精神科实证期刊阅读报告EBM-styleJournalReading课件.ppt

1、精神科實 證 期 刊 閱 讀 報 告EBM-style Journal Reading報告人：R1 李秀瓊 指導臨床教師：Dr.鄭怡君日期：2009/08/25地點：十樓精神科會議室Clinical Scenario（臨床情境）n40歲未婚林先生，七年前被診斷重鬱症與邊緣性人格n在規則服藥與接受心理治療的情況下，仍陸續住院19次，每次住院均因為生活事件生活事件(失戀、被同事批評、與母親衝突、奶奶過世、家人生病等)、而出現酗酒、酗酒、失眠、情緒低落、注意力不集中、食慾差、反應慢、失眠、情緒低落、注意力不集中、食慾差、反應慢、體重變化大、甚至自殘體重變化大、甚至自殘(潑汽油自焚、撞玻璃、撞牆、割腕

2、、剁手指、跳樓、用香煙燙腳等)。Clinical Scenario（臨床情境）n接受心理治療多年n曾使用過的抗憂鬱劑有以下幾種:Efexor(150 mg/day)、Seroxat(40 mg/day)、Remeron(120 mg/day)、Bupropion(300 mg/day)n目前使用的藥物nLexapro 2hsnWellbutrin 2#qdnSeroquel(200)2#hsnLamictal(50)1-0-2-0nRivotril(2)2#ONnPropranolol(10)1#bidnRitalin(10)2#tidaClinical Scenario（臨床情境）n入院後除

3、原有的藥物與心理治療外，請病人每天騎固定式腳踏車運動30分鐘以上n病人描述每次騎腳踏車的半個小時一直到騎完的一兩個小時內心情都變好Clinical Uncertainty PICO 問題nCan a patient with depression benefits from exercise?臨床個案的PICO Patient/Problema patient with major depressionInterventionExercise+antidepressant+psychotherapyComparisonAntidepressant+psychotherapyOutcomeHos

4、pital stayType of Question:Therapy Search Terms&Strategy:（搜尋關鍵字與策略）n資料庫：pubmedn搜尋日期：2009/08/16n搜尋關鍵字與策略：n#2Search(depress*AND(exercise OR physical activit*)AND systematicsb Limits:published in the last 1 year,only items with abstracts,Humans,Meta-Analysis,Review08:36:4819n#1Search(depress*AND(exerci

5、se OR physical activit*)AND systematicsb08:36:05185 find the paper that Im most interested inBest available evidence:（挑選可獲得之最佳研究證據）nCitation/s:nExercise for depression(Review)The Cochrane Library,2009,Issue 3nLead authors name:Mead GE,Morley W,Campbell P,Greig CA,McMurdo M,Lawlor DAThe Study:-1nEnro

6、lled the articles published before May 2008 nA total of 28 RCT trials were includednType of participants:n7 studies use clinical populationsnclinical interview in 9 studiesnThe other 12 studies:Beck Depression Inventory、CES-D、Geriatric Depression Scale、Depression Adjective Checklist,Symptom Checklis

7、t Score、Minnesota Multiple Personality Inventory in selectionThe Study:-2nTypes of interventions:n有氧運動（跑步、在跑步機上行走、有氧訓練、跳舞、騎固定式腳踏車、氣功、太極.）n室內vs戶外運動n團體vs單獨運動n運動期間：10天16週nTypes of outcomesn住院長短、patient and clinical global impression、sickness impact profile、quality of lifenLevel of Evidence:1aLevel of E

8、vidence:1aThe Study:-3本篇文獻的PICO(T)Patient/ProblemDepressive patients(inpatient,outpatient)InterventionExerciseComparisonSocial activities,CBT,bright-light therapy,antidepressantsOutcome住院長短、patient and clinical global impression、sickness impact profile、quality of lifeTime10天16週The Evidence:Exercise

9、ControlnPrimary outcome measurenReduction in symptom severity at post-treatment (95%CI-1.12 to-0.51)large clinical effect.nPrimary outcome measurenReduction in symptom severity at follow-up nlong-term follow-up data found only a moderate effect(SMD-0.44,95%CI-0.71 to-0.18).nno statistical heterogene

10、ityThe Evidence:Exercise Control（長期）The Evidence:Exercise=CBTnno significant difference between the two interventions(95%CI-0.51,0.18)nNo statistical heterogeneityThe Evidence:Exercise Bright light therapynexercise was superior to bright light therapy(95%CI-10.20,-2.60).The Evidence:Exercise=Antidep

11、ressantsnno significant difference between the two interventions(SMD was-0.04 95%CI-0.31,0.24)Comment&Discussion:-1 n限制：n本文所收錄的研究中，對於憂鬱症的定義範圍太廣，住院者、門診病人、甚至一般人有憂鬱症狀者均有。n若運動對於憂鬱症者有幫助，本文並沒有說明最適合的運動方式、運動的時間和持續多久、戶外或室內運動等的效果Comment&Discussion:-2 n運動之抗憂鬱效果可能的機轉（J Psychiatry Neurosci 2006;31(2):84-92.）n如同抗

12、憂鬱劑，運動會增加大腦中新的神經元之合成，特別在hippocampus中神經元合成增加23倍n這點可以解釋為何憂鬱症病人運動後其食慾與體重會回復正常。n運動能否抗憂鬱，有不同的學者以不同的角度研究，其中心理學家以運動後對於壓力事件的忍受程度分析，結果與我們的假設相反-運動組在長達8個月的運動後，其壓力忍受程度並沒有比不運動組來得高（Psychosomatic Medicine 55:347-363,1993）。n由以上三篇文獻綜合來看，運動使得大腦的神經元增加、到形成抗憂鬱效果，中間的心理與行為歷程仍然有待探討。Comment&Discussion:-3 回到臨床個案情境Clinical bo

13、ttom line 臨床決策底線臨床決策底線n To treatment depressive patients,exercise was effective compared with no treatment or control intervention.(95%CI-1.12,-0.51)證據等級證據等級1a,1a,建議等級建議等級B BReferences:nExercise for depression(Review).The Cochrane Library 2009,Issue 3nAntidepressant effects of exercise:Evidence for

14、an adult-neurogenesis hypothesis?J Psychiatry Neurosci 2006;31(2):84-92.nRegular Exercise and Aerobic Fitness in Relation to Psychological Make-up and Physiological Stress Reactivity.Psychosomatic Medicine 55:347-363(1993)結 論（標題 Title）To treat depressive patients,exercise did seem to be more effective than control intervention nAppraised by:Lee,Hsiu-chiungnDate:2009.8.25nE-mail:u9300010cc.kmu.edu.twnKill or Update By: