1、憂鬱症與 HRV 關聯之研究,簡報大綱,憂鬱症簡介憂鬱症與心血管疾病憂鬱症與 HRV (有關聯性之研究)憂鬱症與 HRV (無關聯性之研究)心得,憂鬱症簡介(1/2),主要症狀憂鬱症又稱抑鬱症，是一種常見的精神心理疾病，又稱為心靈上的感冒。患者一般主觀上感到強烈的悲傷和憂鬱，阻礙其正常生活和社會交往。心理學上的憂鬱症不同於正常範圍內的情感脆弱或暫時的心情不好。它是一種由生理及心理精神因素所致的疾患。病情在任何年齡階段均可出現，包括兒童。憂鬱症患者常常可能會想哭、經常大發脾氣，心情總是不好，睡不好，吃也吃不好，每天胸口悶悶的，什麼都覺得煩惱，四肢無力，記性差，不能集中精神，做事緩慢，對什麼都提不
2、起勁，沒有信心，常常想不開，更想尋死。有些症狀會與習得無助感相關。,憂鬱症簡介(2/2),病因生理因素主要是荷爾蒙問題，例如產後抑鬱症。藥物濫用也會容易產生憂鬱症。遺傳因素根據研究發現，患有憂鬱症的母親，她的孩子患有憂鬱症的可能性比一般人高兩倍。生活壓力，壓力管理問題社會急速變化使人未能適應，隨時產生挫敗感。節奏緊張，壓力不斷增加，管理不善，會影響個人情緒，例如過於繁複的考試。性格因素如果性格內向，不善於溝通，便會比較容易得抑鬱症。,憂鬱症與心血管疾病,憂鬱症與心血管疾病、腦中風之共病關係。急性心肌梗塞之後，出現憂鬱症者，易增加死亡率。心臟學者的研究已證實憂鬱症是缺血性心臟病的一項獨立危險因子
3、，不是發生心臟病之後的情緒心理反應。聯合國世界衛生組織提出呼籲：憂鬱症是 21 世紀三個重大疾病之一。,憂鬱症與心血管疾病,血小板功能異常：憂鬱症患者的血小板功能異常，促使這些病人較容易產生血栓凝集，因此增加心血管疾病之易受性。目前可以測得憂鬱症患者血小板功能異常項目如下：血小板活化及凝集血小板細粒釋放介質血栓形成,血小板功能異常血小板活化及凝結,血小板活化及聚集時，其表面有多種蛋白質會活化，其中 glycoproteinb/a 在凝集時佔了最重要的角色，這個蛋白質活化後，成為 fibrinogen 及/或 von Willebrand 因子的接受器，有一種接受器的抗體，叫 anti-liga
4、nd-induced binding site (LIBS) 抗體，當這種抗體增加時，表示 glycoproteinb/a 與 fibrinogen 之結合增加，即促成凝集作用的活化。（心肌梗塞或不穩定心絞痛）,血小板功能異常血小板細粒釋放介質,當血小板活化後，由血管受傷處 (即內皮細胞剝落處)，釋放一些含在 a 細粒內促進細胞分解與分裂的因子，包括血小板因子-4，(platelet factor 4, PF4)、b-thromboglobulin (b-TG)、血清素 (serotonin) 與 thromboxane A2，這些因子進一步活化血小板，使更多血小板聚集，促進動脈粥狀塊破裂，最
5、終形成血栓。,血小板功能異常血栓形成,由粥狀動脈硬化發生之開始，憂鬱症就參與角色，先是動脈內皮細胞功能異常，吸引低密度膽固醇與單球細胞附著，同時內皮細胞分泌細胞激素 (cytokines)，供白血球單球細胞由血管壁進入動脈內層，再變成巨噬細胞，吸收更多膽固醇後，變成胖胖的發泡細胞 (foam cell)。這時內皮細胞，平滑肌細胞再分泌酵素，使平滑肌移動，在發泡細胞表面形成一層如帽子的膜層，當受到壓力，或發泡細胞的頂膜變薄時，便會破裂。此時分泌的 prothrombin 便都變成 thrombin，即血栓形成。,憂鬱症與 HRV (有關聯性之研究),研究已指出有三種精神狀態與HRV減少有關：1.
6、 攻擊性人格 (易怒)2. 衝動型3. 焦慮型 (特別是恐慌症) 與憂鬱症,憂鬱症與HRV (世代研究),Frasure-Smith 等人由 222 例急性心肌梗塞病人之追蹤研究，已明顯指出，憂鬱症是心臟病死亡的重要預測指標，他們也認為心臟病人死亡，多數原因是心律不整，特別是心室早期收縮、HRV減少則容易產生心律不整，加速動脈硬化與死亡，HRV減少時，相對地，交感神經較易興奮，對心律不整是雪上加霜。Frasure-Smith N, Lesparance F, Talajic M: Depression and 18-month prognosis often myocardial infrac
7、tion. Circulation 1995;91:999-1005.,憂鬱症與HRV (個案對照研究),Tucker等人以 SSRI paroxetine 來治療 17 例恐慌症，另以 16 例為對照組。Paroxetine 組用 20 mg/d，共四週，結果恐慌症得到改善，同時發現其交感神經活動減少，副交感神經活動增加，心跳速率可變性恢復正常。同樣地，用來治療憂鬱症也有相同的效果，不影響HRV。心房纖動 (afrial fibrillntion) 的病人，不管以那一型抗心律不整劑，來控制心跳速率或速度，研究發現 3.5 年後，約有一半病人發生腦中風，此時其心跳是規律的，HRV卻下降了；可見
8、心跳速率或速度，不是絕對的重要，HRV較重要。Gorman JM, Sloan RP: Heart rate variability in depressive and anxiety disorders. Am Heart J 2000;140:S77-83. 20. Glassman AH, Rodriguez AI, Shapiro PA: The use of antidepressant drugs in patients with heart disease. J Clin Psychiatry 1998;59:16-21.,憂鬱症與HRV無顯著關聯之研究,Objective Th
9、ere are conflicting results on the relationship between heart rate variability (HRV) and major depression. There is some research reporting decreased heart rate variability in depressed patients, which may result in increased cardiovascular mortality and morbidity. This study aims to investigate the
10、 HRV in a group of physically healthy depressed patients in comparison to healthy subjects. MethodTwenty-one depressed subjects were compared to same number of healthy controls on the measures of HRV as measured by Kardiosis DL 700 Digital tree channel recorder Holter monitors. The study group was a
11、lso assessed with Hamilton anxiety and depression scales. The HRV measures were compared in between the two groups and correlations between levels of anxiety and depression with HRV measures were sought for.,Results There was no statistically significant difference between the study and control grou
12、ps on the measures of HRV. No significant relationship between the levels of anxiety and depression and HRV measures were found. Conclusions In physically healthy depressed adults HRV does not differ from healthy subjects. This means that depression does not pose an additional risk factor for cardio
13、vascular disease in physically healthy adults. This finding gives support to some previous research which did not find any relationship between depression and heart rate variability.,There was no statistically significant difference in gender between the two groups as well as in terms of years of ed
14、ucation. Table 2. In the patient group mean Hamilton depression scores was 22.23.9 and the mean Hamilton anxiety scores was 21.64.7.,Time domain parameters were studied. The parameters were as follows: rMSSD, pNN50, SDNN,SDNN index, SDANN. There were no significant differences in any of these parame
15、ters between the major depressive and healthy control groups.,We think that this is related to the sample studied. In almost all studies concerning HRV and depression the samples are composed of patients with coronary heart disease(冠狀動脈心臟疾病).As is indicated in the methods section, our study group wa
16、s composed of depressed subjects without a known coronary artery disease.In this group of physically healthy depressed patients depression did not emerge as a predictor of heart rate variability.Conflicting results have been reported on the relationship between HRV and depression and our study lends
17、 support to the view that no association exists between these two, at least in physically healthy adult depressed patients.,心得,參考文獻,憂鬱症是心血管與腦血管疾病的危險因子陳金柱 呂炎原、吳尚德、 郭宗正台灣醫界2005,5月,第48卷第5期Heart Rate Variability in Depressed PatientsKemal Sayar, M.D.1, Huseyin Gulec, M.D.1,Mustafa Gokce, M.D.2, smail Ak, M.D.1,
