Depressiya Pri Shizofrenii 1

8/19/2019 Depressiya Pri Shizofrenii 1

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Çíà÷èìîñòü äåïðåññèè ïðè øèçîôðåíèè

Âûÿâëåíèå äåïðåññèè ïðè øèçîôðåíèè âàæíî ïî ðÿäó ïðè÷èí. Âî-ïåðâûõ, ïîòîìó, ÷òî îíà ïðåäñòàâ-ëÿåò ñîáîé ñóùåñòâåííîå äîïîëíèòåëüíîå áðåìÿäëÿ ïàöèåíòà. Âî-âòîðûõ, îíà ñâÿçàíà ñ ðÿäîì äðó-

ãèõ íåãàòèâíûõ èñõîäîâ, âêëþ÷àÿ ñóèöèäû è ñóè-öèäàëüíûå ïîïûòêè (1). Áðåìÿ äåïðåññèè â îáùåéïîïóëÿöèè ÿâëÿåòñÿ îáùåïðèçíàííûì, íî åå ëåã÷åíåäîîöåíèòü â ïîïóëÿöèè áîëüíûõ øèçîôðåíèåé.Âìåñòå ñ òåì, äåïðåññèÿ ïðè øèçîôðåíèè îêàçûâà-åòñÿ ñòàòèñòè÷åñêè çíà÷èìûì ñèìïòîìàòè÷åñêèìêîððåëÿòîì êà÷åñòâà æèçíè â ýòîé ïîïóëÿöèè (27).Äîêàçàòåëüíîñòü ñâÿçè ìåæäó äåïðåññèåé è èñõî-äîì íàèáîëåå ñèëüíà â îòíîøåíèè ñóèöèäàëüíûõïîïûòîê è çàâåðøåííûõ ñóèöèäîâ. Â ñðàâíåíèè ñîáùåé ïîïóëÿöèåé, ðèñê ñóèöèäà â òå÷åíèå æèçíèïðè øèçîôðåíèè â 20 ðàç âûøå (30). ×àñòîòà ïðåä-øåñòâóþùåé äåïðåññèè â ãðóïïå ïàöèåíòîâ ñ øè-

çîôðåíèåé, ñîâåðøèâøèõ çàâåðøåííûé ñóèöèä,âûøå ïî ñðàâíåíèþ ñ êîíòðîëüíîé ãðóïïîé æèâûõïàöèåíòîâ (32) è âûøå ïðè çàâåðøåííûõ ñóèöèäàõïî ñðàâíåíèþ ñ ñîâåðøèâøèìè ñóèöèäàëüíûå ïî-ïûòêè (13). Ïàöèåíòû ñ ïîïûòêàìè ñóèöèäà â àíàì-íåçå îáíàðóæèâàþò áîëåå âûðàæåííóþ ñòåïåíüäåïðåññèè, ÷åì ïàöèåíòû áåç òàêèõ ïîïûòîê (1).

Íåñêîëüêî èññëåäîâàíèé ïîêàçàëè âçàèìîñâÿçüìåæäó íàëè÷èåì äåïðåññèè è ïîâòîðíûì îáîñòðå-íèåì. Ïîäâûáîðêà ïàöèåíòîâ â îäíîì èç êàòàìíå-ñòè÷åñêèõ èññëåäîâàíèé ïåðâîãî ýïèçîäà íàáëþäà-ëàñü â òå÷åíèå ñåìè ëåò. Äåïðåññèÿ â íà÷àëå íàáëþ-äåíèÿ îêàçàëàñü åäèíñòâåííûì ñèìïòîìàòè÷åñêèìïðåäèêòîðîì âðåìåíè, ïðåäøåñòâóþùåãî ðåãîñïè-òàëèçàöèè (14). Îäíàêî, ýòè äàííûå íå áûëè óñòîé-÷èâûìè (25). Äåïðåññèÿ, ðàçâèâàþùàÿñÿ ïîñëå îñ-òðîãî ïñèõîòè÷åñêîãî ýïèçîäà, îêàçàëàñü òàêæåïðåäèêòîðîì ïîâòîðíîãî îáîñòðåíèÿ (22, 28), è äåï-

ðåññèâíûå ñèìïòîìû áûëè ðåòðîñïåêòèâíî îöåíå-íû êàê ïðåäèêòîðû íàñòóïàþùåãî îáîñòðåíèÿ (19).

Íà ðàñïîçíàâàíèå, îöåíêó è ëå÷åíèå äåïðåññèèïðè øèçîôðåíèè ïîâëèÿë ðÿä ôàêòîðîâ. Äåïðåññèÿáûëà ïðèçíàíà ñèìïòîìîì øèçîôðåíèè åùå ñî âðå-ìåí Êðåïåëèíà (26), îäíàêî ðàçäåëåíèå áîëüøèõïñèõîçîâ íà êàòåãîðèè êîãíèòèâíûõ è àôôåêòèâíûõ

ïñèõîçîâ ïîñòàâèëî ñòàòóñ ðàññòðîéñòâ íàñòðîåíèÿïðè øèçîôðåíèè â äâóñìûñëåííóþ ñèòóàöèþ. Êà-

òåãîðèÿ øèçîàôôåêòèâíîãî ðàññòðîéñòâà ÿâëÿåòñÿïîïûòêîé ðàçðåøèòü äèëåììó ñîñóùåñòâîâàíèÿïñèõîòè÷åñêèõ ñèìïòîìîâ ñ ðàññòðîéñòâàìè íà-ñòðîåíèÿ (12). Ê ñîæàëåíèþ, ñîîòâåòñòâóþùèå êðè-òåðèè ýòîãî ðàññòðîéñòâà îñòàëèñü íåîïðåäåëåííû-

ìè. Íåñïåöèôè÷íîñòü äåïðåññèâíûõ ñèìïòîìîâïðè ïîñòàíîâêå äèàãíîçà áûëà îñâåùåíà ïðè èçó-÷åíèè ïåðâûõ ïñèõîòè÷åñêèõ ýïèçîäîâ ó áîëüíûõèç î÷åð÷åííîé òåððèòîðèè îáñëóæèâàíèÿ. Èññëåäî-âàòåëè îáíàðóæèëè, ÷òî ñòåïåíü âûðàæåííîñòè äåï-

ðåññèè áûëà ñõîäíà â òðåõ ãðóïïàõ ïàöèåíòîâ: ñàôôåêòèâíûìè ïñèõîçàìè, øèçîôðåíèåé è íåóòî÷-íåííûìè ïñèõîçàìè (11).

Îäíèì èç ïîäõîäîâ ê óñòàíîâëåíèþ ðàñïðîñòðà-íåííîñòè äåïðåññèè ïðè øèçîôðåíèè ÿâëÿåòñÿ ýïè-äåìèîëîãè÷åñêîå èññëåäîâàíèå. Îäíî òàêîå èññëå-äîâàíèå ïîêàçàëî, ÷òî òîãäà êàê â îáùåé ïîïóëÿöèè

ðàñïðîñòðàíåííîñòü äåïðåññèè â òå÷åíèå âñåé æèç-

íè ñîñòàâëÿëà 7,3%, â ïîïóëÿöèè áîëüíûõ øèçîô- ðåíèåé îíà äîñòèãàëà 54% (10). Îòñþäà âûâåäåíîñîîòíîøåíèå ðèñêà äåïðåññèè â òå÷åíèå æèçíè óáîëüíûõ øèçîôðåíèåé â ñðàâíåíèè ñ îáùåé ïîïó-ëÿöèåé 15,9. Îáçîð èññëåäîâàíèé ïî ðàñïðîñòðà-íåííîñòè äåïðåññèè â äàííûé ìîìåíò âðåìåíèïðåäïîëàãàåò, ÷òî â ñðåäíåì îíà ñîñòàâëÿåò 25%(33). Îäíàêî ýòà öèôðà ìîæåò ââîäèòü â çàáëóæäå-íèå, ïîñêîëüêó ðàñïðîñòðàíåííîñòü äåïðåññèè âäàííûé ìîìåíò âðåìåíè âàðüèðóåò â ñîîòâåòñòâèèñî ñòàäèåé çàáîëåâàíèÿ. Èññëåäîâàíèÿ íà÷àëà øè-çîôðåíèè, ïðåäïðèíÿòûå Âñåìèðíîé Îðãàíèçàöè-åé Çäðàâîîõðàíåíèÿ, ïîêàçàëè, ÷òî äåïðåññèÿ áûëà

ïåðâûì ïðèçíàêîì íåáëàãîïîëó÷èÿ, îòìå÷åííûìñåìüÿìè áîëüíûõ øèçîôðåíèåé (20). Òùàòåëüíûå

ðåòðîñïåêòèâíûå èññëåäîâàíèÿ ïîêàçàëè, ÷òî ýòîñèìïòîì ïðîäðîìà ó áîëåå ïîëîâèíû ïàöèåíòîâïåðåä ïåðâîé ìàíèôåñòàöèåé çàáîëåâàíèÿ (16). Ðàñ-ïðîñòðàíåííîñòü äåïðåññèè â äàííûé ìîìåíò âðå-ìåíè âûøå â ïåðèîä îáîñòðåíèÿ, ÷åì â ïåðèîä ðå-ìèññèè (22), â îäíîì èç èññëåäîâàíèé – ïî÷òè âäâîå(11, 21). Ðàñïðîñòðàíåííîñòü äåïðåññèè â äàííûéìîìåíò âðåìåíè ïðîùå èíòåðïðåòèðîâàòü ïðè íà-ëè÷èè òî÷íîãî îïðåäåëåíèÿ òîãî, ÷òî ÿâëÿåòñÿ ñëó-÷àåì äåïðåññèè. Äðóãîé ïóòü èçó÷åíèÿ äèàïàçîíàè ñòåïåíè âûðàæåííîñòè äåïðåññèè ñîñòîèò â ñðàâ-íåíèè ãðóïï ñ èñïîëüçîâàíèåì øêàë èçìåðåíèÿ

ÓÄÊ 616.895.8–06:616.892–02:616.1/.4–072.8

ÄÅÏÐÅÑÑÈß ÏÐÈ ØÈÇÎÔÐÅÍÈÈ

Ä. Àääèíãòîí

Êàôåäðà ïñèõèàòðèè Óíèâåðñèòåòà Êàëãàðè, Êàíàäà



äåïðåññèè. Ðåçóëüòàòû äëÿ òðåõ ãðóïï ïàöèåíòîâïðåäñòàâëåíû íà ðèñ. 1.

Ðèñ. 1 ïîêàçûâàåò ÷àñòîòó ðàçëè÷íîé âûðàæåííî-ñòè äåïðåññèè â òðåõ ãðóïïàõ áîëüíûõ: 100 ñòà-áèëüíûõ àìáóëàòîðíûõ ïàöèåíòîâ ñ øèçîôðåíèåé(ÀÁØ), 50 ñòàöèîíàðíûõ áîëüíûõ ñ îáîñòðåíèåìøèçîôðåíèè (ÑÁØ) è ãðóïïà áîëüíûõ, ãîñïèòàëè-çèðîâàííûõ â îñòðîì ñîñòîÿíèè ñ ïåðâè÷íûì äè-àãíîçîì äåïðåññèè (ÑÁÄ). Äåïðåññèÿ îöåíèâàëàñüîäíèì è òåì æå ñòðóêòóðèðîâàííûì èíòåðâüþ ïî

Øêàëå äåïðåññèè ïðè øèçîôðåíèè Êàëãàðè – Calgary Depression Scale for Schizophrenia (CDSS).

Ðàñïîçíàâàíèå è èçìåðåíèå äåïðåññèè ïðèøèçîôðåíèè

Îöåíêà äåïðåññèè ïðè øèçîôðåíèè áûëà çàòðóä-íåíà èç-çà ðÿäà ìåòîäîëîãè÷åñêèõ àñïåêòîâ. Ýòèàñïåêòû îòíîñÿòñÿ êàê ê êàòåãîðèàëüíûì, òàê èïîñëåäîâàòåëüíûì èçìåðåíèÿì äåïðåññèè. ÑèñòåìàDSM IV âêëþ÷àåò ñëåäóþùåå çàìå÷àíèå î äèàãíî-ñòè÷åñêèõ êðèòåðèÿõ áîëüøîãî äåïðåññèâíîãîýïèçîäà: «Íå âêëþ÷àþòñÿ ñèìïòîìû, êîòîðûå ÿâíîñâÿçàíû ñ ñîìàòè÷åñêèì çàáîëåâàíèåì, èëè íå-

êîíãðóýíòíûìè íàñòðîåíèþ áðåäîì èëè ãàëëþöè-íàöèÿìè» (7). Ýòî çàìå÷àíèå òåîðåòè÷åñêè ïðåïÿò-ñòâóåò äèàãíîçó áîëüøîãî äåïðåññèâíîãî ýïèçîäàïðè íàëè÷èè øèçîôðåíèè. Îíî òàêæå äàåò íåÿñíûåóêàçàíèÿ â îòíîøåíèè èíòåðïðåòàöèè èíäèâèäóàëü-íûõ ñèìïòîìîâ. Íàïðèìåð, åñëè ïàöèåíò, íàõîäÿ-ùèéñÿ â ðåìèññèè øèçîôðåíèè, â òå÷åíèå äëèòåëü-íîãî âðåìåíè æàëîâàëñÿ íà óòðàòó èíòåðåñîâ, íå-äîñòàòîê ýíåðãèè è ïëîõóþ êîíöåíòðàöèþâíèìàíèÿ, òåïåðü íà÷àë îáíàðóæèâàòü äâà äîïîëíè-òåëüíûõ ñèìïòîìà – äåïðåññèþ è ÷óâñòâî ìàëîöåí-íîñòè. Ó ïàöèåíòà èìååòñÿ ïÿòü ñèìïòîìîâ, òðåáó-þùèõñÿ äëÿ ïîñòàíîâêè äèàãíîçà áîëüøîãî äåïðåñ-ñèâíîãî ýïèçîäà. Â äèàãíîñòè÷åñêîì ðóêîâîäñòâå íå

ñîäåðæèòñÿ, ïîìèìî îáùåãî çàìå÷àíèÿ î êðèòåðè-ÿõ èñêëþ÷åíèÿ, êàê ïîñòóïàòü ñ ýòèì ïàöèåíòîì.Ýòîò àñïåêò âàæåí êàê äëÿ êëèíèöèñòîâ, òàê è äëÿèññëåäîâàòåëåé, äëÿ îòáîðà ïàöèåíòîâ ñ öåëüþ îï-

ðåäåëåííûõ òåðàïåâòè÷åñêèõ ñòðàòåãèé, òàêèõ êàêëå÷åíèå àíòèäåïðåññàíòàìè. Êëèíèöèñò ìîæåò ïðè-íÿòü ïðàêòè÷åñêîå ðåøåíèå ñ ó÷åòîì äèôôåðåíöè-

àëüíî-äèàãíîñòè÷åñêîé ñõåìû, êîòîðàÿ ïðèâîäèòñÿíèæå.Èñïîëüçîâàíèå ïîñëåäîâàòåëüíûõ èçìåðåíèé

äåïðåññèè îñëîæíÿåòñÿ òàêæå âçàèìíûì ïåðåêðû-âàíèåì íåãàòèâíûõ è äåïðåññèâíûõ ñèìïòîìîâ.Ðàíåå íàèáîëåå øèðîêî ïðèìåíÿåìûì èíñòðóìåí-òîì èçìåðåíèÿ äåïðåññèè ïðè øèçîôðåíèè áûëàØêàëà äåïðåññèè Ãàìèëüòîíà – Hamilton DepressionRating Scale (HDRS). Îäíàêî, àâòîð øêàëû ÿñíîóêàçûâàë, ÷òî øêàëà äîëæíà áûòü èñïîëüçîâàíàòîëüêî äëÿ ïîïóëÿöèè ïàöèåíòîâ ñ áîëüøèì äåïðåñ-ñèâíûì ýïèçîäîì (17, 18). Ðÿä èññëåäîâàíèé âûÿ-âèëè ïñèõîìåòðè÷åñêèå ïðîáëåìû ýòîãî èíñòðóìåí-

òà ïðè øèçîôðåíèè. Íàïðèìåð, èññëåäîâàíèå ÷åòû- ðåõ ãðóïï áîëüíûõ, â êîòîðûõ âñ å îòâå÷à ëèêðèòåðèÿì áîëüøîãî äåïðåññèâíîãî ýïèçîäà, îáíà-

ðóæèëî, ÷òî â ãðóïïå øèçîôðåíèè áîëüøàÿ äåïðåñ-ñèÿ êîëè÷åñòâåííî îòëè÷àëàñü îò ãðóïïû ñ îñíîâ-íûì äèàãíîçîì äåïðåññèè (9). Äâà èññëåäîâàíèÿ, âêîòîðûõ èçó÷àëèñü ôàêòîðû HDRS â âûáîðêå áîëü-íûõ øèçîôðåíèåé, ïîêàçàëè íàëè÷èå çíà÷èìûõñîâïàäåíèé ìåæäó ôàêòîðàìè HDRS è íåãàòèâíûìñèíäðîìîì (5, 15). Ïîçäíåå â êëèíè÷åñêèõ èññëå-äîâàíèÿõ øèçîôðåíèè èñïîëüçîâàëàñü Øêàëà äåï-

ðåññèè Ìîíòãîìåðè-Àñáåðãà – Montgomery AsbergDepression Rating Scale (MADRS) (29, 35). Êàê è

HDRS, MADRS áûëà ðàçðàáîòàíà äëÿ áîëüíûõ ñîñíîâíûì äèàãíîçîì äåïðåññèè. Øêàëà âêëþ÷àåò10 ïóíêòîâ, èç êîòîðûõ òðè (ìåäëèòåëüíîñòü, íåñïî-ñîáíîñòü ÷óâñòâîâàòü è íàáëþäàåìàÿ ïå÷àëü) îáíà-

ðóæèëè óìåðåííûå êîððåëÿöèè ñ íåãàòèâíûì ñèí-äðîìîì (23). Õîòÿ â òîì æå èññëåäîâàíèè âûÿâëå-íà òîëüêî íåáîëüøàÿ êîððåëÿöèÿ ìåæäó îáùèìáàëëîì ïî MADRS è áàëëîì ïî øêàëå íåãàòèâíûõñèìïòîìîâ, î ñòåïåíè âûðàæåííîñòè äåïðåññèè íåñîîáùàåòñÿ, ÷òî çàòðóäíÿåò îöåíêó çíà÷èìîñòèâûÿâëåííîé íèçêîé êîððåëÿöèè.

Ïîçäíåå áûëà ðàçðàáîòàíà øêàëà, ñïåöèàëüíîïðåäíàçíà÷åííàÿ äëÿ îöåíêè äåïðåññèè ïðè øèçîô-

ðåíèè. Ýòî Øêàëà äåïðåññèè ïðè øèçîôðåíèè Êàë-ãàðè – Calgary Depression Scale for Schizophrenia(CDSS) (2). Ðàçðàáîòêà øêàëû ïðîèñõîäèëà â íå-ñêîëüêî ýòàïîâ. Ïåðâûå ïóíêòû áûëè âûáðàíû ñïîìîùüþ ôàêòîðíîãî àíàëèçà èç êîìïëåêñà ñèìï-òîìîâ, âçÿòûõ èç Îáñëåäîâàíèÿ íàñòîÿùåãî ñîñòî-ÿíèÿ (Present State Examination) è èç HDRS. Ïåðâî-íà÷àëüíî áûë âûáðàí êîìïëåêñ èç 11 ñèìïòîìîâ ñîçíà÷èìîé êîððåëÿöèåé. Â ïîñëåäóþùåì áûëî ñî-ñòàâëåíî ïîëóñòðóêòóðèðîâàííîå èíòåðâüþ ñ áàë-ëàìè äëÿ ðåéòèíãà ñèìïòîìîâ. Çàòåì íàäåæíîñòü èâàëèäíîñòü øêàëû áûëè îöåíåíû â íîâîé âûáîðêåàìáóëàòîðíûõ è ñòàöèîíàðíûõ ïàöèåíòîâ ñ øèçîô-

ðåíèåé. Ïîëó÷åííàÿ â ðåçóëüòàòå øêàëà èç 9 ïóíê-

Ðèñ. 1. Âûðàæåííîñòü äåïðåññèè â òðåõ ãðóïïàõ: ÀÁØ – àì-áóëàòîðíûå áîëüíûå øèçîôðåíèåé, ÑÁØ – ñòàöèîíàðíûå áîëü-

íûå øèçîôðåíèåé, ÑÁÄ – ñòàöèîíàðíûå áîëüíûå äåïðåññèåé

ÀÁØ

ÑÁÄ

ÑÁ Ø

Áàëëû ïî CDSS



òîâ îáíàðóæèëà âûñîêóþ âíóòðåííþþ íàäåæíîñòüè âûñîêóþ íàäåæíîñòü ïðè èñïîëüçîâàíèè ðàçíû-ìè ðåéòåðàìè. Âíåøíÿÿ âàëèäíîñòü áûëà ïîäòâåð-æäåíà çíà÷èìûìè êîððåëÿöèÿìè ñ äðóãèìè èçìå-

ðåíèÿìè äåïðåññèè. Â òðåòüåì èññëåäîâàíèè èçó-÷àëîñü ñîîòíîøåíèå ñ íåãàòèâíûìè ñèìïòîìàìè è

÷óâñòâèòåëüíîñòü è ñïåöèôè÷íîñòü ïðè îöåíêå íà-ëè÷èÿ áîëüøîãî äåïðåññèâíîãî ðàññòðîéñòâà. Ôàê-òîðíûé àíàëèç ïîäòâåðäèë, ÷òî ìîäåëü, ïðåäïîëà-ãàþùàÿ ñïåöèôè÷íîñòü äåïðåññèâíûõ, íåãàòèâíûõè ýêñòðàïèðàìèäíûõ ñèìïòîìîâ, áûëà âûñîêî ñòà-òèñòè÷åñêè çíà÷èìîé. Â ñðàâíåíèè ñ HDRS, CDSSïîêàçàëà ñòàáèëüíóþ ôàêòîðíóþ ñòðóêòóðó êàê ïðèîáîñòðåíèè, òàê è â ðåìèññèè, â ñî÷åòàíèè ñ õîðî-øåé äèôôåðåíöèàöèåé ìåæäó íåãàòèâíûìè è äåï-

ðåññèâíûìè ñèìïòîìàìè.CDSS ïåðåâåäåíà íà 22 ÿçûêà è äîñòóïíà íà ñàé-

òå http://www.ucalgary.ca/cdss/. Àíãëèéñêàÿ âåðñèÿáûëà âàëèäèçèðîâàíà â ðÿäå äðóãèõ öåíòðîâ, à ïå-

ðåâîäû òàêæå ïðîøëè íåçàâèñèìóþ âàëèäèçàöèþ.Øêàëà áûëà ðåêîìåíäîâàíà êàê çîëîòîé ñòàíäàðòäëÿ îöåíêè äåïðåññèè ïðè øèçîôðåíèè (12).

Áîëüøèíñòâî êëèíèöèñòîâ äî ñèõ ïîð íå èñ-ïîëüçóþò øêàëû â êëèíè÷åñêîé ïðàêòèêå, õîòÿ èõèñïîëüçîâàíèå ïîñòîÿííî ðàñøèðÿåòñÿ. Ê ñ÷àñòüþ,îïðîñ îïûòíûõ êëèíèöèñòîâ ïîêàçàë, ÷òî îíè òî÷-íî îïðåäåëÿëè òðè êëþ÷åâûõ ñèìïòîìà, êîòîðûåïîçâîëÿëè èì âûÿâëÿòü è îöåíèâàòü òÿæåñòü äåï-

ðåññèè ïðè øèçîôðåíèè (34). Êàæäûé èç ýòèõ òðåõñèìïòîìîâ (ïîäàâëåííîå íàñòðîåíèå, ÷óâñòâî áåç-íàäåæíîñòè è ñóèöèäàëüíûå ìûñëè) ÿâëÿåòñÿ ïóí-êòîì CDSS (òàáë. 1).

Ëå÷åíèå äåïðåññèè ïðè øèçîôðåíèè

S.G.Siris (34) íåäàâíî îïóáëèêîâàë îñíîâàííûéíà ïîñëåäíèõ äàííûõ îáçîð ìåòîäîâ ëå÷åíèÿ äåï-

ðåññèè ïðè øèçîôðåíèè. Ðåêîìåíäàöèè îïèðàþò-ñÿ íà ïîäõîä ê äèôôåðåíöèàëüíîìó äèàãíîçó äåï-

ðåññèè, ðàíåå ñôîðìóëèðîâàííûé S.J .Bartels èR.E.Drake (8). Ýòè àâòîðû êëàññèôèöèðîâàëè äåï-

ðåññèþ íà òðè êàòåãîðèè: ïåðâàÿ – îðãàíè÷åñêàÿ,èëè âòîðè÷íàÿ ïî îòíîøåíèþ ê ýêñòðàïèðàìèäíûìïîáî÷íûì ýôôåêòàì; âòîðàÿ – ñâÿçàííàÿ ñ îñòðûìïñèõîçîì; òðåòüÿ – äåïðåññèÿ â ñòàáèëüíîé èëè

ðåìèññèîííîé ôàçå. Ïîñëåäíÿÿ ìîæåò áûòü êëàñ-ñèôèöèðîâàíà íà ïðîäðîìàëüíóþ, îñòðûå ïðîáëå-

ìû ïðèñïîñîáëåíèÿ, âòîðè÷íûé äåïðåññèâíûé ñèí-äðîì è õðîíè÷åñêóþ äåìîðàëèçàöèþ.

Ýòîò ïîäõîä èìååò áîëüøèå òåîðåòè÷åñêèå ïðå-èìóùåñòâà, õîòÿ è ìàëî ïîäòâåðæäåí ðåêîìåíäàöè-ÿìè, îñíîâàííûìè íà äîêàçàòåëüñòâàõ, ñ ïîääåðæ-êîé ðàíäîìèçèðîâàííûõ êëèíè÷åñêèõ èññëåäîâà-íèé. Ýòîò ïîäõîä èìååò òàêæå òî ïðåèìóùåñòâî,÷òî òðåáóåò îò êëèíèöèñòà ïðîâîäèòü ïîäðîáíîåñîáåñåäîâàíèå è îöåíêó ñîñòîÿíèÿ. Âàæíî ïîìíèòüî äâóõ àñïåêòàõ. Õîòÿ ïàöèåíòû áåç äåïðåññèè ìî-ãóò èìåòü áîëåå âûñîêóþ ñðåäíþþ ñòåïåíü âûðà-æåííîñòè íåãàòèâíûõ ñèìïòîìîâ, ÷åì äåïðåññèâ-íûå ïàöèåíòû, ýòè äâà ñèíäðîìà íå ÿâëÿþòñÿ âçà-èìîèñêëþ÷àþùèìè (4). Âî-âòîðûõ, áîëüíûåøèçîôðåíèåé ÿâëÿþòñÿ äîñòàòî÷íî íàäåæíûìè èñ-

òî÷íèêàìè èíôîðìàöèè î ñòåïåíè âûðàæåííîñòèñâîåé äåïðåññèè. Øêàëû, îñíîâàííûå íà ñàìîîò÷å-òå áîëüíûõ, è øêàëû, çàïîëíÿåìûå èññëåäîâàòåëåì,èìåþò âûñîêóþ êîððåëÿöèþ (3).

Ëå÷åíèå äåïðåññèè ïðè øèçîôðåíèè ñëåäóåòäèôôåðåíöèàëüíîìó äèàãíîçó, ÷òî îáñóæäàëîñüâûøå. Ëå÷åíèå ýêñòðàïèðàìèäíûõ ïîáî÷íûõ ýô-ôåêòîâ àíòèïñèõîòèêîâ äîëæíî îïèðàòüñÿ íà ïðî-ôèëàêòèêó êàê íà ïåðâóþ ñòðàòåãèþ. Ýòî ïðîùåîñóùåñòâèòü ïðè òåðàïèè àíòèïñèõîòèêàìè âòîðî-ãî ïîêîëåíèÿ. Óìåíüøåíèå äîçû ïðåäïî÷òèòåëüíîïî ñðàâíåíèþ ñ íàçíà÷åíèåì àíòèõîëèíåðãè÷åñêèõïðåïàðàòîâ, êîòîðûå ñàìè îáëàäàþò ïîáî÷íûì äåé-

ñòâèåì, âêëþ÷àþùèì êîãíèòèâíûå íàðóøåíèÿ.

Òàáëèöà 2

Подтипы депрессии при шизофрении

Ýòèîëîãèÿ Ïîäòèïû Ëå÷åíèå

Îðãàíè÷åñêàÿ Ýêñòðàïèðàìèäíûå Àíòèïñèõîòèê

ïîáî÷íûå âòîðîãîýôôåêòû ïîêîëåíèÿ

Óìåíüøåíèå äîçû

Àíòèõîëèíåðãè÷åñêèå ïðåïàðàòû

Áîëåçíè Èíòåãðèðîâàííûå

çàâèñèìîñòè íàðêîëîãè÷åñêèå

è ïñèõèàòðè÷åñêèå

ñëóæáû

Äðóãèå îðãàíè- Ëå÷åíèå îñíîâíîãî

÷åñêèå ïðè÷èíû ðàññòðîéñòâà

Îñòðûé ïñèõîç Ïîâòîðíîå Àíòèïñèõîòèêè

îáîñòðåíèå âòîðîãî ïîêîëåíèÿ

Òåðàïåâòè÷åñêàÿ Êëîçàïèí

ðåçèñòåíòíîñòü

Ñòàáèëüíàÿ Ïðîäðîì Óâåëè÷åíèå äîçû

ôàçà ïîâòîðíîãî àíòèïñèõîòèêà èëè

îáîñòðåíèÿ óìåíüøåíèå ñ òðåññàÎñòðàÿ Ïîääåðæêà

äèñôîðèÿ è ïñèõîòåðàïèÿ

Ïîñòïñèõîòè÷åñêàÿ Àíòèäåïðåññàíò

äåïðåññèÿ èëè êîãíèòèâíàÿ

òåðàïèÿ

Õðîíè÷åñêàÿ Ïîääåðæêà, òðåíèíã

äåìîðàëèçàöèÿ íàâûêîâ èëè

êîãíèòèâíàÿ òåðàïèÿ

Òàáëèöà 1

Ключевые скрининговые вопросы для распознаваниядепрессии при шизофрении

Ñèìïòîì Âîïðîñ

Äåïðåññèÿ Êàê áû âû îïèñàëè ñâîå íàñòðîå-

íèå â ïîñëåäíèå äâå íåäåëè?

×óâñòâî áåçíàäåæíîñòè Êàêèì Âû âèäèòå ñâîå áóäóùåå?Êàçàëàñü ëè Âàì æèçíü áåçíàäåæ-

íîé?

Ñóèöèä ×óâñòâîâàëè ëè Âû, ÷òî æèòü íåñòîèò? Äóìàëè ëè Âû êîãäà-íèáóäü

î òîì, ÷òîáû ñî âñåì ýòèì

ïîêîí÷èòü?



Êîìîðáèäíîå çëîóïîòðåáëåíèå ïñèõîàêòèâíûìèâåùåñòâàìè òàêæå ÿâëÿåòñÿ ôàêòîðîì ðèñêà âîçíèê-

íîâåíèÿ äåïðåññèè. Íàèáîëåå ðàñïðîñòðàíåíî çëî-óïîòðåáëåíèå àëêîãîëåì. Íåñìîòðÿ íà òðóäíîñòèëå÷åíèÿ êîìîðáèäíûõ áîëåçíåé çàâèñèìîñòè, ðåêî-ìåíäóåòñÿ èíòåãðàòèâíûé ïîäõîä ê òåðàïèè îáîèõ

ðàññòðîéñòâ.Ïðè ëå÷åíèè ïîâòîðíûõ îáîñòðåíèé îñíîâíîé

òåðàïèåé ñëóæàò àíòèïñèõîòè÷åñêèå ïðåïàðàòû.Ïðåäïîëàãàåòñÿ, ÷òî àíòèïñèõîòèêè âòîðîãî ïîêî-ëåíèÿ èìåþò ïðåèìóùåñòâî ïåðåä ïðåïàðàòàìèïåðâîãî ïîêîëåíèÿ. Íàèáîëåå ñèëüíàÿ äîêàçàòåëü-íàÿ áàçà ñóùåñòâóåò â îòíîøåíèè èñïîëüçîâàíèÿêëîçàïèíà ïðè ðåçèñòåíòíîé ê òåðàïèè øèçîôðå-íèè. Èìååòñÿ ðÿä ïóòåé, êàê àíòèïñèõîòèêè âòîðî-

ãî ïîêîëåíèÿ ìîãóò ïîâëèÿòü íà âûðàæåííîñòü äåï- ðåññèè. Ýòè âîçìîæíîñòè ïðåäñòàâëåíû íà ðèñ. 2.Ñ äðóãîé ñòîðîíû, àíòèïñèõîòèêè âòîðîãî ïîêîëå-íèÿ ìîãóò îêàçûâàòü ïðÿìîé àíòèäåïðåññèâíûéýôôåêò, êàê îòðàæåíî íà ðèñ. 3.

Äëÿ ëå÷åíèÿ ïðîäðîìà ïîâòîðíîãî îáîñòðåíèÿ ðåêîìåíäóþòñÿ äâå âîçìîæíûå ñòðàòåãèè, íè îäíàèç êîòîðûõ íå ïîäêðåïëåíà ñèëüíîé äîêàçàòåëüíîéáàçîé. Ðåêîìåíäóþòñÿ êàê óìåíüøåíèå ñòðåññà, òàêè óâåëè÷åíèå äîçû àíòèïñèõîòè÷åñêîé òåðàïèè. Êàêè ëþáûå äðóãèå ëþäè, áîëüíûå øèçîôðåíèåé ìî-ãóò èñïûòûâàòü îñòðûå äèñôîðè÷åñêèå ðåàêöèè.Ïðè ýòîì ñëåäóåò, âî-ïåðâûõ, óáåäèòüñÿ, ÷òî ïàöè-åíò íàõîäèòñÿ â áåçîïàñíîì îêðóæåíèè, è âî-âòî-

ðûõ, ïðåäîñòàâèòü åìó ëè÷íîñòíóþ è ïðîôåññèî-íàëüíóþ ïîääåðæêó.

Ïîñòïñèõîòè÷åñêàÿ äåïðåññèÿ â îáùåì âèäå îïè-ñûâàåòñÿ êàê ðàçâèòèå áîëüøîãî äåïðåññèâíîãîýïèçîäà âî âðåìÿ ôàçû ñòàáèëüíîé ðåìèññèè. Åñòü

íåêîòîðûå äàííûå â ïîääåðæêó äîïîëíèòåëüíîãîèñïîëüçîâàíèÿ àíòèäåïðåññàíòîâ. Ýòà ñòðàòåãèÿ

ïîääåðæèâàåòñÿ â Êàíàäñêîì ðóêîâîäñòâå êëèíè-÷åñêîé ïðàêòèêè ïðè ëå÷åíèè øèçîôðåíèè (6) è â

ðóêîâîäñòâå Àìåðèêàíñêîé ïñèõèàòðè÷åñêîé àññî-öèàöèè (7). Íåñìîòðÿ íà ýòó ïîääåðæêó, óáåäèòåëü-íûå äâîéíûå ñëåïûå ïëàöåáî-êîíòðîëèðóåìûå èñ-ñëåäîâàíèÿ îñòàþòñÿ ìàëî÷èñëåííûìè, è íè îäíîèç íèõ íå êàñàåòñÿ èíãèáèòîðîâ îáðàòíîãî çàõâàòàñåðîòîíèíà. Îäíàêî, íåäàâíåå àêòèâíîå êîíòðîëè-

ðóåìîå èññëåäîâàíèå ïîêàçàëî ýêâèâàëåíòíîñòüñåðòðàëèíà è èìèïðàìèíà (24). Äàííûå î òîì, ÷òîêàêîé-ëèáî èç ýòèõ ïðåïàðàòîâ ýôôåêòèâíåå, ÷åìïëàöåáî, íåäîñòàòî÷íû. Áûëî ïîêàçàíî, ÷òî ïðèíåïñèõîòè÷åñêîé äåïðåññèè ýôôåêòèâíà êîãíèòèâ-

íàÿ òåðàïèÿ, êîòîðàÿ òàêæå ïîìîãàåò â ëå÷åíèè ðå-çèäóàëüíûõ ïðîäóêòèâíûõ ñèìïòîìîâ (31). Íåáå-çîñíîâàòåëüíî îæèäàòü, ÷òî îíà ìîæåò áûòü ïîëåç-íîé ïðè ïîñò-ïñèõîòè÷åñêîé äåïðåññèè, íî äàííûõçà ýòî íåäîñòàòî÷íî, è ðåñóðñû äëÿ òàêîãî ëå÷åíèÿíå âñåãäà äîñòóïíû.

Ïðè õðîíè÷åñêîé äåìîðàëèçàöèè ìîæíî ïîìî÷ü ðÿäîì âìåøàòåëüñòâ, âêëþ÷àÿ ïîçèòèâíîå è ïîääåð-æèâàþùåå îêðóæåíèå â êëèíèêå. Áîëåå ñïåöèôè÷-íûå âìåøàòåëüñòâà âêëþ÷àþò ïðîãðàììû òðåíèí-ãà ñîöèàëüíûõ íàâûêîâ è ïðîãðàììû ïîääåðæêèòðóäîóñòðîéñòâà.

Ðàñïîçíàâàíèå è ëå÷åíèå äåïðåññèè ïðè øèçîô- ðåíèè ÿâëÿþòñÿ âàæíûì êîìïîíåíòîì òåðàïèèøèçîôðåíèè. Îíî ìîæåò ñóùåñòâåííî ïîâëèÿòü íàêà÷åñòâî æèçíè áîëüíûõ è äîëæíî áûòü ÷àñòüþâñåîáúåìëþùåãî ïëàíà ïî óìåíüøåíèþ óðîâíÿñóèöèäîâ è ïîïûòîê ñóèöèäîâ â ýòîé ïîïóëÿöèèâûñîêîãî ðèñêà.

Ðèñ. 2. Ýôôåêòèâíàÿ àíòèïñèõîòè÷åñêàÿ òåîðèÿ Ðèñ. 3. Òåîðèÿ àíòèäåïðåññèâíîãî äåéñòâèÿ àíòèïñèõîòèêà

ËÈÒÅÐÀÒÓÐÀ

1. Addington D., Addington J. Attempted suicide and depression inschizophrenia // Acta Psychiatr. Scand. – 1992. – Vol. 85. – P. 288–291.

2. Addington D., Addington J., Maticka-Tyndale E. Reliability andvalidity of a depression rating scale for schizophrenics. A structured

interview guide for the Hamilton Depression Rating Scale // Schizophrenia Res. – 1992. – Vol. 6. – P. 201–208.

3. Addington D., Addington J., Maticka-Tyndale E. Ratingdepression in schizophrenia. A comparison of a self report and an observerreport scale. A structured interview guide for the Hamilton DepressionRating Scale // J. Nerv. Ment. Dis. – 1993. – Vol. 181. – P. 561–565.

4. Addington D., Addington J., Maticka-Tyndale E. Specificity of theCalgary Depression Scale. A structured interview guide for the Hamilton



Depression Rating Scale // Schizophrenia Res. – 1994. – Vol. 11. – P.239–244.

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6. Addington D., Bassett A., Cook P. et al. Canadian clinical practiceguidelines for the treatment of schizophrenia // Can. J. Psychiatry. – 1998.

– Vol. 43, Suppl. 2. – P. 25S–39S.7. American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders; Fourth Edition. – Washington, DC:American Psychiatric Association, 1994.

8. Bartels S.J., Drake R.E. Depressive symptoms in schizophrenia:comprehensive differential diagnosis // Compr. Psychiatry. – 1988. – Vol.29. – P. 467–483.

9. Becker R.E., Singh M.M., Meiscer N., Shillcutt S. Clinicalsignificance, evaluation and management of secondary depression inschizophrenia // J. Clin. Psychiatry. – 1985. – Vol. 46. – P. 26–32.

10.Bland R.C., Newman S.C., Orn N.H. Schizophrenia: life time co-morbidity in a community sample // Acta Psychiatr. Scand. – 1987. – Vol.75. – P. 383–391.

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DEPRESSION IN SCHIZOPHRENIA

D. Addington

Depression in schizophrenia is important both because of its negativeimpact on patient outcome and quality of life and because of theassociation with suicide and attempted suicide. The severity and

prevalence of depression varies according to the stage of the illness. It isimportant to recognize that depression is one of the most common of

prodromal symptoms. Levels of depression tend to be highest in the acute phase and are more persistent following the first episode. Recognitionand measurement of depression is challenging because of the overlap withnegative symptoms, but depression can be distinguished from negativesymptoms by the clinician, either by using key questions or by the use

of specific rating scales. Treatment is best determined after considerationof a differential diagnosis. As with the treatment of other comorbidsyndromes there is limited evidence from randomized controlled studies.Treatment options for a post psychotic depression include the standardtreatments for depression such as antidepressants and perhaps cognitivetherapy. There is some evidence to suggest that second generationantipsychotic medication may have a better impact on depression whencompared with traditional ones. Recognition and treatment of depressionis an important part of any strategy to reduce suicide and attemptedsuicide in this high-risk population.

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Depressiya Pri Shizofrenii 1