【作者】 王琦；

【导师】 栗克清；

【作者基本信息】 河北大学 ， 神经病学， 2019， 硕士

【摘要】 目的:分别采用高低频重复经颅磁刺激(rTMS)方法治疗抑郁症患者,观察患者治疗前后临床症状改善情况以及对患者自杀观念的影响,对比两种刺激频率下重复经颅磁刺激对抑郁症患者的治疗作用,以期为患者降低自杀风险、改善抑郁症患者临床症状提供科学的理论依据,为患者选取耐受性以及安全性更优的刺激方法提供参考。方法:1.选取来自2018年1月1日至2019年1月1日河北省第六人民医院住院患者。对同意参加此研究并已经签署知情同意书的患者进行筛选,将符合入组标准的患者按照随机数字表方法分成3组,分别为高频、低频治疗组,药物对照组,三组患者均常规给予五羟色胺再摄取抑制剂类抗抑郁药物。排除中途退出研究患者,高频治疗组患者30例,低频治疗组患者32例,药物对照组患者30例。2.刺激部位采用传统“5cm”定位法确认,高频刺激靶点为左侧背外侧前额叶(DLPFC),以与之对应的右背外侧前额叶皮质靶点计为低频刺激靶点。高频治疗组刺激靶点为DLPFC,刺激频率为10HZ;低频治疗组刺激靶点为右背外侧前额叶皮质,刺激频率为1HZ。两组患者在相应的刺激模式下,每次均刺激40个序列,每个序列刺激序列中刺激时间为5秒,间隔时间为20秒,一次治疗中患者共计接受1500个刺激脉冲。每天治疗1次,1周治疗5次,治疗时间为2周,共计10次治疗。3.每组患者于基线期,治疗2周时,治疗4周末进行汉密尔顿抑郁量表(HAMD)、临床疗效总评量表(CGI)、贝克自杀意念问卷(SSI)的评分,基线期患者需填写患者一般情况调查表。4.采用EPIDATA 3.02双录入资料;应用SPSS 20.0统计软件包对数据进行统计处理,一般资料进行描述性统计分析;正态分布的计量资料采用均数±标准差表示,时间与组别的交互作用比较采用重复测量的方差分析,简单效应分析采用Bronfenni方法进行事后检验;采用相关分析和多元逐步线性回归方法分析抑郁症状和自杀强度之间的关系;计数资料采用χ~2检验;检验水准α=0.05,双侧检验。结果:1.将高频治疗组、低频治疗组和药物对照组入组患者的性别、年龄、婚姻状况、文化程度、在家中的排行情况、发病诱因、病程、药物使用情况、基线期HAMD-17、SSI、CGI量表评分进行比较,结果显示差异均无统计学意义。(p>0.05)2.高频与低频治疗组随着时间,其HAMD总分及各项因子均呈下降趋势,而药物对照组的各因子评分下降幅度小于前两组。治疗2周末和4周末时,高频治疗组与低频治疗组的HAMD-17总分、睡眠因子分均显著低于药物对照组,高频治疗组与低频治疗组的评分均未有显著差异。3.在第2周末时,高频与低频治疗组的自杀意念评分显著低于治疗前,而药物治疗组的下降幅度小于前两组;高频治疗组与低频治疗组的自杀意念评分显著低于药物对照组。第4周末时,三组间的自杀意念评分差异缩小。4.高频、低频治疗组,药物对照组中,患者自杀意念程度、危险程度多与认知障碍因子,阻滞因子,HAMD总分成正相关(p﹤0.05),治疗4周末,自杀意念程度与睡眠障碍呈显著负相关(r=-0.395,p﹤0.05)。5.高频治疗组、药物对照组中,认知障碍因子、阻滞因子、HAMD总分在多元线性回归分析中可进入回归方程,对于患者的自杀意念程度以及危险程度有较好的预测作用。低频组患者以4周意念程度为因变量,认知障碍为自变量,结果发现,认知障碍未能进入回归方程,(p﹥0.05)。6.治疗2周末时,高频治疗组与低频治疗组的CGI评分均显著低于药物对照组,而高频、低频治疗组间无显著性差异。结论:1.高频rTMS联合SSRIs类抗抑郁药物与低频rTMS联合SSRIs类抗抑郁药物治疗方案对于抑郁症状有显著、持续的改善作用,且效果优于仅用药物治疗者,但是rTMS刺激频率对于其改善作用没有影响;2.高频rTMS联合SSRIs类抗抑郁药物与低频rTMS联合SSRIs类抗抑郁药物治疗方案对于自杀意念有显著、快速的改善作用,而非仅用药物治疗者,但这2周的rTMS治疗作用不够持久;3.认知障碍、阻滞与自杀意念、自杀风险呈显著正相关,且在多个特定阶段,具有预测作用。更多还原

【Abstract】 Objective:The patients with depression were treated with high and low frequency repetitive transcranial magnetic stimulation respectively.the improvement of clinical symptoms and the effect on suicidal ideation were observed before and after treatment.To compare the therapeutic effects of repeated transcranial magnetic stimulation on patients with depression at two stimulation frequencies in order to provide a scientific theoretical basis for reducing the risk of suicide and improving the clinical symptoms of patients with depression.It provides a reference for patients to select more tolerable and safe stimulation methods.Methods:1.The patients with depression were treated with high and low frequency repetitive transcranial magnetic stimulation respectively.the improvement of clinical symptoms and the effect on suicidal ideation were observed before and after treatment.To compare the therapeutic effects of repeated transcranial magnetic stimulation on patients with depression at two stimulation frequencies in order to provide a scientific theoretical basis for reducing the risk of suicide and improving the clinical symptoms of patients with depression.It provides a reference for patients to select more tolerable and safe stimulation methods.2.The traditional"5cm"localization method was used to confirm that the target of high frequency stimulation was(DLPFC),of the left dorsolateral prefrontal lobe,and the corresponding target point of the right dorsolateral prefrontal cortex was counted as the target of low frequency stimulation.In the high frequency treatment group,the stimulation target was DLPFC,stimulation frequency of 10HZ,and in the low frequency treatment group,the stimulation target was the right dorsolateral prefrontal cortex,and the stimulation frequency was 1HZ.Under the corresponding stimulation mode,40 sequences were stimulated in both groups.the stimulation time was 5 seconds and the interval was 20 seconds in each sequence.a total of 1500 stimulation pulses were received in one treatment.The patients were treated once a day,5 times a week,and the treatment time was 2 weeks,a total of 10 times3.The scores of Hamilton depression scale(HAMD),clinical efficacy scale(CGI)and Baker suicidal ideation questionnaire(SSI)were measured at baseline,2 weeks and 4 weeks after treatment in each group.Baseline patients need to fill out a questionnaire on the general situation of patients.4.Using EPIDATA 3.02 double input data,SPSS 20.0statistical software package for statistical processing,descriptive statistical analysis of general data,the measurement data of normal distribution are expressed by mean±standard deviation,the data of normal distribution are expressed by mean±standard deviation,and the measurement data of normal distribution are expressed by mean±standard deviation.The interaction between time and group was compared by repeated measurement analysis of variance,Bronfenni method was used for ex post test,correlation analysis and multiple stepwise linear regression method were used to analyze the relationship between depressive symptoms and suicide intensity.The counting data were tested byχ~2 test,the test levelα=0.05,bilateral test.Results:1.The patients in high frequency treatment group,low frequency treatment group and drug control group were divided into three groups:sex,age,marital status,education level,ranking at home,inducement,course of disease,drug use,baseline HAMD-17,SSI,The scores of CGI scale were compared.The results showed that the difference was not statistically significant.(P>0.05)2.With time,the total score and each factor of HAMD in the high frequency and low frequency treatment group showed a downward trend,but the decrease range of each factor score in the drug control group was less than that in the first two groups.At the end of the 2nd and 4th week of treatment,the total score of HAMD-17 and the score of sleep factor in the high frequency treatment group and the low frequency treatment group were significantly lower than those in the drug control group,but there was no significant difference between the high frequency treatment group and the low frequency treatment group.3.At the end of the second week,the suicidal ideation scores in the high frequency and low frequency treatment groups were significantly lower than those before treatment,while the decrease in the drug treatment group was less than that in the first two groups,and the suicidal ideation scores in the high frequency treatment group and the low frequency treatment group were significantly lower than those in the drug control group.At the end of the 4th week,the difference in suicidal ideation scores among the three groups narrowed.4.In high frequency and low frequency treatment group and drug control group,the degree of suicidal ideation and risk were positively correlated with cognitive impairment factor,blocking factor and total score of HAMD(p<0 05).There was a significant negative correlation between suicidal ideation and sleep disorder(r=-0.395,p<0.05).5.In high frequency treatment group and drug control group,cognitive impairment factor,blocking factor and HAMD total score can enter the regression equation in multiple linear regression analysis,which can predict the degree of suicidal ideation and risk of patients.In the low frequency group,the 4-week mental degree was taken as the dependent variable and the cognitive impairment as the independent variable.the results showed that the cognitive impairment could not enter the regression equation,(p>0.05)the results showed that the cognitive impairment could not enter the regression equation.6.At the end of the second week of treatment,the CGI scores of the high frequency treatment group and the low frequency treatment group were significantly lower than those of the drug control group,but there was no significant difference between the high frequency and low frequency treatment groups.Conclusion:1.High frequency rTMS combined with SSRIs antidepressants and low frequency rTMS combined with SSRIs antidepressants had significant and continuous improvement on depressive symptoms,and the effect was better than that of drug therapy alone.However,the frequency of rTMS stimulation had no effect on its improvement.2.High frequency rTMS combined with SSRIs antidepressants and low frequency rTMS combined with SSRIs antidepressants had a significant and rapid effect on suicidal ideation,but the therapeutic effect of rTMS was not lasting enough in these two weeks.3.Cognitive impairment and block were positively correlated with suicidal ideation and suicide risk,and had predictive effect in many specific stages.更多还原