Akiskal H S
Department of Psychiatry, University of California at San Diego, La Jolla 92093-0603.
J Clin Psychiatry. 1994 Apr;55 Suppl:46-52.
This paper reviews recent evidence on two prevalent course patterns of major depressive illness arising from dysthymic and cyclothymic temperamental substrates. The first pattern, known as "double depression," typically begins insidiously in childhood or adolescence, pursues a low-grade intermittent course, and is complicated by superimposed highly recurrent major depressions. Patients with this pattern respond to TCAs, MAOIs (classical and reversible), and SSRIs (of which the best current evidence is for fluoxetine). The second pattern, that of "cyclothymic depression," is represented by bipolar II and related soft bipolar disorders; it pursues a more fluctuating course from onset in juvenile or early adult years, and appears susceptible to rapid cycling upon tricyclic antidepressant administration. For patients exhibiting the latter pattern, bupropion, MAOIs, and low-dose SSRIs all seem beneficial, but should be preferably used in conjunction with lithium or other mood stabilizers such as valproate; thyroid augmentation is particularly relevant to these cyclothymic depressions. Practical and supportive psychotherapeutic approaches would be useful for double depressive patients, while psychoeducation and attention to rhythmopathy would be more relevant for those with cyclothymic depressions. Conjugal and other interpersonal strains should also be addressed in both affective subtypes. The evidence reviewed does not support the commonly held belief that depressions associated with "personality" disorders respond suboptimally to treatment. On the contrary,the temperamental dysregulation underlying depressive subtypes defined by course appears responsive--even overresponsive--to a new spectrum of thymoleptic agents. These considerations underscore the close link between innovative temperament-based classifications of depressive illness and emerging clinical management strategies with thymoleptic agents and psychosocial interventions.
本文回顾了近期关于两种主要抑郁症常见病程模式的证据，这两种模式源于心境恶劣和环性心境气质基础。第一种模式，即“双重抑郁”，通常在童年或青少年期隐匿起病，呈低度间歇性病程，并伴有叠加的高度复发性重度抑郁症。具有这种模式的患者对三环类抗抑郁药、单胺氧化酶抑制剂（经典型和可逆型）以及选择性5-羟色胺再摄取抑制剂（目前最佳证据表明氟西汀效果最佳）有反应。第二种模式，即“环性心境障碍性抑郁”，由双相II型及相关的软双相障碍所代表；它从青少年期或成年早期起病，病程波动更大，在使用三环类抗抑郁药时似乎易出现快速循环发作。对于表现出后一种模式的患者，安非他酮、单胺氧化酶抑制剂和低剂量选择性5-羟色胺再摄取抑制剂似乎都有益，但最好与锂盐或其他心境稳定剂如丙戊酸盐联合使用；甲状腺素补充对这些环性心境障碍性抑郁尤为重要。实用的支持性心理治疗方法对双重抑郁患者有用，而心理教育和对节律紊乱的关注对环性心境障碍性抑郁患者更相关。在这两种情感亚型中，还应处理婚姻及其他人际关系紧张问题。所回顾的证据不支持普遍持有的观点，即与“人格”障碍相关的抑郁症对治疗反应欠佳。相反，由病程定义的抑郁亚型所潜在的气质失调对一系列新的心境稳定剂似乎有反应——甚至反应过度。这些考虑强调了基于气质的创新性抑郁症分类与使用心境稳定剂和社会心理干预措施的新兴临床管理策略之间的紧密联系。
