its antidepressant effect. Most patients will have some degree of residual insomnia after ECT, and will require some consideration of whether additional, targeted assessment and treatment of insomnia is warranted.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01028508.
目的
抗抑郁药物除了具有抗抑郁作用外，还对睡眠有多种影响。电惊厥疗法（ECT）是否对抑郁患者的感知睡眠有影响尚不清楚。这项次要分析研究了 ECT 对感知睡眠的影响，而不考虑其抗抑郁作用。
方法
根据 DSM-IV 标准，患有重度抑郁症的老年患者接受了开放标签的高剂量、右侧单侧超短脉冲 ECT，同时联合文拉法辛，作为参加国家心理健康研究所支持的研究“延长老年抑郁缓解时间”（PRIDE）第 1 阶段的一部分。PRIDE 第 1 阶段的参与者招募期从 2009 年 2 月延长至 2014 年 8 月。使用汉密尔顿抑郁评定量表 24 项（HDRS₂₄）来衡量抑郁严重程度，使用 HDRS₂₄ 中的失眠严重程度测量项提取失眠严重程度的测量值。根据 HDRS₂₄ 中的 3 项睡眠测量项的总和（分别为 4-6 或 0-3），参与者在基线时被分为“高失眠”或“低失眠”亚型。失眠评分在 ECT 期间进行随访，并根据所有 HDRS₂₄ 非睡眠测量项的总和进行调整。使用广义线性模型对失眠评分进行纵向分析。
结果
共有 240 名患者参加，其中 48.3%为高失眠组，51.7%为低失眠组。尽管高失眠组的失眠评分有所降低，但尽管在 ECT 过程中睡眠辅助工具的使用率从 8.6%增加到 23.2%，只有 12.4%的患者在接受 ECT 后失眠得到缓解。失眠症状的改善程度与非失眠症状的改善程度平行。HDRS 非睡眠项目（HDRS-sleep）总和的“低”改善程度伴随着失眠评分的“低”改善程度（改变值为-1.6±1.2，P<0.0001），而 HDRS 非睡眠项目总和的“高”改善程度伴随着失眠评分的“更高”改善程度（改变值为-3.1±1.6，P<0.0001）。在调整非失眠症状后，低失眠组的失眠状况没有变化。
结论
我们发现，ECT 联合文拉法辛具有适度的抗失眠作用，这与其抗抑郁作用有关。大多数患者在 ECT 后会有一定程度的残余失眠，需要考虑是否需要额外的、有针对性的失眠评估和治疗。
试验注册
ClinicalTrials.gov 标识符：NCT01028508。
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