Depresia Adultului

DEPRESIAADULTULU I
GHID DE PRACTIC PENTRU MEDICIIDE FAMILIE
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D E C E AU N E L 2 I D E EG H I D U R I
M E D IC I DE I FA M I L I E M
R#s"!(s!l la aceast# @(tre%are este clar /i li+"e e: "e(tr! a o$eri /i asig!ra @(griHiri e @(alt# calitate "ro$esio(al# "acie()ilor lor4 Ghi !rile e "ractic# s!(t reco+a( #r i "e(tr! iag(osticarea 3 +o(ito0 rizarea /i tratarea %olilor /i ac!zelo r "acie()ilor4 Reco+a( #ril e se %azeaz # "e st! i!l celor +ai rece(te "!%lica)ii /tii()i$ice4 2 a(aliz# ate(t# a acestor res!rse relev# ce ac)i!(i e iag(osticare 3 tera"ie sa! "reve()ie s0a! ove it a $i cele +ai e$icie(te @( activitatea +e ic!l!i e $a+ilie4 La "ri+a ve ere "oate "#rea $oarte !/or s# scrii ghi !ri4 N! este e loc a/a4 Me ici e $a+ilie c! eA"erie()# st! iaz# literat!ra /tii()i$ic# !"# o a(!0 +it# +eto ologie3 eval!eaz# critic articolele a$ere(te s!%iect!l!i /i $ac o selec)ie a ecvat# a acestora4 De ce +e ici e $a+ilieM Pe(tr! c# (!+ai ei /ti! circ!+sta()ele @( care l!creaz# +e ic!l e $a+i0 lie4 Aceste circ!+sta()e s!(t eose%it e i+"orta(te @( realizarea !(!i ghi "e care ei @(/i/i @l vor a"lica4 Fa"t!l c# +e icii e $a+ilie @/i ela%oreaz# "ro"riile ghi !ri $olosi( @( acest sco" +eto ologia e!ro"ea(# /i a a"tG( reco+a( #rile eA"erie()ei /i activit#)ilor lor3 (! "oate !ce ecGt la cre/terea calit#)ii serviciilor o$erite e ace/tia "acie()ilor4 Ghi !rile (! "ot $i co"iate !"# cele ale altor )#ri4 Ele re$lect# a ev#r!ri /tii()i$ice a a"tate eA"erie()ei +e icilor i( )ara !( e @/i es$#/oar# activi0 tatea4 Acest l!cr! le co($er# valoare /i !ce la o%G( irea e @(alt# eA"er0 tiz# cali$icat#4 Cea +ai %!(# $or+!l# este ca $iecare )ar# s#0/i "ro !c# "ro"riile ghi !ri3 @( "ro"ria s"ecialitate4 Co()i(!t!l ghi !rilor )i(e sea+a e as"ecte ca: $!(c)io(area /i $!(c)io(alitatea siste+!l!i e s#(#tate3 rol!l +e ic!l!i e
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$a+ilie @( siste+3 ivizi!(ea atri%!)iilor @(tre ceilal)i s"eciali/ti /i +e ic!l e $a+ilie etc4 D!"# ela%orarea ghi !rilor co($or+ celor e +ai s!s3 "as!l !r+#tor cel +ai i+"orta(t este i+"le+e(tarea acestora @( ca%i(etele +e icilor e $a+i0 lie4 I( acest +o+e(t (e a$l#+ ac!+4 Me icii e $a+ilie a! (evoie e i(str!ire @( a"licarea ghi !rilo r4 A"licarea "oate avea s!cces (!+ai cG( +e ic!l a @()eles $oarte %i(e +otiva)ia "e care se %azeaz# ghi !rile4 N!+ai @()elegG( corect +e(irea acestora3 +e ic!l e $a+ilie le va $olosi co(str!ctiv /i @( sco"!l "e(tr! care a! $ost create4 U( ghi este e $a"t o i($or+a)ie at# +e ic!l!i care are atoria s# o $oloseasc# i(telige(t4 I()eleg "ri( aceasta c# @( a(!+ite sit!a)ii +e ic!l va re$lecta3 va a(aliza ate(t /i va hot#r@ @( ce caz!ri (! va !r+a reco+a( #rile ghi !l!i4 Alegerea sa va $i %azat# "e co(si era)ii $or+!late c! arg!+e(te %i(e +otivate4 Pe sc!rt s"!s3 ghi !rile @l aH!t# "e +e ic!l e $a+ilie s# a$le care este cel +ai %!( +o 3 %azat "e ovezi3 e a trata o "ro%le+# @( "ractica l!i4 I(tr!cGt ezvoltarea /tii()i$ic# este @(tr0o co(ti(!# e$ervesce()# /i "e(tr! c# circ!+sta()ele @( care +e icii e $a+ilie @/i es$#/oar# activitatea se "ot schi+%a3 ghi !rile tre%!ie reviz!ite @( +o reg!lat4 Este o +isi!(e "e care +e icii e $a+ilie tre%!ie s# o @( e"li(easc# @( viitor3 o at# ce a! "or(it la acest e+ers care le0a o$erit eA"erie()a /i i0a $#c!t s# @()eleag# valoarea /i i+"orta()a l!cr!l!i %i(e $#c!t4 M# re$er +ai s!s la +e icii care a! l!crat s!% coor o(area i(te(siv# /i i(s"irat# a Ce(tr!l!i Na)io(al e St! ii "e(tr! Me ici(a Fa+iliei NCNSMFO3 re!/i( ast$el s# realizeze !( +are "as @(ai(te "rivi( calitatea @( MF4 Este !( "as "e care asiste()a "ri+ar# i( Ro+G(ia @l $ace c#tre calitate4 I+i +a(i$est s"era()a c# eci e()ii i( siste+!l e s#(#tate ro+G(esc vor rec!(oa/te acest l!cr! /i vor s!s)i(e er!larea activit#)ilor CNSMF "e(tr! ezvoltarea +e ici(ei e $a+ilie i( Ro+G(ia4 Doresc s#0+i eA"ri+ res"ect!l $a)# e +e+%rii /i cola%oratorii CNSMF care a! "arc!rs trea"t# c! trea"t# eta"ele +!(cii atGt e la%orioase e creare a ghi !rilor3 c! +!lt# "asi!(e /i #r!ire4 C! eose%it# co(si era)ie3 Dr4 Pa( va( Es
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GRUPUL DE E LA92RARE Dr4 I!lia(a Po"a3 +e ic "ri+ar +e ici(a $a+iliei3 Ia/i Dr4 I!lia(a Piciorea(!3 +e ic "ri+ar +e ici(a $a+iliei3 co+!(a Hol%oca3 H! 4 Ia/i Dr4 A!rel Co( rea3 +e ic "ri+ar +e ici(a $a+iliei3 Ia/i Dr4 Maria Io(i)#3 +e ic "ri+ar +e ici(a $a+iliei3 co+!(a Ci!rea3 H! 4 Ia/i Dr4 Da(a Cte$a(a Po"esc!3 +e ic "ri+ar +e ici(a $a+iliei3 co+!(a Dele(i3 H! 4 Ia/i C2NSULTANKI &4 Pro$4 Dr4 RoAa(a Chiri)# Q +e ic "sihiatr! 64 Pro$4 Dr4 Lasile Chiri)# Q +e ic "sihiatr! =4 Dr4 Ra !Teo oresc! Q +e ic "sihiatr! ?4 Psiholog Do+(ica Petrovai >4 Dr4 Car+e( Grigorovici Q +e ic "sihiatr! '4 Dr4 Ra ! A( rei Q +e ic "sihiatr! ;4 Dr4 Livi! Da( Q +e ic "sihiatr! REFERENKI &4 Dr4 A(ca 9ala( 64 Dr4 Cristi(a 9ar%! =4 Dr4 Ta(ia 9er(stei( ?4 Dr4 Doi(a 9!(esc! >4 Dr4 A ria(a Da(/orea( '4 Dr4 A(ca Delea(! ;4 Dr4 Ele(a M# #li(a D!+itresc! <4 Dr4 Cristi(a Isar 84 Dr4 Doi(a Laz# r Pi(ga &74 Dr4 Doi(a Mari(a P!ver ea(! &&4 Dr4 Ioa(a Mateesc! &64 Dr4 Mihaela N#stas# &=4 Dr4 Livi! 2"rea &=4 Dr4 Da( Dor! Pletea &?4 Dr4 Co(sta()a Po"a &>4 Dr4 Mari!s Potera/! &'4 Dr4 Cristia( S#( ! lesc! &;4 Dr4 Maria Livia S!hastr! &<4 Dr4 Hora)i! T#(#sesc! &84 Dr4 Dacia(a To+a
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GHIDULUI
Acest ghi e "ractic# a $ost ela%orat c! sco"!l e a $or+!la reco+a( #ri %azate "e ovezile eAiste(te "rivi( iag(ostic!l /i +a(age+e(t!l t!l%!r#rii e"resive a a !lt!l!i @( +e ici(a "ri+ar#4 Di( gr!"!l heteroge( al acestor a$ec)i!(i3 ghi !l se re$er# (!+ai la cele i e(ti$icate e Clasi$icarea I(ter(a0 )io(al# a Mala iilor 0 CIM &7 re"t e"iso e"resiv NF=6O /i t!l%!rare e"re0 siv# rec!re(t# NF==O4 Reco+a( #rile tera"e!tice $or+!late se a reseaz# (!+ai caz!rilor !/oare /i +o erate al c#ror +a(age +e(t "oate $i e$ect!at e +e ic!l e $a+ilie4 Acelea/i reco+a( #ri "ot $i !tilizate /i e al)i "ro$e0 sio(i/ti care se oc!"# e aceste caz!ri4 &464 CUI
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PREWENTARE
Ghi !l este is"o(i%il @( trei varia(te: &4 Laria(ta "e(tr! +e ici care co()i(e reco+a( #rile $or+!late /i i(str!0 +e(tele e l!cr! (ecesare "racticii e zi c! ziD 64 Laria(ta "lasti$iat# Q !( algorit+ e a"licare a reco+a( #rilo r @( "ractic#D =4 Laria(ta "e(tr! "acie()i care eA"lic# "acie()ilor3 @(tr0!( li+%aH accesi0 %il3 reco+a( #rile ghi !l!i4 &4?4 PLANIFIC AREA RELIWIE I
REC2MANDRIL2r
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64 MET2 D 2 L 2 G IA
R E A L I W I R G IH I D U L U I
Ela%orarea ghi !rilor e "ractic# @( +e ici(a e $a+ilie a $ost realizat# @( co($or+itate c! +eto ologiil e orga(iza)iilor i(ter(a)io(ale s"ecializat e @( acest o+e(i! NNICE3 SIGNO4 Prel!area /i a a"tare a s0a $#c!t "ri( co(se(s!l gr!"!0 l!i e ela%orare al Ce(tr!l!i Na)io(al e St! ii "e(tr! Me ici(a Fa+iliei c! s"riHi(!l co(s!lta()ilor e la U(iversitatea i( Maastricht /i ai Colegi!l!i 2la( ez al Me icilor e Fa+ilie4 Ela%orat "e "arc!rs!l a 6 a(i3 ghi !l $or+!leaz# reco+a( #r i "e(tr! o %!(# "ractic# @( +e ici(a e $a+ilie ca r#s"!(s la cele +ai i+"orta(te "ro%le+e /i @(tre%#ri "e care +e ic!l e $a+ilie le @(tGl(e/te @( "ractica sa e zi c! zi4 I(tre%#rile $or+!late a! stat la %aza ela%or#rii !(ei strategii e c#!tare siste0 +atic# a celor +ai releva(te articole i( "erioa a 677= 0 67783 @( %azele e ate MEDLINE3 Cochra(e Li%rar-3 Data%ase o$ RevieFs o$ E$$ective(ess NDAREO3 EM9ASE 4 I( sit!a)iile @( care (! s0a! g#sit articole "!%licate @( acest i(terval care s# r#s"!( # @(tre%#rilor e c#!tare3 s0a! c#!tat /i l!at @( co(si e0 rare articolele a"#r!te !"# &8874 D!"# o a(aliz# critic# rig!roas#3 articolele g#site a! $ost triate !"# criterii e vali itate /i releva()#4 Co(cl!ziile articolelor co(si erate vali e sta! la %aza $or+!l#rii reco+a( #rilo r4 For+!larea reco+a( #rilo r a $ost $#c!t# @( a/a $el @(cGt s# eAiste o cores"o(0 e()# clar# @(tre reco+a( ar e Nc!a(ti$icat# "ri( ."!tereJ3 (otat# c! litere: A3 93 CO /i O /i ti"!rile e st! ii care sta! la %aza lor Nc!a(ti$icate "ri( .(ivel!l oveziiJ3 (otate c! ci$re ro+a(e /i litere: I3 Ia3 I% etcO4 S0a !tilizat ta%el! l e co(0 verge()# .Ierarhia ovezilor /i "!terea reco+a( #rilorJ4 Acolo !( e la aceea/i @(tre%are a! eAistat co(cl!zi i iverge(te3 reco+a( are a a $ost $or+!lat# "e %aza co(cl!ziilo r st! iilor celor +ai vali e Ncelor +ai ate(t co(str!ite /i c! risc!l cel +ai +ic e eroareO4 Atrage+ ate()ia @( +o eA"res c#3 !(eori3 r#s"!(0 s!l la a(!+ite ti"!ri e @(tre%#ri3 (! "oate $i g#sit "ri( st! ii "!ter(ice 3 e ti" +eta0a(aliz # sa! trial co(trolat ra( o+izat 3 ceea ce $ace ca i( start3 gra !l reco+a( #ri i s# $ie .i($eriorJ4 Aceasta (! @(sea+(# c# reco+a( #ril e s!(t li"0 site e i+"orta()#4 Colectiv!l e ela%orare a ghi !l!i a $ost co(stit!it i(: X Gr!"!l e ela%orare "ro"ri!0zis3 alc#t!it i( +e ici e $a+ilie vol!(tari3
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c! eA"ertiz# @( o+e(i!l acestei s"ecialit#)i /i care a! "arc!rs eta"ele !(ei "reg#tiri s"eci$ice "rivi( +eto ologia ela%or#rii ghi !rilor3 res"ectiv +e i0 ci(a %azat# "e ovezi4 X Gr!"!l e co(s!lta()i alc#t!it i( re"reze(ta()i ai +e icilor e $a+ilie /i ai celorlalte s"ecialit#)i +e icale i+"licate @( @(griHirea "ersoa(elor c! %oala res"ectiv#3 care a! "artici"at la @(tGl(iri e l!cr!4 X Gr!"!l e re$ere()i care a! rece(zat ghi !rile /i a! $or+!lat o%serva)ii "e(tr! +o i$icarea lor4
Ierarhia
ovezilor /i "!te rea reco+a( #rilor

PUTEREAREC2MANDRIL2R CLASA Q STUDIUL PE 9AWA CRUIA S0A FCUT REC2MANDAREA A Cel "!)i( !( trial co(trolat ra( o+izat ca "arte a literat!rii st! iate3 $oarte %i(e realizat /i c! re$eriri co(siste(te "rivi( reco+a( area res"ectiv# N(ivel!l ovezii Ia /i I%O
IERARHIAD2LEWIL2R NILEL Q TIPUL D2LEWII Ia 0 Dovezi o%)i(!te i( rece(zii siste+atice /i +eta0a(alize e trial!ri cli(ice ra( o+izate I% 0 Dovezi o%)i(!te i( a(aliza !(!i si(g!r trial co(trolat ra( o+izat IIa 0 Dovezi o%)i(!te i( cel "!)i( !( trial cli(ic (era( o+izat3 %i(e e$ect!at II% 0 Dovezi o%)i(!te i( cel "!)i( !( st! i! cli(ic e orice ti"3 %i(e e$ect!at3 cvasi0 eA"eri+e(tal III 0 Dovezi o%)i(!te i( st! ii escri"tive (eeA"eri+e(tale %i(e e$ect!ate3 c!+ ar $i st! ii co+"arative3 st! ii corelative3 /i st! ii e caz IL 0 Dovezi o%)i(!te i( ra"oartele sa! o"i(iile co+itetelor e eA"er)i sa! cele "rove(ite i( eA"erie()a cli(ic# a "erso(alit#)ilor
9 U( st! i! cli(ic %i(e co( !s ar (! !( trial cli(ic ra( o+izat aAat "e ti"!l reco+a( #rii N(ivel!l ovezi IIa3 II%3 IIIO 0 Pri( eAtra"olare e la !( st! i! e ti" I
C Ra"oartele sa! o"i(iile co+itetelor e eA"er)i4 Aceast# clas# i( ic# a%se()a st! iilor e calitate /i c! a"lica%ilitate irect# N(ivel!l ovezii IL O 0 Pri( eAtra"olare e la !( st! i! ti" I3 II sa! III
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=4 CL A S I F CA I REA T U L 9 U R RR IL D2 E P R E S IL E
Criteriile e iag(ostic /i clasi$icare ale t!l%!r#rilor e"resive a! s!$erit (!+e0 roase +o i$ic#ri e0a l!(g!l ti+"!l!i4 I( "reze(t3 @( Ro+G(ia se $olose/t e clasi0 $icarea 2MS i( &886 NClasi$icarea I(ter(a)io(al# a Mala iilor 0 CIM &7O& care e(!+er# /i criteriile e iag(ostic NANEUA &O4 De o larg# !tilizare i(ter(a)io(al# se %!c!r# /i clasi$icarea Asocia)iei A+erica(e e Psihiatrie "!%licat# @( &88? @( .Ma(!al!l e iag(ostic /i statistic# a %olilo r +e(taleJ NDSM ILO4 Criteriile DSM0 IL a! $ost reviz!ite @( 6777 NANEUA 6O4 Co+"arare a celor o!# siste+e +e(0 )io(ate3 relev# ase+#(#r i ar /i !(el e eose%iri N ANEUEL E =3? /i >O4 D!"# CIM &7 eAist#: 0 e"iso e"resiv 0 !/or 0 +o erat 0 sever3 c! /i $#r# si+"to+e "sihotice 0 t!l%!rare e"resiv# rec!re(t# Q c! e"iso c!re(t !sor3 +o erat sa! sever4 For+a e"iso !l!i e"resiv se sta%ileste "ri( i e(ti$icarea (!+#r!l!i e si+"to+e "reze(te i(tr0o list# agreat# e &7 si+"to+e e"resive: N&O stare e"resiv# la !( gra care este evi e(t a(or+al "e(tr! i( ivi 3 "reze(t# @( cea +ai +are "arte a zilei /i a"roa"e zil(ic3 @( +are +#s!r# (ei($l!e()at# e circ!+sta()e /i care !reaz# e cel "!)i( o!# s#"t#+G(iD N6O "ier erea i(teres!l!i sa! "l#cerii "e(tr! activit#)ile care era! @( +o o%i/(!it "l#c!teD N=O i+i(!area e(ergiei sa! $atiga%ilitate cresc!t#D N?O "ier erea @(cre erii /i a res"ect!l!i e si(eD N>O se(ti+e(te (eH!sti$icate e a!to0ac!zare ori e c!l"a%ilizare eAcesiv# /i i(a ecvat#D N'O i ei rec!re(te e +oarte sa! s!ici sa! orice co+"orta+e( t s!ici arD N;O i+i(!area a%ilit#)ii e a gG( i sa! e a se co(ce(tra3 ca e eAe+"l! (esig!ra()# sa! ezitareD N<O +o i$icarea activit#)ii "siho+otorii caracterizat# $ie "ri( agita)ie $ie "ri( @(ceti(ire N$ie s!%iectiv3 $ie o%iectivOD N8O t!l%!r#ri e so+( e orice $elD N&7O +o i$icarea a"etit!l!i Nsc# ere sa! cre/tereO c! +o i$icarea core"!(0 z#toare a gre!t#)ii4 Aceste si+"to+e tre%!ie s# $ie "reze(te e cel "!)i( 6 s#"t#+G(i /i (! tre0 %!ie s# $ie ca!zate e $olosirea vre!(ei s!%sta()e "siho0active sa! e vreo t!l%!rare +e(tal# orga(ic#4 &IL
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?4 DAT E E P I D E M I 2 L 2 G I C E
Prevale()a t!l%!r#rilor e"resive a $ost a(alizat# @( (!+eroas e st! ii tra(sver0 sale realizate @( iverse state sa! regi!(i geogra$ice4 Rez!ltatele variaz# /i atorit# !tiliz#rii !(or chestio(ar e i$erite "e(tr! i e(ti$icarea caz!rilor ca /i a i$ere()elor i(tre cele 6 siste+e e iag(ostic !tilizate NCIM &7 sa! DSM ILO4 I( ge(eral3 ci$rele arat# rate +ari ale "revale()ei la "o"! la)ia a !lt#4 KARA5 REGIUNEA SUA STUDIU AN PRELAL ENKA =4==Y ;47'Y >36<Y &&47Y <36Y ?3<Y <3>'Y
CANADA
EUR2PA DE LEST
&88&0&886 Co+"to( /i cola%4 ; 67770677& Co+"to( /i cola%4 ; < 677> Hasi( /i cola%4 6777 Patte( > ? 677= Lasilia is /i cola%4 677' Patte( /i cola%4 ' A-!so0Mateos /i cola%4 677& N2DINO&&
EAist# "!)i(e ate "rivi( e"resia @( )#rile $ost!l!i %loc co+!(ist4 Co($or+ !(!i st! i! "!%licat @( 677' e$ect!at "e 67>& "ersoa(e c! vGrsta @(tre ?> /i '? a(i i( "o"!la)ia !r%a(# i( R!sia3 Polo(ia /i Re"!%lica Ceha3 "revale()a +e ie a si+"to+elor e"resive la %#r%a)i a $ost e 6=Y @( R!sia3 6&Y @( Polo(ia /i &8Y @( Re"!%lica Ceh#4 La $e+ei3 "revale()a a $ost +ai +are: ??Y3 ?7Y /i =?Y4 &= N!+eroase st! ii e"i e+iologice sta%ilesc ate e "revale()# a e"resiei /i la "o"! la)ia vGrst(ic#4 St! i!l EUR2DEP N677?O a $ost e$ect!at @( 8 ce(0 tre e!ro"e(e "e &= <7< s!%iec)i e "este '> e a(i4 Prevale()a e"resiei a $ost: Isla( a <4<Y3 Liver"ool &747YD Waragoza &74;YD D!%li( &&48YD A+ster a+ &647YD 9erli( &'4>YD Lo( ra &;4=YD Lero(a &<4=Y /i M!(che( 6=4'Y4 Me ia "revale()ei a $ost e &63=Y3 "e seAevalorile s!(t: &?3&Y "e(0 tr! $e+ei /i <3'Y "e(tr! %#r%a)i4 &? 2 rece(zie siste+atic# "!%licat# @(c# i( &888 arat# c# $or+ele +o erate /i severe s!(t rare la vGrst(ici N+e ia e &3<YO @( ti+" ce e"resia +i(or#
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este $recve(t# N+e ia e 83<YO4 Toate $or+ele e e"resie cli(ic# se+(i$ica0 tiv# a! o "revale()# +e ie e &=3>Y4 De"resia e +ai $recve(t# la $e+ei /i la "ersoa(e ce tr#iesc @( co( i)ii socio0eco(o+ice e$avorizate4 &7 I( Ro+G(ia3 "revale()a %olii e"resive ra"ortat# e Re)ea!a e is"e(sare sa(ti(el# MEDINET este +!lt +ai +ic#: 73;=Y N&3&=Y la $e+ei /i 73=6Y la %#r%a)iO4 I( "o"!la)ia a !lt#3 "revale()a e"resiei cre/te c! vGrsta "G(# la !( +aAi+ e &3<=Y @(registrat la gr!"a e >70>? a(i: &> LGrsta &>0&8 6706? 6>068 =70=? =>0=8 ?70?? ?>0?8 >70>? >>0>8 '70'? '>0'8 ;70;? ;>0;8 <70<? Z <> Prevale()a 73& 73&< 736? 73=; 73;? &366 &3<& &3<= &36; &3&= &3>8 &3&8 73<' 738 73>=
Fa)# e (!+#r!l +are e st! ii e "revale()#3 eAist# "!)i(e st! ii e"i0 e+iologice "rivi( i(ci e()a e"resiei4 Mai +!lt3 st! iile eAiste(te arat# +ari i$ere()e @(tre valorile i e(ti$icate4 U( st! i! tra(sversal e$ect!at @( Fi(la( a N@( ca r!l "roiect!l!i 2DINO "e !( lot ra( o+izat e 6888 s!%iec)i c! vGrsta @(tre &< /i '? a(i atGt i( r!ral cGt /i i( !r%a( a esti+at o i(ci e()# a(!al# a t!t!ror t!l%!r#rilor e"resive Ni(cl!zG( atGt e"isoa ele i(i)iale cGt /i rec!re()eleO e 6<3>[4 E"iso !l i(i)ial a av!t o i(ci e()# e 673>[D circa =Y i( "o"!la)ia activ# are !( e"iso e"resiv @( $iecare a(4 &6 I( Ro+G(ia3 i(ci e()a %olii e"resive ra"ortat# e Re)ea!a e is"e(sare
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sa(ti(el# MEDINET a $ost e '3'[3 &737&[ la $e+ei /i =47'[ la %#r%a)i3 e ase+e(ea s!% i(ci e()ele ra"ortate e st! ii i( alte )#ri4 La "o"!la)ia a !lt#3 i(ci e()a e"resiei cre/te c! vGrsta "G(# la !( +aAi+ e &'3>&[ @(registrat la gr!"a e ?>0?8 a(i: LGrsta &>0&8 6706? 6>068 =70=? =>0=8 ?70?? ?>0?8 >70>? >>0>8 '70'? '>0'8 ;70;? ;>0;8 <70<? Z <> I(ci e()a 738; &3<& 63;6 =3>; '3'' &&3&8 &'3>& &?3'> &737< &7366 &=3>> &&36< <3'= '3? <3<<
Co($or+ aceleea/i s!rse3 t!l%!rarea e"resiv# se sit!eaz# "e loc!l 66 @( to"!l celor +ai $recve(te iag(ostice (oi /i "e loc!l 6= @( to"!l celor +ai $recve(te iag(ostice !tilizate @( "ractica +e ic!l!i e $a+ilie $ii( @(tGl(it# c! o $recve()# e &3?< la &77 e co(s!lta)ii4 &>
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>4 IMPAC T U S L 2 C IA L AL D E P R E S I E I
De"resia este !(a i(tre cele +ai i(vali a(te a$ec)i!(i /i "ro !ce o "ovar# se+(i$icativ# atGt i( ivi !l!i cGt /i societ#)ii4 Datele 2MS s!gereaz# c# e"resia este res"o(sa%il# e 'Y i( "ovara t!t!ror %olilor @( E!ro"a @( ter+e(i e isa%ilitate aH!stat# @( a(i e via)# NDALRsO4 Datele "!%licate @( 677? i( 6< e )#ri e!ro"e(e c! o "o"!la)ie total# e ?'' +ilioa(e loc!itori arat# c# cel "!)i( 6& +ilioa(e era! a$ecta)i e e"re0 sie4 Cost!l a(!al total al e"resiei @( E!ro"a a $ost esti+at la &&< +iliar e e e!ro ceea ce @(sea+(# 6>= e!ro5loc!ito r4 Cost!rile irecte a! totalizat ?6 +iliar e e e!ro i( care 66 +iliar e e!ro @(griHirile a+%!latorii3 8 +iliar e e!ro cost!l +e ica)iei /i &7 +iliar e e!ro s"italizarea4 Cost!rile i( irecte atorate e"resiei a! $ost esti+ate la ;' +iliar e e!ro4 Aceste ate $ac i( e"resie cea +ai costisitoare %oal# +e(tal# i( E!ro"a @(s!+G( ==Y i( cost!rile totale4 Chelt!ielile ca!zate e e"resie re"rezi(t# &Y i( total!l eco(o+iei e!ro"e(e4 &' Date "rivi( geogra$ice4 "ovara social# a e"resiei a! $ost "!%licate /i @( alte zo(e
I( SUA "ovara eco(o+ic# a cresc!t e la ;;3? +iliar e e olari @( &887 la <=4& +iliar e @( 67774 Di( aceast# s!+#3 6'4& +iliar e e olari N=&YO a! $ost cost!ri +e icale irecte /i >&4> +iliar e olari N'6YO a! $ost cost!ri la loc!l e +!(ca4 &; I( A!stralia cost!rile totale ale e"resiei @( "erioa a &88;08< a! $ost esti0 +ate la &4< +iliar e e olari i( care 66Y cost!ri irecte4 @( TaiFa( "e(0 tr! &88? e"resia a costat &4? +iliar e e olari i( care 6>Y cost!ri irecte4 @( 6777 a $ost esti+at c# e"resia !(i"olar# a @(s!+at &?46 +ilioa(e DALRs @( Chi(a /i 664; +ilioa(e "e(tr! alte t#ri i( Asia Paci$ic#4 &< Co+"arativ c! alte %oli cro(ice3 e"resia este !(a i(tre cele +ai costisi0 toare a$ec)i!(i3 oc!"G( loc!l al /aselea @( ter+e(i e "ovar# eco(o+ic#4 I( ceea ce "rive/te cost!l +e i! "e "acie(t3 "ovara social# a e"resiei este +ai +are ecGt a altor %oli cro(ice "rec!+ hi"erte(si!(ea3 artrita re!+a0 toi #3 ast+!l %ro(/ic3 osteo"oroza4 &8
67
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De"resia are !( i+"act +aHor /i as!"ra $or)ei e +!(c#4 67 I(tr0!( st! i! "e ;<?'= a !l)i i( care &==>8 a! $ost i e(ti$ica)i ca s!$eri( e e"resie s0a co(statat c# +!(c# /i via)a social# a acestor "ersoa(e a! $ost s!%sta()ial a$ectate e si+"to+ele e"resive4 N!+#r!l e zile e +!(c# "ier !te atorit# e"resiei a cresc!t c! severitatea %olii4 6& Pe lG(g# a%se(teis+!l ri icat3 "ersoa(ele c! e"resie "ier /i schi+%# loc!l e +!(c# +ai $recve(t ecGt cei c! artrit# re!+atoi #3 o s!rs# rec!(osc!t# e iza%ilitate4 6= De"resivii "rezi(t# e ase+e(ea /i i$ic!lt#)i @( +a(age+e(t!l ti+"!l!i3 @( rela)iile i(ter!+a(e /i @( e"li(irea sarci(ilor e servici!4 Per$or+a()a la loc!l e +!(c# "are s# r#+G(# a$ectat# chiar /i !"# a+elioarea si+"to0 +elor e"resive4 66 I( co(cl!zie3 e"resia (etratat# este o %oala $oarte costisitoare c! cost!ri i( irecte @(tr0o "ro"or)ie s!%sta()ial#4 Trata+e(t!l e"resiei ar tre%!i s# $ie @( ate()ia celor ce $ac "oliticile e s#(#tate "e(tr! a evita re"e rc!rsi!(ile (egative ale acestei a$ec)i!(i4 &<
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'4 E T I2 L 2 G IA CI FACT2 R IID E R I S CA I D E P R E S 4 IE I IM P 2 RTA N K A C2 M 2 R 9 ITK D I IL 2 R

As!"ra etiologiei /i $actorilor e risc ai e"resiei "ersist# @(c# +!lte co(0 troverse e/i eAist# eA"lica)ii teoretice ce i+"lic# $actori ge(etici3 "sihologi0 ci3 so+ato0e( ocri(i /i sociali4 Frecve()a cresc!t# a e"resiei @( !(ele $a+ilii "are a s!s)i(e i+"orta()a $actor!l!i ge(etic4 Rol!l $actorilor ge(etici a $ost e+o(strat @( s"ecial "e(0 tr! caz!rile c! e%!t "recoce3 e"resia c! rec!re()e $recve(te /i e"resia cro(ic#4 St! i!l Ge(Re NGe(etics o$ Rec!re(t Earl-02(set De"ressio(O a relevat c# e%!t!l "recoce /i rec!re()a e"iso !l!i e"resiv "revizio(eaz# o cre/tere a risc!l!i e e"resie la r! ele e gra !l @(tGi @( co+"ara)ie c! "o"!la)ia ge(eral#4 6?36 >II% De"resia "are a se tra(s+ite ere itar @( +o egal atGt la %#r%a)i cGt /i la $e+ei4 ';II% U( st! i! e$ect!at "e 67'86 ge+e(i s!0 gereaz# c# $actorii ge(etici i(tervi( /i @( eter+i(area la%ilit#)ii e+o)io(ale N(e!roticis+O care "re is"!(e la e"resie4 6' II% Mo el!l "siho%iologic e "erso(alitate escris e Clo(i(ger i e(ti$ic# !( te+"era+e(t v!l(era%il Nc! te( i()a e a r#s"!( e i(te(s la se+(ale /i sti0 +!li (e$avora%iliO +ai es asociat c! e"resia4 Acesta "are a avea3 e ase+e(ea3 o i+"orta(t# co+"o(e(t# ere itar#4 6;III Teoria ca!zalit#)ii so+atice /i @( s"ecial e( ocri(e este s!s)i(!t# e o%ser0 va)ia c# a(!+ite %oli cro(ice se @(so)esc $recve(t e e"resie4 Patologia so+atic# cro(ic# N+ai $recve(t a$ec)i!(ile graveO se asociaz# c! e"resia @( circa ?&Y i( caz!rile @(griHite e +e ic!l e $a+ilie4 2 a$ec)i!(e +e ical# "e ter+e( l!(g cre/te e a"roAi+ativ o!# ori risc!l e e"resie4 6<368 II% E(!+er#+ i(tre acestea: 0 ia%et!l =7I% 0 a$ec)i!(ile car iace: i($arct!l +iocar ic3 a(gi(a "ectoral# =&3= 6II% 0 hi"o0 /i hi"ertiroi is+!l ==II% 0 +igre(ele3 si(!zitele /i orso"atiile 68II% 0 %ro(ho"(e!+o"atia o%str!ctiv# cro(ic# =?3= >II% 0 l!"!s erite+atos3 scleroza +!lti"l# ='3= ;II% 0 ca(cer!l e sG( =<II% 0 i($ec)ia !ri(ar# Hoas# Nla %#r%a)ii vGrst(iciO =8II% 0 atro$ia cere%ral#4 ?7II% EAist# ovezi care arat# c# /i !(ele si+"to+e cro(ice "ot $i asociate c! e"resia: !rerea3 t!sea3 o%oseala3 i(so+(ia3 is+e(oreea4 ==3?;3?<3?83> 7II%
66
CNSMF I Ghi !ri
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Persiste()a t!l%!r#rii e"resive este +ai $recve(t# la "acie()ii c! co0 +or%i it#)iD la rG( !l s#!3 e"resia "oate i($l!e()a (egativ evol!)ia %olilor cro(ice so+atice4 ?&I% ?63?=3??3?>3? 'II% Toate acestea s!%li(iaz# i+"orta(ta i(ter e"e( e()# care eAist# @(tre e"resie /i a$ec)i!(ile cro(ice so+atice4 De ase+e(ea e"resia "oate $i co+or%i # t!l%!r#rii a(Aioase /i altor %oli "sihice4 6=8 II% S0a! i e(ti$icat o serie e s!%sta()e al c#ror co(s!+ se asociaz# c! e"resia: 0 +e ica+e(te: %eta%loca(te3 IEC3 hi"oli"e+ia(te3 igoAi(a3 i!retice3 %loca()i ai ca(alelor e calci!3 a(algezicele o"ioi e3 coticosteroizii >&II% 0 alcool!l >6II% 0 rog!rile: +arih!a(a3 ca(a%is >=3> ?II% 0 t!t!(!l4 =6II% Di(tre $actorii sociali3 "rezi(t# !( risc "e(tr! e"resie: 0 +e i!l !r%a( >>II% 0 stat!t!l socio0eco(o+ic sc#z!t /i li"sa !(!i a #"ost >'3> ;II% 0 iscri+i(area rasial# sa! et(ic# ><II% 0 caracteristicile loc!l!i e +!(c#: stres!l3 ezechili%r!l e$ort0r#s"lat#3 co( i)iile e +!(c# >83'73' &II% 0 rele trata+e(te @( co"il#rie: a%!z!l /i (egliHarea '6II% 0 eA"!(erea la ezastre @( +as# '=II% La "o"!la)ia vGrst(ic#3 o +etaa(aliz# care a a(alizat toate st! iile "!%li0 cate @( "erioa a &8''0677& a i e(ti$icat ?6 $actori e risc i$eri)i "e(tr! e"resie4 Di(tre ace/tia3 oli!l3 t!l%!r#rile e so+(3 iza%ilitatea3 e"resia a(terioar# /i seA!l $e+i(i( s!(t $actorii e risc cei +ai i+"orta()i4 '? Ia LGrsta @( si(e (! re"rezi(t# !( $actor e risc "e(tr! t!l%!rarea e"resiv#4 Persoa(ele e "este >& e a(i "rezi(t# @(s# o !rat# +ai l!(g# a a$ec)i!(ii /i o rec!re()# cresc!t#4 '>IIa Rec!re()a e"resiei este +ai $recve(t# /i la "ersoa(ele la care "ri+!l e"iso s0a @(registrat la vGrste ti(ere4 ''I% I( co($or+itate c! +o el!l stres0v!l(era%ilitate escris e N!echterlei( /i DaFso( @( &8<?3 a"ari)ia e"resiei "oate $i eA"licat# e ac)i!(ea !(or $ac0 tori trigger N e (at!r# social# sa! eve(i+e(te stresa(te e via)# i(cl!zG( %olile cro(iceO as!"ra !(!i tere( "re is"!s N+o/te(ire ge(etic# /i "erso(a0 litateO4 '<IL I e(ti$icarea $actorilor e risc "e(tr! e"resie ar "!tea aH!ta la e"istarea "recoce a "ersoa(elor "re is"!seD aceste "ersoa(e ar "!tea $i )i(ta !(or i(terve()ii "e(tr! a re !ce $actorii e risc "ote()ial +o i$ica%ili /i "e(tr! a re !ce risc!l a"ari)iei %olii4 '? Ia
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De"resia este a esea o a$ec)i!(e c! evol!)ie li+itat# @( ti+" !r+at# e re+isie co+"let#4 St! iile a! e+o(strat c# @( ti+" ce H!+#tate i( cei iag0 (ostica)i c! e"resie (! vor +ai avea e"isoa e !lterioare3 %oala e"resiv#3 ca /i alte a$ec)i!(i "sihice "rezi(t# o "!ter(ic# te( i()# e rec!re()#4 Pri+!l e"iso e e"resie "oate s!rve(i la orice vGrst#D vGrsta +e ie e e%!t este @(tre 67 /i =7 e a(i4 Pro ro+!l "oate varia co(si era%il e la !( caz la alt!l4 I( l!(ile a(te0 rioare i(stal#rii e"li(e a %olii "ot a"are: a(Aietate3 $o%ii3 si+"to+e e"re0 sive !/oare /i atac!ri e "a(ic#4 I( alte sit!a)ii se "oate ezvolta !( e"iso e"resiv c! i(stalare ra"i # co(sec!tiv# !(!i eve(i+e(t e via)# stresa(t4 Si+"to+ele so+atice o+i(# !(eori ta%lo!l cli(ic co( !cG( +e ic!l la i(vestigarea eAiste()ei !(or "osi%ile a$ec)i!(i so+atice "G(# cG( schi+0 %#rile e is"ozi)ie evi( +ai evi e(te4 '<IL D!rata evol!)iei e"iso !l!i e"resiv (etratat este "!)i( c!(osc!t#4 2 +e0 taa(aliz# "!%licat# @( 677& a !r+#rit evol!)ia a !l)ilor c! e"resie @(scri/i "e listele e a/te"tare "e(tr! "sihotera"ie4 S0a! i e(ti$icat &8 st! ii c! 66& e s!%iec)i !r+#ri)i ti+" e 6 "G(# la 67 e s#"t#+G(i4 S0a o%servat c#3 "e ter+e( sc!rt3 se "oate a/te"ta o i+i(!are a si+"to+atologiei e"resive c! &70&>Y @( li"sa oric#r!i trata+e(t4 Circa 67Y i(tre s!%iec)i se "ot re+ite s"o(ta(4 <>Ia 2 cohorta "ros"ectiv# e$ect!at# @(tre &88'0&888 @( 2la( a "e !( lot e ;7;' "ersoa(e a !lte N&< 0 '? a(iO i( "o"!la)ia ge(eral# a eval!at !rat# e"iso !l!i e"resiv Nst! i!l NEMESISO4 Co($or+ acest!i st! i!3 evol!)ia (at!ral# a e"iso !l!i e"resiv @( "o"!la)ia ge(eral# se caracterizeaz# "ri( aceea c# H!+atate i( cei a$ecta)i se vi( ec# ra"i N@( = l!(iO @( ti+" ce "e(0 tr! rest!l rata rec!"er#rii @(ceti(e/te s"re &6 l!(i N'=Y @( ' l!(i3 ;'Y @( &6 l!(iO eve(i( sta)io(ar# !"# aceea4 A"roa"e 67Y i(tre e"resivi (! s0a! rec!"erat @( 6? l!(i4 Risc!l cro(iciz#rii Nevol!)ie e sa! +ai l!(g# e 6? e l!(iO a $ost co(si e0 ra%il /i si+ilar atGt la "acie()ii tratati cGt /i la cei (etrata)i4 Caracteristicile cli(ice ale e"iso !l!i i(i)ial Nseveritatea e"resiei /i is0 ti+ia asociat#O "ar a $i cei +ai %!(i i( icatori "e(tr! i e(ti$icarea "er0 soa(elor c! o !rat# +ai l!(g# a e"iso !l!i e"resiv4 Ast$el3 !( e"iso e"resiv i(i)ial sever cre/te !rat# +e ie c! ?3> l!(i iar asocierea isti+iei "rel!(ge/te !rata +e ie a e"iso !l!i c! ' l!(i4
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CNSMF I Ghi !ri
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I( $or+ele rec!re(te3 e"isoa ele !lterioare a! o !rat# +ai sc!rt# @( +e ie c! ? l!(i4 '8II% Prog(ostic!l e"resiei la "o"!la)ia vGrst(ic# "are a $i /i +ai rezervat4 Re0 z!ltatele !(ei +etaa(alize "!%licat# @( &888 esti+a! c#3 !"# 6? e l!(i3 oar ==Y i( s!%iec)i a! av!t o evol!)ie $avora%il# @( ti+" ce a"roa"e H!+atate i(tre s!"ravie)!itori "reze(ta! @(c# e"resie4 La vGrst(ici3 e"re0 sia are !( "rog(ostic r#!3 este "ro%a%il cro(ic# ori reca e sa! a+%ele /i este "ro%a%il s!%tratat#4 9olile $izice3 iza%ilitatea3 t!l%!rarea cog(itiv# /i e"re0 sia +ai sever# "ar a $i asociate c! rez!ltate (e$avora%ile4 ;7Ia La aceea/ i gr!"# e vGrst#3 "reze()a e"resiei +i(ore /i s!%cli(ice cre/te e >3> ori risc!l a"ari)iei e"resiei +aHore la & a(4 Aceasta e+o(streaz # se+(i0 $ica)ia cli(ic# a acestor co( i)ii /i s!gereaz# ca ele s!(t "arte a s"ectr!l!i %olii e"resive4 ;&II% Rec!re()a De/i o "arte i(tre "acie()i a! !( si(g!r e"iso e"resiv c! re+itere co+0 "let#3 rata rec!re()ei e"resiei @( co+!(itate /i @( +e ici(a "ri+ar# variaz# @(tre =70?7Y $ii( +ai +are la a !l)ii ti(eri /i la vGrst(ici4 <'Ia Evol!)ia t!l%!r#rii e"resive rec!re(te este varia%il#: o "arte a! cGte !( e"iso la +!l)i a(i e evol!)ie (or+al#3 al)ii a! e"isoa e gr!"ate @(tr0o a(!0 +e "erioa # a eAiste()ei @( ti+" ce al)ii "rezi(t# o cre/tere c! vGrsta a $recve()ei e"isoa elo r4;6IL Factorii e risc "e(tr! rec!re()a e"resiei s!(t re"reze(ta)i e: 0 e"isoa e (!+eroase @( a(tece e(te ;=3; ?II% 0 co($licte $a+iliale ;=II% 0 eve(i+e(te rece(te e via)# ;=II% 0 e"e( e()a e s!%sta()e Nalcool3 cocai(# /i o"iaceeO ;>II% 0 +ai +!lte si+"to+e e"resive rezi !ale4 ;?II% I(tre e"isoa e3 starea ge(eral# revi(e la cea a(terioar#4 I( 670=>Y i( caz!ri "ersist# si+"to+e rezi !ale /i iza%ilitate4 Pacie()ii care co(ti(!# s# @(tr!(easc# criteriile "e(tr! e"iso !l e"resiv e0a l!(g!l evol!)iei t!l0 %!r#rii s!(t cataloga)i re"t cro(iciD cei care ra+G( si+"to+atici N ar $#r# a @(tr!(i criteriile e iag(osticO s!(t co(si era)i "ar)ial re+i/i4 ;6IL Rec# erea se e$i(e/te re"t rea"ari)ia si+"to+elor e"iso !l!i c!re(t3 s!$icie(t e severe "e(tr! a @(tr!(i criteriile si( ro+!l!i e"resiv3 @( +ai "!)i( e ' l!(i !"# re+isia s!% trata+e(t4 &6<3&= 7IL Co+"lica)iile e"resiei i(cl! : z co+"orta+e(t!l agresiv:
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0 a!toagresivitate Nte(tativa e s!ici 3 s!ici !l realizat3 a!to+!tilareaO 0 heteroagresivitatea : +a(i$est#ri clastice NeA4 s"arge3 istr!ge o%iecteO /i agresivitate Nver%al#3 "sihologic# 3 $izic#O z !tilizare e s!%sta()e "sihoactive: alcool3 eriva)i e o"i! Nco ei(#3 heroi(#3 $ortral3 tra+a olO3 eriva)i e ca((a%is3 se ative /i hi"(otice3 cocai(# s!%sta()e sti+!la(te Nco$ei(#3 a+$eta+i(eO3 t!t!(3 solve()i volatili z viraH +a(iacal care "oate sa a"ar# s"o(ta( sa! s!% trata+e(t!l a(ti e0 "resiv z as"ecte socio0$a+iliale: i$ic!lt#)i co(H!gale 3 "are(tale 3 oc!"a)io(ale /i sociale4 De"resia3 @( s"ecial @( $or+a rec!re(t# /i cro(ic# "oate ca!za s!$eri()# "e(tr! $a+ilie /i a(t!raH4 De ase+e(ea3 e"resia "oate co+"lica evol!)ia altor a$ec)i!(i co(co+i0 te(te4 ;6IL Di(tre acestea3 cele +ai grave co+"lica)ii ale t!l%!r#rii e"resive s!(t s!i0 ci !l /i alte acte e viole()#4 Factorii "re ictivi i+"orta()i "e(tr! actele e s!ici viitoare s!(t: istoric!l e te(tativ# e s!ici 3 eval!area s!%iectiv# a severit#)ii e"resiei /i $!+at!l e tig#ri3 $iecare avG( !( e$ect c!+!lativ4 I( "l!s3 atGt "esi+is+!l cGt /i agresivitatea sa! i+"!lsivitatea "rezic actele e s!ici /i $iecare "rezi(t# e ase+e(ea3 e$ect c!+!lati v4 I(terve()iile "rec!+ $ar+acotera"i a "ro$ilactic# agresiv# "e(tr! a "reve(i rec# erea ori rec!re()a si+"to+elor e"resive "ot "roteHa i( ivizii la risc e viitor!l co+"orta+e( t s!ici al4 ;'II% Partic!larit#)i ale evol!)iei s!% trata+e(t I(r#!t#)irea cli(ic# "recoce EAist# !( gr!" e "acie()i a c#ror stare e"resiv# se agraveaz# !"# @(ce0 "erea trata+e(t!l!i a(ti e"resiv4 Aceast# sit!a)ie ar "!tea re"reze(ta istoria (at!ral# a %olii sa! !( e$ect al tera"iei4 I(tr0o cohort# retros"ectiv# "!%licat# @( 677; s0a st! iat @(r#!t#)irea cli(i0 c# "recoce la !( gr!" e '8? "acie()i iag(ostica)i c! e"iso e"resiv +aHor NDSM IIIO /i trata)i c! $l!oAeti(# 67 +g5zi "e(tr! &6 s#"t#+G(i4 I(r#!t#)irea "recoce a $ost i e(ti$icat# la =73?Y i(tre "acie()i4 Aceasta a $ost asociat# c! sc# erea se+(i$icativ# a "ro%a%ilit#)ii re+isiei /i r#s"!(s!0 l!i la < /i &6 s#"t#+G(i4 ;;II% z Si+"to+e rezi !ale I( !r+a trata+e(t!l!i ac!t se "oate o%)i(e re+isia total# Na%se()a si+"0 to+elor %olii /i scor!ri +ici "e scalele e eval!areO3 "ar)ial# N"ersist# !(ele si+"to+e rezi !ale ar (! se @(tr!(esc criteriile e iag(osticO sa! li"sa r#s"!(s!l!i tera"e!tic4
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Si+"to+ele rezi !ale re"rezi(ta !( +arTer al "rog(ostic!l!iD "reze()a acestora este asociat# c! rec# eri +ai $recve(te3 o rat# cresc!t# a s!ici !0 l!i3 cro(icizare3 o cre/tere se+(i$icativa a !tiliz#rii serviciilor +e icale /i isa%ilitate4 Rez!ltatele !(ei cohorte "ros"ective e$ect!at# "e ;87 "acie()i c! e"iso e"resiv +aHor NDSMILO arat# c# cel "!)i( >7Y i( s!%iec)ii c! re+isie "ar)ial# "reze(ta! si+"to+e e t!l%!rare e"resiv# N'>3>YO3 a(Aietate "si0 hic# N>'4'YO3 "ier erea i(teres!l!i /i a%se(teis+ e la loc!l e +!(c# N?83?YO4 I( icatorii e severitate ai e"resiei Ni(so+(ia +ati(al#3 le(toare "siho+otorie3 agita)ie3 hi"oco( rie3 "ier ere @( gre!tate /i sla%# co(/tie(ti0 zare a t!l%!r#riiO3 a! $ost +ai rar ra"orta)i /i e o%icei (! to)i4 Aceste rez!ltate co($ir+# (evoia e a ezvolta strategii e scree(i(g "e(0 tr! si+"to+ele rezi !ale ale e"resiei3 "rec!+ /i e +eto e s"eci$ice e trata+e(t4 ;<3; 8II% z Si+"to+e asociate D!rerea este "reze(t# la 65= i(tre "acie()ii c! e"resie i( +e ici(a "ri0 +ar# care @(ce" trata+e(t!l a(ti e"resiv4 S0a co(statat c# asocierea este +ai $recve(t# la seA!l $e+i(i(4 Ce$aleea /i !rerea +!sc!lar# s!(t si+"to+ele a c#ror "reze()a i( e"e(0 e(t# se asociaz# c! @(ceti(irea re+isiei /i rez!ltate sla%e la = l!(i e trata0 +e(t4 A !l)ii c! e"resie rec!re(t# ar tre%!i s!"!/i !(!i scree(i(g "e(tr! "reze()a !rerii @(ai(te e i(i)ierea trata+e(t!l!i eoarece "reze()a aces0 teia (ecesit# !( trata+e(t +ai agresiv /i "oate $i !( +arTer "e(tr! s!ici 4 2 +ai %!(# rec!(oa/tere3 eval!are /i trata+e(t a !rerii co+or%i e "oate @+%!(#t#)i rez!ltatele trata+e(t!l!i a(ti e"resi v4<73< &II% Si+"to+ele $izice se a+elioreaz# @( "ri+a l!(# e trata+e(t c! ISRS ar @(registreaz# !( "lato! @( l!(ile !lterioare s"re eose%ire e si+"to+ele e"resive care se a+elioreaz# co(sta(t4 <6I% Risc!l e +ortalitate este cresc!t la "acie()ii c! t!l%!rare e"resiv#4 I(tr0o +etaa(aliz# "!%licat# @( 67763 risc!l relativ e +oarte la s!%iec)ii c! e"re0 sie a $ost e &3<& co+"arat c! "ersoa(ele $#r# e"resie4 N! a! $ost g#site i$ere()e +aHore @(tre %#r%a)i /i $e+ei3 e/i risc!l relativ era ceva +ai +are la %#r%a)i4 Acest st! i! e+o(streaz# ca risc!l cresc!t eAist# (! (!+ai @( e"resia +aHor# ci /i @( $or+ele s!%cli(ice ale e"resiei4 I( +!lte caz!ri3 e"resia ar "!tea $i co(si erat# o t!l%!rare a+e(i()#toare e via)# 4<=Ia Ci @( "o"!la)ia vGrst(ic# iag(ostic!l e e"resie este asociat c! cre/terea +ortalit#)ii4 Ta%lo!l "e(tr! i$ere()ele "e seAe este @(c# (eclar4 <?Ia
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<4 D IAG N 2 ST I C U L TUL9UR ID RE I P R E S IL E

REC2MANDRI
R& E$ect!area scree(i(g!l!i e"resiei "e %aza chestio(ar!l!i c! 6 @(tre%#ri R6 Diag(osticarea t!l%!r#rii e"resive "e %aza algorit+!l!i 2MS R= E$ect!area a(a+(ezei co+"lete Na(tece e(te "erso(ale $iziologice /i "atologice3 a(tece e(te here o0colaterale3 istoric!l %olii3 co( i)ii e via)# /i +!(c#O4 R? EAa+e( cli(ic ge(eral "e(tr! eAcl! erea a$ec)i!(ilor so+atice R> E$ect!area e i(vestiga)ii "aracli(ice )i(tite "e(tr! iag(ostic!l i$ere()ial R' Eval!area risc!l!i s!ici ar la $iecare vizit#
9 C
C C C C
<4&4 ELEMENTE
ALE EUAMENULUI CLINIC CARE
2RIENTEAW CTRE DIAGN2STICUL DE DEPRESIE
Diag(ostic!l "ozitiv al t!l%!r#rii e"resive este i$icil e sta%ilit atorit# heteroge(it#)ii (o)i!(ii e e"resie4 EAa+i(area cli(ic# c! o%servarea ate(0 t# a %ol(av!l!i3 c!(oa/terea co+"orta+e(t!l!i a(terior e"resiei3 istoric!l %olii3 a(tece e(tele $a+iliale /i "erso(ale3 $actorii e via)# stresa(ti "ot aH!ta la iag(osticarea caz!l!i4 84&4& ANAMNEWA Motivele "reze(t#rii la +e ic: Ac!zele clasice ale "acie()ilor e"resivi s!(t: 0 is"ozi)ia trist#0 !reroas# o+i(at# e "esi+is+3 isco($ort i(ter(3 a(Aietate3 esc!raHare /i i(satis$ac)ii 0 $atiga%ilitate3 e"!izare $izic# /i "sihic# +ai evi e(t# i+i(ea)a ecGt la s$ir/it!l zilei 0 se(ti+e(te e a!toac!zare /i a!to evalorizare 0 ezi(teres /i i+"osi%ilitatea e a resi+)i %!c!ria "e(tr! activit#)i care a(terior era! agrea%ile /i "l#c!te
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CNSMF I Ghi !ri
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0 is"erare c! "ier erea g!st!l!i vie)ii3 regrete /i stare e (e$ericire care $ac a esea +oartea "re$era%il# vie)ii4 I( "ractica cli(ic#3 se co(stat# $recve(t "acie()i e"resivi care (! re0 lateaz# si+"to+ele +e()io(ate a(terior /i care co(s!lt# i$eri)i +e ici "e(tr!: 0 t!l%!r#ri e so+( 0 t!l%!r#ri e a"etit 0 "ier erea e(ergiei3 $atiga%ilitate 0 ce$alee 0 algii viscerale Nco(stric)ie toracic#3 a"#sare car iac# sa! i$ic!lt#)i res"iratoriiO 0 "al"ita)ii 0 t!l%!r#ri e tra(zit 0 !scarea +!coaselor sa! hi"ersaliva)ie 0 i+i(!area sa! "ier erea li%i o!l!i4 Aceste ac!ze s!(t (esiste+atizate /i eAa+e(!l cli(ic /i "aracli(ic (! "ot i e(ti$ica s!$eri()e so+atice4 CG( s!(t chestio(a)i3 acesti "acie()i rec!(osc @(s# "ier erea i(teres!l!i sa! a "l#cerii "e(tr! activit#)i o%i/(!ite ceea ce "oate ghi a cli(icia(!l c#tre iag(ostic!l e t!l%!rare e"resiv#4 86 IL A(tece e(te here o0colaterale: s!(t i+"orta(te eoarece e"resia a"are +ai $recve(t @( a(!+ite $a+ilii4 I(tereseaz# @( s"ecial caz!rile e: 0 e"resie sa! alte a$ec)i!(i "sihiatrice 0 s!ici 3 viole()# sa! o+!ci eri @( $a+ilie4 <;IL A(tece e(tele here o0colaterale "ozitive (! "ot co(stit!i @(s# !( criteri! @( iag(osticarea caz!l!i c!re(t4 <8 II% A(tece e(te "erso(ale $iziologice: s!(t i+"orta(te ate "rivi( eta"ele e via)# ale $e+eii care cresc v!l(era%ilitatea "e(tr! e"resie: sarci(a3 (a/terea /i leh!zia3 co(trace")ia hor+o(al#3 +e(o"a!za /i tera"ia e s!%stit!)ie hor0 +o(al#4 86IL A(tece e(te "erso(ale "atologice "sihiatrice 0 ta%agis+ 0 alcoolis+ 0 co(s!+ e rog!ri 0 iag(ostice3 s"italiz#ri /i trata+e(te a(terioare 0 co+"orta+e(te s!ici are sa! viole(te <; IL so+atice 0 s!(t i+"orta(te: 0 co( i)iile +e icale care "ot ca!za sa! se "ot @(so)i e si+"0 to+e e"resive <; :
Ghi !ri
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9oli e( ocri(e
hi"o0 sa! hi"ertiroi ie3 hi"er"aratiroi ie3 hi"o"it!ita0 ris+3 %oala C!shi(g3 %oala A iso(3 ia%et zaharat 9oli i($ec)ioase "(e!+o(ie 3 he"atite3 +o(o(!cleoz # i($ec)ioas#3 i($ec)ia HIL3 toAo"las+oz#3 si$ilis ter)iar Colage(oze l!"!s3 artrit# re!+atoi #3 colage(oze +iAte 9oli e (!tri)ie a"ort eAcesiv e vita+i(a 9'3 9&6 sa! e$icie()# e $ola)i3 e$icie()# e tia+i(#3 "elagr# 9oli (e!rologice acci e(t vasc!lar cere%ral3 scleroza +!lti"l#3 %oala ParTi(so(3 e+e()#3 tra!+atis+e cra(ie(e 3 he+ato+ s!%0 !ral cro(ic3 e"ile"sie3 t!+orile siste+!l!i (ervos ce(tral3 t!l%!r#ri e so+( Neo"lazii oricare ar @( s"ecial3 t!+ori a% o+i(ale Ngastro0i(tes0 ti(aleO3 si( roa+e "ara(eo"lazice3 carci(o+atoz#3 %oli he+atologice +alig(e 9oli car iace car io"atie ische+ic#3 i(s!$icie()a car iac# co(gestiv# Diverse a(e+ie3 ast+ %ro(/ic3 9P2C3 e+$ize+3 !rere cro(ic#3 o"rirea $!+at!l!i /i orice alt# %oal# cro(ic# 0 age()ii $ar+acologici sa! s!%sta()e toAice care "ot ca!za si+"to+e e"resive <; : Me ica)ie "ro"ra(olol3 i!retice tiazi ice3 car iovasc!lar# igoAi( Hor+o(i co(t race"tiv e orale3 gl!cocorticoizi 3 steroizi a(a%oli0 za()i A(tii($la+atorii a(tii($la+atori (esteroi ie(e3 Citostatice cicloseri(a3 vi(cristi(a3 vi(%lasti(a A(tie+etice +etoclo"ra+i a Me ica)ie %e(zo iaze"i(e3 se ative0hi"(otice3 "sihiatric# a(ti"sihotice3 a(ticoli(e rgice Altele (arcotice 3 ci+eti i(a 3 ra(iti i(a3 %aclo$e(3 alte +iorelaAa(te3 eta+%!tol3 is!l$ira+ Drog!ri toate "ot "rovoca sa! eAacer%a e"resia @( oricare $az# Ni(toAica)ia ac!t# /i cro(ic#3 sevraHO ToAice i(toAica)ia c! +etale grele3 alcool3 i(sectici e a(tico0 li(esterazice
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CNSMF I Ghi !ri
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Istoric!l a$ec)i!(ii S!(t i+"orta(te ate "rec!+: e%!t!l si+"to+elo r3 !rata3 severitatea /i rec!re()a lor3 "reze()a i eilor s!ici are3 trata+e(te a(terioare4 <;IL Tre%!iesc i e(ti$icate /i sit!a)iile eAiste()iale asociate c! e"resia: 0 %oala 0 "ro%le+e co(H!gale 0 stres!l la loc!l e +!(c# 0 a%!z!l Nviole()a o+estic# 3 a%!z!l $izic sa! seA!alO4 <<IL Co( i)ii e via)# /i +!(c# 0 "ot re"reze(ta $actori e risc "e(tr! e"resie: 0 stres!l /i i(echit#)ile la loc!l e +!(c# 0 stat!s socio0eco(o+ic N(ivel sc#z!t e e !ca)ie /i ve(it3 li"sa a #0 "ost!l!iO 0 izolarea 0 +e i!l !r%a( e o+icili!4 Nv4 Ca"4 $actori e riscO <4&46 EUAMENU L CLINIC 0 tre%!ie realizat @( co(cor a()# c! rez!ltatele a(a+(ezei "e(tr! a$ir+area sa! i($ir+area a$ec)i!(ilor so+atice s!gerate e aceasta4 Pe(tr! eAcl! ere a a$ec)i!(ilor care se +a(i$est# "ri( sa! care "ro !c si+"to+e e"resive Nta%el!l &O este (ecesar# e$ect!area !(!i eAa+e( cli(ic co+"let4 Co($or+ literat!rii "sihiatrice clasice3 ar "le a "e(tr! iag(ostic!l e t!l0 %!rare e"resiv# !r+#toarele ate relevate e i(s"ec)ia "acie(t!l!i: 0 $acies!l e"resiv caracteriza t "ri(: c!loare teroas#3 tr#s#t!ri hi"o+o%ile3 "rivire $iA#3 so%r#3 li"sit# e str#l!cire3 a)i(tit# @( Hos3 s"rG(ce( e /i $r!(te @(cr!(tat# Nse+(!l 2MEGAO3 %!ze strG(se c! co+is!ri c#z!teD 0 "ozi)ia gGr%ovit# c! "r#%!/irea "ost!rii ast$el ca %ol(av!l "are @+%#0 trG(it @(ai(te e vre+eD 0 )i(!ta vesti+e(tar# (egliHat#D 0 +ers @(cet3 gest!ri le(te3 rare3 e +ic# a+"lit! i(eD 0 stare e "rostra)ie @( caz!ri grave4 Pe "arc!rs!l co(s!lta)iei se co(stat# c# "acie(t! l (! "oate !r+#ri e$icie(t co(versa)ia3 (! se "oate co(ce(tra 3 vor%e/te "!)i(3 r#s"!( e +o(osila%i c "e !( to( sti(s @(tret#iat e s!s"i(e /i ge+ete3 "rezi(t# o i ea)ie s#rac# care "oate aH!(ge @( caz!ri grave la o stag(are a gG( irii as!"ra !(ei si(g!re i ei sa! la !( vi i eativ4 U(eori s!(t "reze(te elir!ri sa! hal!ci(a)ii4 EAist# sit!a)ii @( care "acie()ii e"resivi +a(i$est# gra e variate e agita)ie "siho+otorie e la (eli(i/te "G(# la ra"t!s4 86IL
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<4&4= INLESTIGAKII Pot $i (ecesare i(vestiga)ii variate e la caz la caz $!(c)ie e co+or%i it#)i /i "e(tr! !( iag(ostic i$ere()ial corect: 0 he+ole!cogra+# 0 glice+ie3 li"i ogra+#3 aci !ric3 creati(i(#3 calci!3 +ag(ezi!3 so i!3 "otasi!3 clor seric3 "rotei(e serice3 al%!+i(e5 glo%!li(e3 %ilir!%i(#3 $os0 $ataza alcali(#3 LDH3 tra(sa+i(aze3 $ier seric3 0 TSH4 Pot $i solicitate eA"lor#ri a i)io(ale "rec!+: 0 E1G Q cG( eAist# $actori e risc "e(tr! %oli car iovasc!lare3 la "er0 soa(e "este >7 e a(i sa! @( caz e trata+e(te c! a(ti e"resive trici0 clice sa! liti! 0 EEG 0 @( caz e co+i)ialitate 0 RMN Q @( %oli (e!rologice 0 Teste i+!(ologice Q cG( se s!s"ecteaz# colage(oze4 <;IL <464 SCREENINGU L DEPRESIEI Se "oate realiza @( "o"!la)ia ge(eral# sa! (!+ai la "acie()ii c! risc cres0 c!t e t!l%!rare e"resiv# a"licG( !( chestio(ar c! 6 @(tre%#ri 87: &4 L0a)i "ier !t i(teres!l sa! "l#cerea "e(tr! activit#)ile o%i/(!ite @( !lti0 +a l!(#M 64 L0a)i si+tit trist3 e+oralizat sa! (eaH!torat @( !lti+a l!(#M Scree(i(g!l e"resiei "e %aza acest!i chestio(ar "rezi(t# o se(si%ilitate e 8'Y ar o s"eci$icitate e >;Y4 Chestio(ar!l c! 6 @(tre%#ri este !( i(str!+e(t !til @( e"istarea e"resiei a !lt!l!i @( +e ici(a "ri+ar#4 Are caracteristici si+ilare c! alte teste e scree(i(g /i este +ai ra"i 4 8'II% Daca r#s"!(s!l este "ozitiv la a+%ele @(tre%#ri3 "acie(t!l (ecesita e$ect!0 area chestio(ar!l!i e iag(ostic4 <4=4 DIAGN2STICUL P2WITI L AL DEPRESIEI Se realizeaz#3 co($or+ reco+a( #rilor 2MS3 @( o!# eta"e isti(cte: &4 co+"letarea chestio(ar!l!i a!toa +i(istrat care ri ic# s!s"ici!(ea "reze()ei !(ei t!l%!r#ri e"resive 64 co($ir+area iag(ostic!l!i "ri(tr0!( chestio(ar a +i(istrat e +e ic4 8&IL &4 Chestio(ar!l a!toa +i(istra t N.MaHor De"ressio( I(ve(tor-J MDIO co()i(e &7 @(tre%#ri care eA"loreaz # "reze()a3 @( !lti+ele 6 s#"t#+G(i 3 a si+"to+elor 0 criteri! e iag(osticar e /i clasi$icare a/a c!+ s!(t ele e(!()ate e CIM &74 Pacie(t!l tre%!ie s# %i$eze r#s"!(s!l cel +ai a"ro"iat e starea sa4
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CNSMF I Ghi !ri
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Ghi !ri e "ractic# "e(tr! +e icii e $a+ilie I CNSMF
I( !lti+ele Tot De cele +ai Mai +!lt e Mai "!)i( e o!# s#"t43 ti+"!l +!lte ori H!+#tate H!+#tate cGt e es444 i( ti+" i( ti+" &4 L0a)i si+)it i( is"!s sa! tristM > ? = 6 64 L0a)i "ier !t i(teres!l "e(tr! activit#)ile zil(iceM > ? = 6 =4 L0a)i si+)it li"sit e e(ergie /i "!tereM > ? = 6 ?4 L0a)i "ier !t @(cre erea > ? = 6 e si(eM >4 A )i av!t se(ti+e(te e c!l"a%ilitate sa! vi(#M > ? = 6 '4 A)i si+)it c# via)a (! +erit# tr#it#M > ? = 6 ;4 A )i av!t i$ic!lt#)i e co(ce(trare ca e eAe+"l! at!(ci cG( > ? = 6 citi)i sa! v# !ita)i la televizorM > ? = 6 <a4 L0a)i si+)it $oarte o%ositM > ? = 6 <%4 L0a)i si+)it a%#t!tM > ? = 6 84 A )i av!t t!l%!r#ri e so+(M > ? = 6 &7a4 L0a sc#z!t a"etit!lM > ? = 6 &7%4 L0a cresc!t a"etit!lM > ? = 6
U(eori Nicio at#
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Pe(tr! i(ter"retarea chestio(ar!l!i e iag(ostic3 la @(tre%#rile < /i &7 se alege varia(ta a sa! % !( e s0a co(se+(at scor!l cel +ai +are4 Diag(ostic!l e"resiei este "ro%a%il at!(ci cG( "acie(t!l %i$eaz# ? sa! > "e scala chestio(ar!l!i @( cel "!)i(: 0 6 i( "ri+ele = \ 6 i( !lti+ele ; @(tre%#ri ] DEPRESIEUC2AR 0 6 i( "ri+ele = \ ? i( !lti+ele ; @(tre%#ri ] DEPRESIEM2DERAT 0 "ri+ele = \ > i( !lti+ele ; @(tre%#ri ] DEPRESIESELER 64 Co($ir+area iag(ostic!l!i se realizeaz# "ri(tr0!( i(tervi! a"licat e +e ic care tre%!ie s# i e(ti$ice "reze()a criteriilor A39 /i C i( CIM&7 Nv4 A(eAa &O: z Criteri!l A: si+"to+ele t!l%!r#rii e"resive tre%!ie s# !reze e cel "!)i( 6 s#"t#+G(i @( cea +ai +are "arte a ti+"!l!i4 z Criteri!l 9: tre%!ie veri$icat# "reze()a st#rii e"resive N&O3 a sc# erii e(ergiei N6O /i a "ier erii i(teres!l!i Nsi+"to+!l = co($or+ i( CIM &7O4 Se "ot $olosi @(tre%#ri e ge(!l: A )i $ost e"ri+at cea +ai +are "arte a ti+"!l!iM Da N! L0a)i si+)it li"sit e e(ergie @( cea +ai +are "arte a ti+"!l!iM Da N! L0a)i "ier !t i(teres!l "e(tr! activit#)ile o%i/(!ite M Da N! Criteri!l C: "reze()a celorlalte si+"to+e N i( CIM &7O se "oate veri$i0 ca $olosi( !r+#toarele @(tre%#ri: .@( !lti+ele 6 s#"t#+G(i3 a)i av!t vre!(!l i( !r+#toarele si+"to+e @( cea +ai +are "arte a ti+"!l!iMJ
z
Da Pier erea @(cre erii @( si(e sa! se(ti+e(te Da Se(ti+e(te e a!to0ac!zare sa! e vi(#M Da GG( !ri rec!re(te e +oarteM
N! e i(!tilitate M N! N! N! N!
Da Di+i(!area ca"acit#)ii e co(ce(trareM Da
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CNSMF I Ghi !ri
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Lor%i)i sa! v# +i/ca)i +ai @(cet ecGt (or+al sa! s!(te)i +ai agitat ecGt e o%icei M Da T!l%!r#ri e so+( @( $iecare (oa"teM Da A"etit sc#z!t /i5sa! "ier ere @( gre!tateM N! N!
Da N! D!"# co($ir+area iag(ostic!l!i e e"resie3 +e ic!l va calc!la "!(cta0 H!l cores"!(z#tor chestio(ar!l!i MDI3 @(s!+#( toate valorile la care s0a r#s"!(s c! ? sa! >4 Se va realiza !( scor e +i(i+ &' /i +aAi+ >7: 0 e"resia !soar#: &' 0 67 0 e"resia +e ie: 6? 0 =7 0 e"resia sever#: =6 0 >7 Calc!larea "!(ctaH!l!i va $i (ecesar# /i !lterior3 @( "roces!l e +o(ito0 rizare al a$ec)i!(ii3 cG( va "er+ite a"recierea evol!)iei s!% trata+e(t4 I( co(cl!zie3 "e(tr! iag(ostic!l "ozitiv /i e severitate al e"iso !l!i e"resiv Nco($or+ CIM &7O se "oate !tiliza algorit+!l !r+ator: Algorit+ e iag(ostic Si+"to+e ce !reaz# e
6 s#"t#+G(i @(cea +ai +are "arte a ti+"!l!i
8&
9& Stare e"resiv#M 96 E(ergie scaz!t#M 9= Pier erea i(teres!l!iM Cl Pier erea @(cre erii @( si(eM C6 Se(ti+e(te e vi(#M C= GG( !ri rec!re(te e +oarteM C? Di+i(!area co(ce(tr#rii M C> Le(toare sa! agita)ie M C' T!l%!r#ri e so+(M C; T!l%!r#ri e a"etitM Scor chestio(ar a!toa +i(istrat
F=647 De"resia !/oar# 6 c#s!)e c! DA 6 c#s!)e c! DA
F=64& De"resia +o erat# 6 c#s!)e c! DA ? c#s!)e c! DA
F=646 De"resia sever# = c#s!)e c! DA > c#s!)e c! DA
&' 0 67
6? 0 =7
=6 0 >7
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<4?4 DIAGN2STICUL DIFERENKIA L AL TUL9URRI I DEPRESIL E "oate $i i$i0 cil i+"licG( o +!ltit! i(e e a$ec)i!(i atGt "sihice cit /i orga(ice4 Se vor avea @( ve ere: A4 a$ec)i!(i so+atice: !( (!+#r i+"orta(t e %oli orga(ice se "ot asocia c! si+"to+e e"resive4 For+!la +(e+oteh(ic# LINDECAK I "oate aH!ta la e(!+erarea acestora: &4 L 0 a$ec)i!(i vasc!lare: i($arct!l e +iocar 3 i(s!$icie()a car iac# co(gestiv#3 ateroscleroza cere%ral# 64 I 0 %oli i($ec)ioase: si$ilis3 e(ce$alit#3 t!%e rc!loz#3 a%cese cere%rale3 gri"a3 "(e!+o(ia /i alte st#ri i($ec)ioase "rel!(gite =4 N 0 (eo"lazii: t!+ori cere%rale3 ale gla( elor e( ocri(e3 "a(creatice /i orice t!+or# c! +etastaze ?4 D 0 %oli ege(erative N e+e()eleO /i e$icite vita+i(ice N"elagraO >4 E 0 a$ec)i!(i e( ocri(e: hi"o"it!itaris+3 acro+egalia3 hi"o /i hi"er0 tiroi ie3 hi"o /i hi"er"aratiroi ie3 ia%et zaharat3 i(s!li(o+3 hi"o0 go(a is+3 +e(o"a!za3 si( ro+ C!shi(g3 i(s!$icie()a a re(al# '4 C 0 co(ge(itale: e"ile"sia3 istro$ia +!sc!lara3 ataAia Frie reich /i e"resia asociat# variatelor +al$or+a)ii co(ge(itale car iace sa! +!ltio rga(ice ;4 A 0 %oli a!toi+!(e : scleroza +!lti"l# /i l!"!s!l erite+atos <4 T 0 tra!+atis+e: e"resia "osttra!+atic#3 aste(ia (e!roci rc!latorie3 si( ro+!l "ostco(t!zio(al 84 I 0 i(toAica)ii c!: "l!+%3 alcool3 %ro+D hi"o /i hi"e rcalce+ia3 hi"o"otase+ia3 !re+ia3 a(oAia i( %olile res"iratorii cro(ice3 a(e0 +ia3 tera"ia cortizo(ic# etc4 8?IL 94 c! a$ec)i!(i "sihiatrice 0 isti+ia 0 re"rezi(t# o $or+a cro(ic# e e"resie care !reaz# e cel "!)i( oi a(i /i care se +a(i$est# "ri( si+"to+e +ai "!)i(e /i +ai "!)i( severe4 Si+"to+ele (! @( e"li(esc criteriile e iag(ostic ale t!l%!r#rii e"resive4 <;IL 0 t!l%!rarea +iAt# a(Aioas# /i e"resiv# Q eAist# !(ele si+"to+e s"eci$ice a+%elor t!l%!r#ri ar care (! @(tr!(esc criteriile e iag0 (ostic "e(tr! (ici !(a i( cele o!# a$ec)i!(i 4 0 t!l%!rarea e a a"tare c! si+"to+e e"resive Q stare e"resiv# !/oar#3 tra(zitorie care s!rvi(e @( !r+a eA"!(erii la !( $actor stre0 sa(t4 Si+"to+ele (! @( e"li(esc criteriile e iag(ostic ale t!l0 %!r#rii e"resive4
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Re"reze(tarea sche+atic# a a$ec)i!(i lor c! care se $ace iag(ostic!l re()ial al e"iso !l!i e"resiv
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0 oli!l Q re"rezi(t# o reac)ie (or+al# la o "ier ere +aHor# Q ece0 s!l !(ei r! e a"ro"iate sa! "riete(4 Pot eAista +!lte i( si+"0 to+ele e"resiei ar "ersoa(ele a$late @( aceasta sit!a)ie (! +a(i0 $est# se(ti+e(te e i(!tilitate sa! vi(# /i (! a! i ea)ie s!ici al#4 D!rat# si+"to+elor este varia%il# ar @( ge(eral acestea se re+it sa! se ate(!eaz# @( cGteva l!(i4 <;38 =IL 0 t!l%!rarea %i"olar# Q co(st# @( alter(area e"isoa elor +a(iacale /i a celor e"resive3 aceast# alter(a()# $ii( @(trer!"t# e "erioa e e (or+alitate4 0 e+e()a Q "ot eAista si+"to+e e"resive ar coeAist# c! e$icit!l cog(iti v4 0 t!l%!r#ri schizoa$ective Q "rezi(t# e"isoa e "sihotice @( a%se()a t!l0 %!r#rilor e is"ozi)ie4 Algorit+ e iag(ostic i$ere()ial al t!l%!r#rilor e is"ozi)ie
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84>4 ELALUARE A RISCULU I SUICIDA R : tre%!ie realizat# atGt i(i)ial cGt /i "e "arc!rs!l trata+e(t!l!i "G(# la re+iterea total# a si+"to+elo r4
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CNSMF I Ghi !ri
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Risc!l s!ici ar a"are la !(ii e"resivi +ai a esea @( $aza "recoce a rec!0 "er#rii ecGt @( $aza ac!t# a %olii4 <;IL ETAPE LESCREENINGULUIRISCULUI SUICIDAR8;IL &4 Pacie()ii e"resivi tre%!ie @(tre%a)i ac# a! gG( !ri e +oarte sa! s!i0 ci sa! ac# se si+t is"era)i /i c# via)a (! +ai +erit# tr#it#4 64 Dac# r#s"!(s!l este "ozitiv3 tre%!ie @(tre%a)i es"re "la(!rile e s!ici 4 0 CGt e +!lt se gG( esc la s!ici M 0 S0a! gG( it la o +eto a e s!ici M 0 A! acces la +aterialele (ecesare s!ici !l!iM 0 Ci0a! l!at r#+as %!( sa! a! scris (ote e a ioM 0 Care s!(t co( i)iile s"eciale care ar gr#%i s!ici !lM 0 Ce ar "!tea @+"ie ica s!ici !lM =4 Eval!area $actorilor e risc "e(tr! s!ici : aO "sihosociali 0 seA!l +asc!li( 0 vGrsta ava(sat# 0 celi%atar sa! care tr#ie/te si(g!r %O a(a+(eza 0 te(tativ# a(terioar# e s!ici 0 istoric $a+ilial e s!ici 0 istoric $a+ilial e a%!z e s!%sta()e cO cli(ic5 iag(ostic 0 ez(# eH e 0 $e(o+e(e "sihotice 0 %oli cro(ice 0 a%!z e s!%sta()e ?4 Este (ecesar# co(s!lta)ie "sihiatric# /i trata+e(t e !rge()# ac#: 0 gG( !rile e s!ici s!(t "ersiste(te 0 "acie(t! l are istoric e te(tativ# e s!ici sa! !( "la( act!al e s!ici 0 "acie(t!l are cG)iva $actori e risc "e(tr! s!ici 4
Ghi !ri
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84 T RATA M E N T U L TUL9UR ID RE I P R E S IL E
Acest ghi e "ractic# $or+!leaz# reco+a( #ri "rivi( trata+e(t!l e"re0 siei !/oare /i +o erate al c#r!i +a(age+e(t "oate $i e$ect!at e +e ic!l e $a+ilie4
REC2MANDRI
R; Psihotera"ie @( e"iso !l e"resiv +o erat
e"resiv !/or
A C
R< Psihotera"ie sa! $ar+acotera"ie @( e"iso !l
Meto ele tera"e!tice "e(tr! e"resie "ot $i gr!"ate @( !r+atoarele cate0 gorii: z Psihotera"ie z Far+acotera"ie z Alte +eto e tera"e!tice Acestea se "ot $olosi si(g!re sa! @( asociere @( $!(c)ie e $or+a cli(ic#3 e evol!)ia a(terioar#3 e co+or%i it#)i3 e "re$eri()ele "acie(t!l!i /i e is"o(i%il!l e "erso(al cali$icat @( a a"lica tera"iile "sihologice4 I( i$ere(t e +eto a aleas#3 trata+e(t!l tre%!ie sa $ie "otrivit3 e$icace3 o"ti+al3 asociat c! e$ecte a verse +i(i+e /i acce"tat e "acie(t4 2%iectivele trata+e(t!l!i s!(t !r+#toarele: &4 re+isia t!t!ror se+(elor /i si+"to+elor e"resiei 64 rei(tegrarea oc!"a)io(al# /i "sihosocial# a "acie(t!l!i e"resiv =4 re !cerea risc!l!i "e(tr! rec# ere /i rec!re()#4 <<IL D!"# ghi !l NICE'< i(terve()iile tera"e!tice a resate "ate @( > tre"te $!(c)ie e $or+a cli(ic# a %olii: e"resiei "ot $i gr!0
?7
CNSMF I Ghi !ri
e $a+ilie
Pa/ii i(terve()iilor tera"e!tice @( e"resie
84&4 PSIH2TERAPIA
REC2MANDRI
R8 Utilizarea tera"iei cog(itiv co+"orta+e(tale @( trata+e(t!l a+%!latori! al t!l%!r#rii e"resive !/oare /i +o erate3 ac!t# cGt /i @( tera"ia e @(tre)i(ere /i "ro$ilactic#4 R&7 Utilizarea tera"iei i(ter"erso(ale @( trata+e(t!l a+%!latori! al t!l%!r#rii e"resive !/oare /i +o erate3 ac!te cGt /i @( tera"ia e @(tre)i(ere /i "ro$ilactic#4 R&& P9L @( trata+e(t!l e"resiei !/oare la a !lt @( +e ici(a "ri+ar#4 R&6 Co(silierea ca +o alitate e trata+e(t a e"resiei !/oare @( +e ici(a "ri+ar#4
A 9
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I( trata+e(t!l e"resiei !/oare /i +o erate3 i(terve()iile "sihologice $!r0 (izate e "sihologi acre ita)i re"rezi(t# o alter(ativ#4 I(tre $ar+acotera"ie /i "sihotera"ie (! s!(t i$ere()e +aHore @( ceea ce "rive/te e$icie()aD alegerea !(eia i(tre ele tre%!ie s# se %azeze "e criterii "rec!+ "reze()a co(trai( ica)iilor3 acces!l la trata+e(t /i "re$eri()ele "acie()ilor4 8<Ia Psihotera"ia s0a ove it !til# /i @( co+%i(a)ie c! tera"ia +e ica+e(toas# crescG( co+"lia()a4 88Ia Asocierea se reco+a( # @( e"resiile cro(iceD (! s0a! e+o(strat %e(e$icii @( caz!rile !/oare sa! +o erate (o(cro(ice4 6??Ia &77III Trata+e(t!l "sihologic "e(tr! e"resie este $recve(t reco+a( at /i !"# e/ec!l +e ica)iei4 &7&Ia Meto ele "sihotera"e!tice c!"ri( : &4 tera"ia cog(itiv co+"orta+e(tal# NTCCO 64 tera"ia i(ter"erso(al# NTIPO =4 tera"ia "ri( rezolvarea "ro%le+elor N.Pro%le+ solvi(g thera"-J0 P9LO ?4 co(silierea >4 "sihotera"ia "siho i(a+ic# e sc!rt# !rat# '4 tera"ia "sihologic# e sc!rt# !rat# ;4 tera"ia e c!"l! <4 tera"ia co+"orta+e(tal#4 '<IL Di(tre acestea3 "ri+ele ? co(stit!ie +eto e a caror e$icie()# a $ost ove it#4 Liste ale "sihotera"e!)ilor c! li%er# "ractic# i( Ro+G(ia "ot $i g#site "e site0!rile Fe era)iei Ro+G(e e Psihotera"ie NN htt":55FF F4"sihotera"ie4ro5O /i Colegi!l!i Psihologilor i( Ro+G(ia Nhtt":55FF F4co"si4ro5O4 I4 TERAPIAC2GNITIL C2MP2RTAMENTAL NTCCO TCC este o i(terve()ie "sihologic# str!ct!rat# care eriv# i( +o el!l co+"orta+e(tal al t!l%!r#rilor a$ective @( care "acie(t!l: 0 cola%oreaz# c! !( "sihotera"e!t "e(tr! a i e(ti$ica ti"!rile /i e$ec0 tele gG( !rilor3 cre i()elor /i i(ter"ret#rilor as!"ra si+"to+elo r3 se(ti+e(telor /i5sa! a "ro%le+elor act!ale3 0 ezvolta a%ilit#)i e a i e(ti$ica3 +o(itoriza /i co(tracara gG( !rile3 cre i()ele /i i(ter"ret#rile legate e si+"to+ele sa! "ro%le+ele )i(t#3 0 e"ri( e a%ilit#)i a ecvate "e(tr! rezolvarea "ro%le+elo r4 '<IL
?6
CNSMF I Ghi !ri
e $a+ilie
TCC "or(e/te e la "re+isa c# gG( irea /i a!toeval!area (! s!(t oar si+"to+e colaterale ale e"resiei ci Hoac# !( rol ce(tral @( e"resoge(eza /i @(tre)i(erea ei4 TCC !r+#re/te tria a: 0 i+agi(e (egativ# es"re si(e N.s!(t i(!tilJO3 0 eval!are (egativ# a +e i!l!i a+%ia(t ostil /i rece N.(i+e(i (! +# a"reciaz#JO 0 "roiectare (egativ# a viitor!l!i N.(! voi $i $ericit (icio at#JO4 86IL Co($or+ rez!ltatelor !(ei +etaa(alize i( 67763 TCC ca /i TIP /i $ar+a0 cotera"ia "oate $i co(si erat# "ri+a li(ie e trata+e(t @( e"resia !/oar# /i +o erat# a "acie()ilor (es"italiza)i4 &7=Ia TCC "oate $i la $el e e$icie(t# ca /i +e ica)ia @( trata+e(t!l i(i)ial al e"resiei +o erate /i severeD gra !l e e$icie()# "oate e"i( e ecisiv e eA"erie()a /i eA"ertiza "sihotera"e!t!l!i4 &78I% I( ceea ce "rive/te "reve()ia rec# erii !"# re+isie3 TCC este la $el e e$i0 cie(t# ca /i $l!oAeti(aD asocierea lor (! a a !s %e(e$icii4 &&7I% Tera"ia co+0 %i(at# a $ost +ai e$icie(t# @(s# la "acie()ii vGrst(ici c! e"resie sever#4 &&&I% A(alizG( cost0e$icie()a +ai +!ltor alter(ative tera"e!tice "ri(tre care /i TCC3 s0a co(cl!zio(at ca (! eAist# i$ere()e se+(i$icative @(tre aces0 tea4 &&6I% Aceast# +eto # e tera"ie a e"resiei "are a $i +ai cost0e$icie(t# ac# este e$ect!at# @(tr0!( servici! "!%lic e s#(#tate ecGt @(tr0!(!l "ri0 vat4 &&=Ia De/i "e ter+e( sc!rt "sihotera"ia @(cl!zi( TCC a $ost +ai e$icie(t# $a)# e @(griHirile !z!ale i( +e ici(a "ri+ar#3 !"# !( a( (! a! eAistat i$e0 re()e se+(i$icative4 &&?I% Noile +o ele e "sihotera"ie "e(tr! e"resie NTCC tele$o(ic /i co+"!te0 rizatO "ot @+%!(#t#)i acces!l /i +otiva)ia "acie()ilor e a !r+a trata+e(t!l crescG( se+(i$icativ satis$ac)ia /i rez!ltatele cli(ice4 &&>I%&&'Ia II4 TERAPIAINTERPERS2NALNTIPO Tera"ia i(ter"erso(al# este o i(terve()ie "sihologic# str!ct!rat# @( care "siholog!l /i "acie(t!l cola%oreaz# "e(tr! i e(ti$icarea "ro%le+elor cheie legate e co($licte i(ter"erso(ale3 oli!3 a%ilit#)i sociale /i a e$ectelor aces0 tora as!"ra si+"to+elor /i se(ti+e(telor c!re(te "e care ca!t# s# le re !c# @(v#)G( s# le acce"te /i s# le rezolve4 La $el ca /i @( caz!l altor trata+e(te3 tera"ia i(ter"erso(al# (! "oate $i co(si erat# !( trata+e(t !(iversal "e(tr! e"resie4 &76III
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2 +etaa(aliz# "!%licat# @( 6776 arat# c# TIP ca /i TCC /i $ar+acotera"ia "oate $i co(si erat# "ri+a li(ie e trata+e(t @( e"resia !/oar# /i +o erat# a "acie()ilor (es"italiza)i4 &7=Ia U( st! i! !lterior e+o(streaz# c# TIP este o $or+# e$icie(t# e "sihote0 ra"ie "e(tr! t!l%!rarea e"resiv# /i "oate $i s!"erioar# altor $or+e e "si0 hotera"ie4 Rez!ltatele acestei cercetari arat# c#: &4 TIP este s!"erioar# TCC /i "lace%o4 64 e$ect!l TIP a $ost si+ilar c! al +e ica)iei =4 asocierea TIP c! +e ica)ia (! a a !s %e(e$icii4 St! i!l a !r+#rit e$icie()a TIP atGt @( trata+e(tele ac!te cGt /i @( cele e @(tre)i(ere /i "ro$ilactice4 &7?Ia EAist# ovezi care arat# c# TIP @+%!(#t#)e/te rela)iile i(ter"erso(ale s"re eose%ire e TCC care "are s# re !c# +ai ales risc!l a%a( o(!l!i tera"e!0 tic4 &7>III La "o"!la)ia vGrst(ic#3 asocierea TIP c! (ortri"tili(a este o alter(ativ# te0 ra"e!tic# @( s"ecial "e(tr! "reve(irea rec# erilor $ii( +ai e$icie(t# @( +e()i(erea i(tegr#rii sociale co+"arativ c! +o(otera"ia4 &7'3&7;3&7 <I% III4 TERAPIA PRIN REW2LLAREAPR29L EME L2R N.PR29LEM S2LLING THERAPRJ0 P9LO Se e$i(e/te ca o i(terve()ie "sihologic# str!ct!rat# @( care "acie(t!l /i "sihotera"e!t!l 0 i e(ti$ic# /i "rioritizeaz# "ro%le+ele "ri(ci"ale3 0 i e(ti$ic# sarci(i s"eci$ice /i $eza%ile care s# !c# la rezolvarea "ro%le0 +elor3 0 ezvolt# a"tit! i(i (ecesare "e(tr! a $ace $a)# "ro%le+elo r s"eci$ice4 '<IL P9L "oate $i a"licat# @( +e ici(a "ri+ar# e c#tre +e icii e $a+ilie sa! e asiste(te care a! %e(e$iciat e o "reg#tire s"ecial# @( acest o+e(i!4 I(tr0!( trial co(trolat ra( o+izat s0a g#sit c# P9L este la $el e e$icie(t ca a+itri"tili(a /i +!lt +ai e$icie(t# ecit "lace%o la "acie()ii c! e"resie !/oar#4 Pacie()ii a! $ost satis$#c!)i e aceast# +eto # tera"e!tic# care s0a ove it $eza%il# /i a (ecesitat (!+ai = ore /i H!+#tate4 &&<I% De/i i()ial "acie()ii a! $ost +ai @(crez#tori @( rec!"erare a "ri( tera"ie +e0 ica+e(toas# ecGt "ri( P9L e$ect!at# e asiste(te3 s0a ove it c# asocierea P9L c! +e ica)ia este e$icie(t# /i "ro !ce !( gra cresc!t e satis$ac)ie4 &&8I% Pri( co+"ararea P9L c! "sihoe !ca)ia e gr!" la a !l)ii c! e"resie
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CNSMF I Ghi !ri
e $a+ilie
!/oar# s0a e+o(strat c# a ere()a la P9L este s!"erioar#3 rata $ii( se+(i$icativ +ai sc#z!t#4 &&>I% I( +e ici(a "ri+ar# P9L este o o")i!(e tera"e!tic# /i @( "acie()ilor vGrst(ici c! e"resie !/oar#4 U( trial co(trolat ra( %licat @( 6777 arat# c# !tilizarea P9L a+elioreaz# si+"to+ele aceea/i +#s!r# ar +ai ra"i ecGt "lace%o4 &&;I%
e a%a( o( trata+e(t!l o+izat "!0 e"resiei @(
IL4 C2NSILIEREA Co(silierea este !( "roces siste+atic care o$er# i( ivi !l!i "osi%ilitatea e a eA"lora3 e$i(i3 clari$ica /i rezolva "ro%le+e3 e a l!a ecizii3 e a $ace $a)# crizelor /i e a @+%!(#t#)i rela)iile c! ceilal)i4 Este !( ter+e( ge(eric care escrie o ga+# larg# e i(terve()ii N"siho i(a+ice3 siste+ice sa! cog0 (itiv Q co+"orta+e(taleO ale !(!i co(silier care l!creaz# c! "acie()ii e o%icei @( +e ici(a "ri+ar#4 '<IL 2 +etaa(aliz# "!%licat# @( 677= co+"ar# e$icie()a co(silierii c! @(griHi0 rile !z!ale $!r(izate e +e icii e $a+ilie3 c! TCC /i c! tera"ia a(ti e"re0 siv#4 Pe ter+e( sc!rt co(silierea a ove it o e$icie()# cli(ic# +ai +are ecit @(griHirile !z!ale4 Acest rez!ltat (! s0a co($ir+at "e ter+e( l!(g4 Co(silierea "oate $i !til# ca +o alitate e trata+e(t @( +e ici(a $a+iliei "e(tr! s#(#tatea +i(tala e/i !ce la @+%!(#t#)iri +o este4 &67Ia3 &&?I%
8464 AUT20INGRIPIREAN.SELF0HELPJO
REC2MANDARE
R&= Se reco+a( # i(terve()iile e a!to@(griHire $acilitat# %azate "e tera"ie cog(itiv0co+"orta+e(tal# @( tera"ia e"resiei !/oare a a !lt!l!i
N!+eroas e "!%lica)ii e s"ecialitate arat# c# acces!l "acie()ilor la "sihote0 ra"ia ove it e$icie(t# este i$icil i( ca!za (!+#r!l! i li+itat e s"eciali/ti c! "reg#tire a ecvat# 4 I(terve()iile "sihologice +i(i+e ezvoltate +ai ales @( SUA /i c!(osc!t e @( literat!ra a(glo$o(a s!% ter+e(!l ge(eric e .sel$0hel"J ar "!tea co(stit!i o sol!)ie la "ro%le+a listelor e a/te"tare 4 9azate cel +ai a esea "e teh(ici e tera"ie cog(itiv0co+"orta+e(tal# 3 aceste i(terve()ii se a reseaz# $or+elor !/oare /i +o erate e e"resie /i a(Aietate ar /i altor "ro%le+e "si0 hiatrice "rec!+: e"e( e()a e s!%sta()e3 t!l%!r#rilor e ali+e(ta)ie3 stres!l!i
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"osttra!+atic 4 A!to0@(griHirea are la %az# o +eto # tera"e!tic # sta( ar izat# care "er+ite "ersoa(ei s# se aH!te "e si(e @(s#/i $#r# !( a"ort se+(i$icativ i( "artea tera"e!t!l!i 4 Este ese()ial @(s# ca +eto a s# $ie @()eleas# e "acie(t care s0o a"lice ast$el i( e"e( e( t N."!re5!(s!""orte sel$0hel"JO4 EAist# /i varia(ta e a!to0@(griHire $acilitat# care i+"lic# sc!rte sesi!(i s!s)i(!te e tera"e!t N.g!i e 5s!""orte sel$0hel"JO4 Tera"e!)ii "ot $i atGt "sihologi cGt /i +e ici sa! asiste(te ar /i "erso(al "ara+e ical care a "ri+it "reg#tire e s"ecialitate @( acest o+e(i!4 Meto ele e sel$0hel" $olosesc o serie e +ateriale "rec!+: c#r)i ti"#rite N.%i%liotera"ieJO3 oc!+e(te "e s!"ort electro(ic3 a! io sa! vi eo "rec!+ /i "rogra+e i(teractive "e i(ter(et4 Larietatea acestor $or+e e "reze(tare @(cearc# s# satis$ac# "re$eri()ele "acie()ilorD %i%liotera"ia ra+G(e @(s# cea +ai !tilizat#4 C#r)ile e sel$0hel" s!(t $oarte "o"!lare /i se a$la a esea @( to"!rile vG(z#rilor4 Se a"reciaz# c# @( SUA a"ar a(!al circa 6777 e ast$el e +ateriale4 Foarte "!)i(e i(tre ele s!(t @(s# veri$icate "ri( st! ii /i e$i0 cie()a lor ove it#4 N! @( !lti+!l rG( tre%!ie s!%li(iat c# +aterialele e sel$0hel" s!(t i$erite e cele care a! re"t sco" e !ca)ia "acie()ilor4 2%iectivele i(terve()iilor e sel$0hel" s!(t tera"e!tice /i3 eci3 i$erite e e !ca)ia "acie()ilor care0/i "ro"!(e (!+ai i($or+area acestora c! "rivire la %oal# /i acest l!cr! tre%!ie av!t @( ve ere e cei care "ro !c ast$el e +ate0 riale ar /i e cei care le reco+a( #4 &66III '<IL Este .sel$0hel"J e$icie(t @( tratarea e"resieiM St! iile as!"ra acestei +eto e tera"e!tice a! relevat c#: 0 sel$0hel" (! a a !s %e(e$icii "acie()ilor e "e lista e a/te"tare4 &6=I% 0 @( +e ici(a "ri+ar# se "ot i+"le+e(ta servicii e sel$0hel" $acilitat e asiste(te s"ecial "reg#tite4 &6&I% 0 %i%liotera"ia %azat# "e TCC este !til# "e(tr! !(ele "ersoa(e cG( se o$er# /i $acilitare a i)io(al# Ng!i e sel$0hel"O4 &6?3&6 >Ia 0 "rogra+ele e sel$0hel" a +i(istrate "ri( i(ter(et ar tre%!i i(cl!se @(tre varia(tele e trata+e(t "e(tr! e"resia !/oar# /i +o erat#4 &6'3&6; I% Co(cl!zia ge(eral# a a!torilor este ca s!(t (ecesare st! ii s!"li+e(tare @( +e ici(a "ri+ar# "e(tr! a i(vestiga cost0e$icie()a sel$0hel" ca /i cea +ai "otrivit# $or+# /i "reze(tare a +aterialelo r4 I( Ro+G(ia (! a! "!t!t $i i e(ti$icate "rogra+e e "reg#tire a tera"e!)ilor @( aceast# +eto # /i (ici +ateriale a resate "acie()ilor4
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CNSMF I Ghi !ri
e $a+ilie
84=4 TRATAMENTULFARMAC2L2GIC
REC2MANDRI
R&? D!rata $azei ac!te a trata+e(t!l!i a(ti e"resiv s# $ie e &7 0&6 s#"t#+G(i4 R&> D!rata $azei e co(ti(!are a trata+e(t!l!i a(ti e"resiv s# $ie e cel "!)i( ' l!(i !"# re+isi!(ea e"iso !l!i e"resi v4 R&' Trata+e(t e @(tre)i(ere (!+ai la "acie()ii care "rezi(t# $actori e risc "e(tr! rec!re()#4 R&; D!rata $azei e @(tre)i(ere a trata+e(t!l! i a(ti e"resiv s# $ie e 6 a(i la "acie()ii care a! "reze(ta t 6 sa! +ai +!lte e"isoa e e"resive @(so)ite e t!l%!rare $!(c)io(al# se+(i$icativ#4
A C C C
Me ica)ia a(ti e"resiv# este !tilizat# e "este "atr!zeci e a(i @( trata0 +e(t!l e"resiei e/i +eca(is+ele e ac)i!(e s!(t @(c# i(co+"let @()elese4 Cercet#rile s0a! $ocalizat as!"ra "ert!r%#rilor @( (e!rotra(s+isia cere%ral# /i a +eca(is+elor care +e iaz#3 la (ivel cel!lar3 +o i$ic#rile "e ter+e( l!(g care se "ro !c @( $!(c)io(area (e!ro(ilor s!% ac)i!(ea a(ti e"resivelo r4 Te( i()a act!al# @( trata+e(t!l t!l%!r#rii e"resive +aHore este aceea e sta( ar izare4 Se i$ere()iaz# ast$el: trata+e(t!l e"iso !l!i ac!t /i trata+e(0 t!l e @(tre)i(ere4 &6<IL Pe(tr! o +ai %!(# @()elegere3 1!"$er /i cola%oratorii &8; a! i+agi(at !r+#0 toarea sche+a care s!r"ri( e evol!)ia s!% trata+e(t a t!l%!r#rii e"resive:
Dup: Kupfer DJ: Long-treatment of depression. J Clin Psychiatry 1991: !"#uppl$:!%-&'
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$aza ac!t#: are ca sco" @(l#t!rarea t!t!ror si+"to+elor /i se+(elor e"iso !l!i e"resiv c!re(t /i rei(tegrarea "sihosocial# /i oc!"a)io(al# a "acie(t!l!i Nre+isiaO4 Re+isia Na%se()a si+"to+elor (ecesare iag(os0 tic!l!iO "oate s!rve(i s"o(ta( sa! c! trata+e(t4 ac# starea "acie(t!l!i se @+%!(#t#)e/te se+(i$icativ3 chiar ac# (! s0a re+is co+"let3 se eclar# c# "acie(t!l a r#s"!(s la trata+e(t4 R#s"!(s!l la trata+e(t ese+(eaz# o a+eliorare c! cel "!)i( >7Y a si+"to+atologiei e"re0 sive @(so)it# e o @+%!(#t#)ire +o erat# a st#rii ge(erale4 &6<IL Trata+e(t!l a(ti e"resiv @( $aza ac!t# ar tre%!i sa $ie a"licat o "erioa a e ti+" s!$icie(t e l!(g# "e(tr! a "er+ite eval!area r#s"!(s!l!i "acie(t!l!i Nsa! li"sa r#s"!(s!l!i O4 Trata+e(t!l este co(si erat e$icie(t3 ac# !"# ?0' s#"t#+G(i e tera"ie +e ica+e(toas# sa! '0< s#"t#+G(i e "sihotera"ie3 a"are cel "!)i( !( r#s"!(s "ar)ial N e$i(it re"t o sc# ere a severit#)ii si+"0 to+elor c! 6>0?8YO4 U( trata+e(t c! a(ti e"resive ti+" e &70&6 s#"0 t#+G(i eter+i(# @( ge(eral o re+isie a si+"to+elo r3 e/i o e"li(# @(s#(#0 to/ire a $!(c)iilor "sihosociale (ecesit# +ai +!lt ti+"4 <<IL Acest l!cr! este s!s)i(!t e rez!ltatele !(!i trial co(trolat ra( o+izat care e+o(streaz# i+"orta()a eAti( erii "erioa ei e trata+e(t "e(tr! e"resie "este < s#"t#+G(i4 I( acest st! i! +ai +!lt e H!+#tate i(tre "acie()ii care (! a! r#s"!(s la trata+e(t !"# < s#"t#+G(i3 a! o%)i(!t re+isia !"# 6? e s#"t#+G(i4 &68I% Dac# "acie(t!l arat# !( r#s"!(s "ar)ial la trata+e(t !"# ?0' s#"t#+G(i3 acela/i trata+e(t ar tre%!i s# $ie co(ti(!at @(c# ?0' s#"t#+G(i4 Dac# "acie(0 t!l (! r#s"!( e eloc Nsc# erea s!% 6>Y a severit#)ii si+"to+elorO ti+" e ' s#"t#+G(i sa! r#s"!( e "ar)ial !"# &7 Q &6 s#"t#+G(i3 tre%!ie l!at# @( co(si erare alt# o")i!(e tera"e!tic#4 Nvezi algorit+ O<<IL
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CNSMF I Ghi !ri
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%O Trata+e(t!l e @(tre)i(ere Trata+e(t!l e @(tre)i(ere are ca sco" "ro$ilaAia rec!re()elor4 U( (o! e"iso Nrec!re()aO "oate s# a"ar# +ai tGrzi!3 !"# l!(i sa! a(i4 Trata+e(t!l e @(tre)i(ere va $i i( icat (!+ai @( "reze()a $actorilor e risc "e(tr! rec!re()# /i a(!+e: z "ersiste()a si+"to+atologiei rezi !ale z "reze()a rec!re()elor +!lti"le @( a(tece e(te z "reze()a ere it#)ii @(c#rcate Na(tece e(te here o0colaterale "sihiatriceO z "reze()a risc!l!i e s!ici /i a te(tativelor a(terioare z "reze()a e co+or%i it#)i severe: t!l%!rare e "erso(alitate3 a%!z e rog!ri3 a%!z e alcool z !rata +are a e"isoa elor a(terioare z "reze()a isti+iei z e%!t!l "recoce al a$ec)i!(ii /i "reze()a a cel "!)i( 6 e"isoa e a(terioa0 re4 &6<IL MaHoritatea eA"er)ilor reco+a( # co(ti(!area trata+e(t!l!i c! +e ica)ie a(ti e"resiv#: 0 ti+" e 6 a(i la "acie()ii care a! "reze(tat 6 sa! +ai +!lte e"isoa e e"resive @(so)ite e t!l%!rare $!(ctio(al# se+(i$icativ#3 '<IL 0 "e(tr! cel "!)i( !( a( ac# "acie(t!l a "reze(tat !( si(g!r e"iso e e"resie sever#3 0 "e(tr! &0= a(i la "acie()ii c! o!# e"isoa e severe3 0 "e(tr! +ai +!lt e = a(i ac# eAist# a(tece e(te e = sa! +ai +!lte ast0 $el e e"isoa e4 &=&IL S!(t trei +a(iere e r#s"!(s la a(ti e"resive: Q re+isie co+"let# N!( "roce(t sit!at @( H!r!l valorii e >7YOD Q re+isie "ar)ial# Na"roAi+ativ =7YOD Q li"sa !(!i r#s"!(s N@(tr0!( "roce(t @(griHor#tor e 67YO4 Dac# a #!g#+ la aceste ate $a"t!l c# "o"!la)ia c! care se @(tGl(e/te +e ic!l "racticia( este +!lt i$erit# e lot!rile "e care se $ac ast$el e st! ii Nco( i)ii so+atice sa! "sihiatrice co+or%i e3 t!l%!r#ri e "erso(alitate3 risc s!ici ar /4aO "!te+ "res!"!(e c# ratele e r#s"!(s la a(ti e"resive s!(t chiar +ai +ici4 Di( acest +otiv3 @( !lti+ii a(i a cresc!t gra !l e "reoc!0 "are "rivi( a/a0(!+itele $or+e rezi !ale3 reziste(te /i res"ectiv3 cele re$ractare la trata+e(t4 &6<IL
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Ca!zele reziste()ei la trata+e(t!l a(ti e"resiv: 0 iag(ostic i(corect 0 trata+e(t i(corect N"osologie i($erioar# ozei tera"e!tice3 sc!rt# e trata+e(tO 0 e$ecte sec!( are ale trata+e(telor 0 sche+# tera"e!tic# co+"licat# 0 i(terac)i!(i +e ica+e(toase 0 li"s# e e$icacitate "erce"!t# 0 co+or%i it#)i +e icale sa! "sihiatrice (e iag(osticate 0 agravare sa! si+"to+atologie rezi !al# a %olii s!%iace(te 0 (o(co+"lia()# sa! co+"lia()# e$icitar# 0 vGrst# @(ai(tat# 0 seA $e+i(i( 0 a(tece e(te e is$!(c)ie tiroi ia(# 0 a(tece e(te $a+iliale e t!l%!r#ri ale is"ozi)iei 0 stresori "sihosociali 0 "ier eri +!lti"le 0 sla%# cola%orare c! cli(icia(!l 0 stat!t socio0c!lt!ral sc#z!t 0 e"resie c! a ev#rat re$ractar# la trata+e(t4 6=<IL
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CNSMF I Ghi !ri
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Clasi$icarea a(ti e"resivelor este /i @( "reze(t !( s!%iect co(troversat atorit# i(tric#rii +eca(is+elor e ac)i!(e ale acestora4 Re)i(e+ !r+#0 toarea clasi$icare si+"li$icat#:
I(hi%itorii selectivi e reca"tare a seroto(i(ei NISRSO X X X X X X X X X X X X X X X X X Fl!oAeti(a NFl!oAi(3 Fl!ra(3 Magrila(3 Fl!oAeti(e3 Prozac O Fl!voAa+i(a NFevari(3 Fl!voAa+i(e ParoAeti(a NArTetis3 SeroAat3 ReAeti(3 PaAete(3 Pal!AetilO Sertrali(a NSerli$t3 Ase(tra3 Sti+!loto(3 Wolo$tO Citalo"ra+ NCitalora(3 Li(isa(O Escitalo"ra+ NCi"raleAO I+i"ra+i(a A+itri"tili(a NA+itri"tili(O Dezi"ra+i(a Clo+i"ra+i(a NA(a$ra(ilO Di%e(ze"i(a DoAe"i(a NDoAe"i(O 2"i"ra+ol Le(la$aAi(a N E$ecti(3 LelaAi(3 Le(la$aAi(aO Mil(aci"ra( NIAelO D!loAeti(a NC-+%altaO
A(ti e"resivele triciclice NATCO
I(hi%itori e reca"tare ai seroto(i(ei /i (ora re(ali(ei NIRSNO A(ti e"resive ati"ice
I(hi%itorii e +o(oa+i(oAi az# NIMA2O Ti+osta%ilizatoare
X X X X X X X X X X X X X X
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CNSMF I Ghi !ri
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Me ica)ia a(ti e" resiv#: oze reco+a( ate3 e$ecte sec!( a re /i i(terac)i!(i +e ica+e(toase
&4 I(hi%itorii selectivi e reca"tare a seroto(i(ei NISRSO
REC2MANDRI
I(hi%itorii selectivi e reca"tare a seroto(i(ei se reco+a( # ca +e i0 ca)ie e "ri+# li(ie @( tera"ia t!l%!r#rii e"resive: R&< Escitalo"ra+ @( oza e &7067 +g "e zi @( trata+e(t!l e"iso !l!i ac!t /i e @(tre)i(ere A R&8 Citalo"ra+ @( oza e 670?7 +g5zi @( trata+e(t!l e"iso !l!i A ac!t /i e @(tre)i(ere R67 Sertrali(a @( oza e >70677 +g5zi @( trata+e(t!l A e"iso !l!i ac!t R6& Fl!oAeti(a @( oza e 670<7 +g5zi @( trata+e(t!l A e"iso !l!i ac!t /i e @(tre)i(ere R66 ParoAeti(a @( oza e 670?7 +g5zi @( trata+e(t!l e"iso !l!i ac!t A Me ica+e(tele i( clasa ISRS i(hi%# reca"tarea seroto(i(ei la (ivel "re0 si(a"tic4 2 "arte i( re"reze(ta()ii acestei clase i(hi%# /i reca"tarea (or0 a re(ali(ei /i5sa! a o"a+i(ei4 '<IL 2 +etaa(aliz# e$ect!at# e /i cola%4 a relevat c# trata+e(t!l c! ISRS este asociat c! o @+%!(#t#)ire a si+"0 to+elor e"resiei care e%!teaz# la s$Gr/it!l "ri+ei s#"t#+G(i e trata+e(t /i co(ti(!#3 c! o rat# escresc#toare3 @(c# cel "!)i( ' s#"t#+G(i4 &==Ia Ava(taHe Co+"arativ c! celelalte clase tera"e!tice3 ISRS s!(t +ai %i(e tolerate $ii( asociate c! +ai "!)i(e e$ecte sec!( are a(ticoli(ergice3 car iotoAice3 se a0 re /i cre/tere "o( eral#4 St! iile rece(te a! relevat c# +e ica+e(tele i( clasa ISRS s!(t +ai e$icie(te ecGt cele i( clasa ATC atGt "e(tr! "acie()ii c! e"resie ti"ic# cGt /i "e(tr! "acie()ii c! si+"to+e e"resive ati"ice c!+ ar $i hi"erso+(ia3 hi"er$agia3 hi"erse(si%ilitatea /i hi"erreactivitatea a$ec0 tiv#4 <<3' <IL A +i(istrarea ISRS (! cre/te i(ci e()a %olii coro(arie(e4 &=?II%
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Aceste ava(taHe le i( ic# ca /i "ri+# li(ie @( tera"ia e"resiei4 E$ecte sec!( are De/i cele +ai $recve(te e$ecte sec!( are s!(t grea)a3 iareea /i ce$aleea3 tre%!ie av!t @( ve ere risc!l cresc!t "e(tr! s!ici /i a!to0v#t#+are eter+i0 (at e ISRS4'<IL 2 rece(zie siste+atic# care a c!"ri(s ;76 trial!ri a o%servat o cre/tere se+(i$icativ# a ratei te(tativelor e s!ici la "acie()ii care a! "ri+it ISRS atGt $a)# e "lace%o cGt /i $a)# e alte i(terve()ii tera"e!tice N+oclo%e+i 3 +a"rotili(3 +ia(seri( /i "sihotera"ieO4 A(aliza ISRS vers!s ATC (! a etec0 tat o i$ere()# a ratei te(tativelor e s!ici 4&=>Ia 2rice ast$el e risc tre%!ie "!s @( %ala()# c! e$icie()a ISRS @( trata+e(t!l e"resiei4 At!(ci ca( "rescrie !( ISRS3 cli(icia(!l ar tre%!i s# avertizeze "acie(t!l as!"ra risc!l!i "osi%il e co+"orta+e(t s!ici ar /i s#0l +o(itori0 zeze @( ea"roa"e @( "erioa a e trata+e(t i(i)ial4 &='Ia Escitalo"ra+ Escitalo"ra+!l3 cel +ai selectiv i(hi%itor e reca"tare a seroto(i(ei NISRSO is"o(i%il3 este e(a(tio+er!l 0S3 activ tera"e!tic al RS0citoalo"ra+!l!i4 Prezi(t# !( e%!t ra"i al ac)i!(ii3 e$ecte a verse @( ge(eral +i(ore /i i(ter0 ac)i!(i re !se c! alte +e ica+e(te a(ti e"resive4 &=<3&? ?I%&=;III Dozele e &7067 +g5zi s!(t e$icie(te /i %i(e tolerate la "acie()ii i( +e i0 ci(a "ri+ar# c! t!l%!rare e"resiv#4 &=83&?7 I% EAist# ovezi i(s!$icie(te as!"ra i$ere()ei e e$icie()# @(tre escitalo"ra+ /i alte a(ti e"resive @( ceea ce "rive/te r#s"!(s!l la 6 s#"t#+G(i e trata0 +e(t4 6?=Ia S!"erioritatea e$icie()ei escitalo"ra+!l!i $a)# e ceilal)i re"reze(ta()i ai clasei ISRS ar /i $a)# e IRSN Nve(la$aAi(a /i !loAeti(aO atGt @( ceea ce "rive/te r#s"!(s!l la trata+e(t cGt /i re+isia Ni(cl!siv @( "o"!la)ia c! e"re0 sie sever#O a $ost relevat# @(s# e alte +etaa(alize4 &?&3&8< Ia La "acie()ii c! e"resie sever# escitalo"ra+!l @( oze e &7067 +g5zi a $ost s!"erior "aroAeti(ei @( oze e 670?7+g5zi la s$Gr/it!l "erioa ei trata0 +e(t!l!i e @(tre)i(ere ar /i @( trata+e(t!l e l!(g# !rat#4 A+%ele "ro0 !c @( egal# +#s!r# is$!(c)ie seA!al# ar si+"to+ele isco(ti(!it#)ii trata0 +e(t!l!i s!(t +ai i+"orta(te la "aroAeti(#4 Rata total# e re(!()are la trata0 +e(t "e(tr! "acie()ii trata)i c! escitalo"ra+ N&8YO a $ost se+(i$icativ +ai +ic# ec#t "e(tr! "aroAeti(# N=6YO4 &?63&?= I%
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CNSMF I Ghi !ri
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St! iile care co+"ar# escitalo"ra+!l c! ve(la$aAi(a arat# c# escitalo"ra0 +!l este: 0 se+(i$icativ +ai %i(e tolerat la ozele +aAi+e reco+a( ate N67 +g5zi3 res"ectiv 66> +g5ziO &??3&? >I% 0 res"o(sa%il e o rat# +ai +ic# a e$ectelor a verse /i a si+"to+elor e !rge()# &?>I% 0 +ai ra"i @( o%)i(erea re+isiei s!s)i(!te &?>I% 0 +ai ie$ti(4 &?'I% Escitalo"ra+!l este %i(e tolerat /i @( trata+e(t!l e l!(g# !rat#4 &68I% T!l%!rarea e"resiv# este o a$ec)i!(e rec!re(t# care (ecesit# $recve(t +e()i(erea !(!i trata+e(t a(ti e"resiv e !rat#4 Escitalo"ra+!l /i0a ar#tat e$i0 cie()a atGt @( trata+e(t! l i(i)ial cGt /i @( cel e @(tre)i(ere al t!l%!r#rii e"re0 sive4 Trata+e(t!l e @(tre)i(ere c! escitalo"ra + a $ost %i(e tolerat /i a re !s se+(i$icativ risc!l e rec!re()# a e"resiei4 Pacie()ii c! "!)i(e si+"to+e rezi !ale !"# "erioa a e co(ti(!ar e a trata+e(t!l! i c! escitalo"ra + a! "reze(tat o rat# @(alt# e rec!re()# a e"resiei ca( li s0a schi+%at trata+e(0 t!l c! "lace%o 3 e+o(strG( (ecesitate a !(ei tera"ii e @(tre)i(ere a t!l%!r#rii e"resive rec!re(te !"# cele ?0' l!(i @( care s0a o%)i(!t re+isia i(i)ial# a si+"to+elo r3 chiar ac# s!(t "reze(te "!)i(e si+"to+e rezi !ale 4 &?;3&?< I% Citalo"ra+ Citalo"ra+!l este o +iAt!ra race+ic# a s0citalo"ra+ /i r0citalo"ra+4 '<IL De/i citalo"ra+!l este !( +e ica+e(t a(ti e"resiv c! e$icie()# ove it#3 la $el e %i(e tolerat3 %e(e$iciile sale s!(t i($erioare escitalo"ra+!l!i @( trata+e(t!l t!l%!r#rii e"resive +o erat# s"re sever#3 "e to)i "ara+etrii e a"reciere a e$icacit#)ii4 &?83&> 7III De ase+e(ea3 e$ect!l citalo"ra+!l!i se i(staleaz# +ai le(t ecGt la escitalo"ra+4 &=<I% Doza e 670?7 +g5zi citalo"ra+ este %i(e tolerat# /i este e$icie(t# @( "re0 ve(irea rec!re()ei t!l%!r#rii e"resive @( trata+e(t!l e l!(g# !rat#3 i(cl!0 siv la vGrst(ici4 &683&> &I% Datorit# car iotoAicit#)ii +ai re !se3 citalo"ra+!l Nca /i sertrali(aO ar tre0 %!i co(si erat ca "ri+a li(ie @( trata+e(t!l %olii e"resive la "acie()ii c! %oal# coro(aria(#4 &>6I% Citalo"ra+!l a $ost @( +o clar asociat c! !( risc +ai +ic e s!ici @( co+"ara)ie c! ve(la$aAi(a3 $l!oAeti(a /i othie"i(!l4 &>=II%
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Sertrali(a Trata+e(t!l c! sertrali(# @( oze e >70677 +g5zi s0a ove it e$icie(t @( e"resie4 2 +etaa(aliz # "!%licat# @( 6778 a evi e()iat c# sertrali(a este +ai e$icie(t# @( trata+e(t!l $azei ac!te a e"iso !l! i e"resiv ecGt $l!oAeti(a /i +ai %i(e tolerat# ecGt a+itri"tili(a3 i+i"ra+i(a 3 "aroAeti( a /i +irtaza"i(a 4 Acela/i st! i! arat# c# sertrali(a este @(s# +ai "!)i( e$icie(t# ecGt +irtaza"i( a /i +ai r#! tolerat# ecGt %!"ro"io(a 4 Cea +ai $recve(t# reac)ie a vers# se+(alat# @( ti+"!l trata+e(t!l! i c! sertrali(# a $ost iareea4 6?7Ia&'<I% Co+"arG( e$icie()a sertrali(ei c! alte a(ti e"resive e ge(era)ia a o!a la < s#"t#+G(i e trata+e(t3 o alt# +etaa(aliz# rece(t# N6778O g#se/te c# aceasta este +ai e$icie(t# ecGt $l!oAeti(a /i alte ISRS0!ri ca /i clas#4 Fa)# e celelalte a(ti e"resive (oi3 sertrali(a "rezi(t# !( ava(taH co(siste(t ar (ese+(i$icativ statistic4 A!torii co(cl!zio(eaz# c# sertrali(a ar "!tea $i !( ca( i at @( tera"ia e "ri+# i(te()ie @( e"resie4 6?&Ia La vGrst(icii c! e"resie3 o oz# zil(ic# $leAi%il# e >7 Q &77 +g sertrali0 (# a $ost +ai e$icie(t# /i +ai %i(e tolerat#3 e/i (! s0a i e(ti$icat o i$ere()# i+"orta(t# $a)# e "lace%o !"# < s#"t#+G(i e trata+e(t &><I% La "acie()ii c! %oal# coro(aria(# asociat# e"resiei3 a +i(istarea e ci0 talo"ra+ sa! sertrali(# ar tre%!i co(si erat# ca "ri+a o")i!(e e trata+e(t4 &>6 I% A(alizG( rez!ltatele !(!i trial cli(ic ra( o+izat3 /i cola%oratorii a! co(0 statat c# sertrali(a $olosit# @( oz# tera"e!tic# (! o$er# o "rotec)ie se+(i0 $icativ# @+"otriva rec!re()ei e"resiei4 &>8I% Fl!oAeti(a Fl!oAeti(a3 "ri+!l ISRS !tilizat3 are e$ecte re !se as!"ra altor (e!rotra(s0 +i)#tori /i este %i(e a%sor%it# !"# a +i(istrarea oral# ati(gG( o co(ce(0 tra)ie "las+atic# +aAi+# !"# '0< ore4 Are !( ti+" e @(H!+#t#)ire e &0 ? zile @( ti+" ce +eta%olit!l s#! activ3 (or$l!oAeti(a3 are !( ti+" e @(H!0 +#t#)ire e ;0&7 zile4 Aceast# caracteristic# "roteHeaz# @+"otriva (o(co+0 "lia()ei s"ora ice "rec!+ /i @+"otriva $e(o+e(elor ce eriv# i( a%a(0 o(!l tera"e!tic4 2 rece(zie siste+atic# care a a(alizat toate st! iile releva(te a co($ir+at c# $l!oAeti(a este sig!r# /i e$icie(t# @( trata+e(t!l e"resiei3 chiar i( "ri+a s#"t#+G(# e trata+e(t4 Doza e 67 +g5zi este cea +ai $recve(t $olosit# @( trata+e(t!l e"resiei /i are !( "ro$il e sig!ra()# /i tolera()# +ai %!( $a)#
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CNSMF I Ghi !ri
e $a+ilie
e ozele +ai +ari4 &>? Ia I(tr0!( trial cli(ic +!ltice(tric3 s0a co(statat c# a +i(istrarea !(ei $or+!le e(tericQ"roteHat# e $l!oAeti(# N87 +gO3 o si(0 g!r# at# "e s#"t#+G(#3 ti+" e 6> e s#"t#+G(i3 este e$icie(t#3 sig!r# /i %i(e tolerat# "e(tr! co(ti(!area trata+e(t!l!i e"resiei la "acie()ii care a! r#s"!(s la trata+e(t!l ac!t c! 67 +g 5zi e $l!oAeti(#4 Mo(itorizarea trata0 +e(t!l!i e l!(g# !rat# "e(tr! evi e()ierea re+isiei este i+"orta(t# i( i$ere(t e oza e a +i(istrare4 &>>I% Ava(taHe Fa)# e a(ti e"resivele triciclice3 $l!oAeti(a are !( "ro$il e sig!ra()# s!0 "erior care re !ce i(ci e()a a%a( o(!l!i tera"e!tic "recoce3 @+%!(#t#)i( ast$el co+"lia()a "acie(t!l!i3 asociat c! o e$icie()# si+ilar# as!"ra si+"0 to+elor e"resive4 Fl!oAeti(a s0a ove it a $i sig!r# /i e$icie(t# atGt la vGrst0 (ici cGt /i la gravi e chiar i( "ri+!l tri+estr! e sarci(#D +ai +!lt3 ea (! a $ost asociat# c! !( risc s!ici ar cresc!t4 &>? Ia St! i!l !(ei cohorte e &>=87 "acie()i e"resivi c! o !rat# +e ie e !r+#rire e =3? a(i a relevat c# !tilizarea $l!oAeti(ei a $ost asociat# c! cel +ai sc#z!t risc s!ici ar @( co+"ara)ie c! celelalte +e ica+e(te i( clasa ISRS4 &>'II% E$ecte sec!( are I(ci e()a e$ectelor a verse e ti" coli(ergic N!sc#ci!(ea g!rii3 co(sti"a)ie3 t!l%!r#ri e ve ereO "rec!+ /i a altor e$ecte a verse Nso+(ole()#3 se are3 a+e)eal# /i "arestezii O este +ai +are la "acie()ii trata)i c! ATC ecGt la cei trata)i c! $l!oAeti(# @( oz# e 67 0<7 +g5zi4 E$ectele sec!( are +ai $recve(t @(tGl(ite !"# a +i(istrarea e $l!oAeti(# s!(t: is$!(c)ia seA!al#3 ce$aleea3 grea)a3 i(so+(ia3 iareea3 a(oreAia /i ri(ita3 aceste e$ecte is"#rG( @( ge0 (eral !"# 6 s#"t#+G(i e a +i(istare3 e/i3 ca /i la alte a(ti e"resive3 is0 $!(c)ia seA!al# "oate "ersista4 U(ele i(tre e$ectele a verse N(ervozitate3 tre+or3 a+e)eal#3 is"e"sieO s!(t +ai rar @(tGl(ite la oza e (!+ai 67 +g5zi4 &>? Ia ParoAeti(a Este !( a(ti e"resiv i( clasa ISRS !tilizat @(c# i( &8864 De/i "rescris $recve(t3 "aroAeti(a N?7+g5ziO este +ai "!)i( e$icie(t# ecGt escitalo"ra+ 67+g5zi @( trata+e(t!l e l!(g# !rat# al "acie()ilor c! e"resie sever#3 rata total# e re(!()are la trata+e(t "e(tr! "acie()ii trata)i c! escitalo"ra+ N&8YO $ii( se+(i$icativ +ai +ic# ecGt "e(tr! "aroAeti(a N=6YO4 Ci rata e re(!()are atorit# e$ectelor a verse la escitalo"ra+ este se+(i$icativ +ai
Ghi !ri
e $a+ilie I CNSMF
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+ica N<YO $a)# e "aroAeti(# N&'YO4 N! a! $ost i$ere()e se+(i$icative ale i(ci e()ei e$ectelor a verse i( ivi !ale "e !rat# trata+e(t!l!i4 &?=I% U( trial co(trolat ra( o+izat @( care =6= e "acie()i a! "ri+it trata+e(t !%l!0or% ti+" e < s#"t#+G(i Ncel "!)i( o oz# $leAi%il# e escitalo"ra+3 &7067+g5zi3 sa! "aroAeti(#3 670?7+g5ziO a relevat o @+%!(#t#)ire @( s#"0 t#+G(a < @( a+%ele gr!"e e trata+e(t3 $#r# i$ere()e statistice @(tre gr!"e4 La "acie()ii c! e"resie sever#3 "aroAeti(a a $ost i($erioar# escitalo"ra+!l!i @( s#"t#+G(a 6; Ns$Gr/it!l "erioa ei trata+e(t!l!i e @(tre)i(ereO4 I( st! i!l +ai s!s a+i(tit s0a i e(ti$icat o "revale()# @(alt# a is$!(c)iilor seA!ale @( "erioa a trata+e(t!l!i e atac c! "aroAeti(#D aceasta a sc#z!t !/or s!% valorile i(i)iale s"re s$#r/it!l "erioa ei e @(tre)i(ere4 I( "erioa a @(trer!"erii /i re !cerii tre"tate a trata+e(t!l!i3 "acie()ii i( gr!"a "aroAeti(ei a! "reze(tat si+"to+e ale isco(ti(!it#)ii trata+e(t!l!i +ai i+"orta(te co+0 "arativ c! gr!"a escitalo"ra+!l!i4 &?6I% ParoAeti(a o$er# acelea/i rez!ltate @( trata+e(t!l e"resiei atGt la a +i(is0 trarea $or+ei c! eli%erare i+e iat# N"aroAeti(a IRO "este ?7 +g5zi cGt /i a $or+ei c! eli%erare co(trolat# N"aroAeti(a CRO "este >7 +g "e zi4 A+%ele $or+e re"rezi(t# trata+e(te e$icie(te /i %i(e tolerate "e(tr! t!l%!rarea e"resiv# la "acie()ii @( vGrst#3 i(cl!siv la cei c! e"resie cro(ic#4 &>;I% 64 A(ti e"resivele triciclice NATCO
REC2MANDARE
R6= Se reco+a( # ATC @( oze e ;> 0 &77 +g5zi @( tera"ia e"resiei ca +e ica)ie e a o!a i(te()ie4
Clasa ATC se $olose/te @( trata+e(t!l e"resiei e "este ?7 e a(i4 Toti re"reze(ta()ii acestei clase "ro !c %locare (ora re(e rgic# sa! seroto(i(er0 gic# ar i$er# @(tre ei "ri( selectivitatea lor: clo+i"ra+i( a are e$ect "ri+ar e %locare seroto(i(e rgic# iar i+i"ra+i( a Q (ora re(e rgic#4 ATC s!(t !ti0 lizate a esea /i @( a$ec)i!(i care (! "rezi(t# i( ica)ii s"eci$ice N !reri (e!0 ro"ateO4 &'7III Trata+e(t!l tre%!ie @(ce"!t c! oze +ici care se cresc tre"tat4 La +!l)i "acie()i (! se "ot ati(ge ozele tera"e!tice atorit# i(tolera()ei Nvezi /i ta%el!l c! oze /i e$ecte sec!( areO4 '<IL La a !l)ii c! e"resie este H!sti$icat trata+e(t!l c! oze +ici e ATC N;>
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CNSMF I Ghi !ri
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0 &77 +g5zi e i+i"ra+i(#3 a+itri"tili(#3 clo+i"ra+i(#3 esi"ra+i(#3 oA0 e"i(#3 os!le"i(#3 tri+i"ra+i(# sa! lo$e"ra+i(#O eoarece are o e$icie()# co+"ara%il# c! ozele +ai +ari e &77 +g5zi /i eter+i(# o rat# +ai re !s# a a%a( o(!l!i tera"e!tic atorat e$ectelor a verse4 &'&Ia EAist# st! ii care s!s)i( c# i+i"ra+i( a ar "!tea $i !( trata+e(t cost0e$i0 cie(t s!"erior $l!oAeti(ei @( "ri+ele ' s#"t#+G(i e trata+e(t la "acie()ii c! t!l%!rare e"resiv#3 @( +e ici(a "ri+ar#4 &'6I% ATC s!(t e$icie(te la "acie()ii c! e"resie sever# care (ecesit# s"italizare4 &'=Ia De ase+e(ea a(ti e"resivele triciclice re"rezi(t# o %!(# alter(ativ# @( sarci(# /i al#"tare e/i ISRS co(stit!ie "ri+a alegere tera"e!tic#4 &'?IL E$ecte sec!( are ATC "ot eter+i(a (!+eroase e$ecte sec!( are atorate %loc#rii !(or rece"tori +!lti"li4 Ele "ro !c e$ecte sec!( are a(ticoli(e rgice Ng!r# !scat#3 co(sti"a)ie3 rete()ie !ri(ar#3 tra(s"ira)ii3 t!l%!r#ri e ve ereO3 se are /i hi"o0 te(si!(e ortostatic#4 Aceste e$ecte sec!( are "ot co( !ce la o co+"lia()# sc#z!t# /i la $olosirea !(or oze s!%o"ti+ale4 C! eAce")ia lo$e"ra+i(ei3 @( oze +ari3 toate ATC s!(t toAice "ro !cG( crize co(v!lsive /i arit+ii4 S!"ra ozele "ot $i letale4 '<IL EAist# ovezi care arat# c# ATC eter+i(# /i o rat# cresc!t# a %olii ische0 +ice coro(arie(e4 De eAe+"l!3 s0a co(statat c# "acie()ii care a! "ri+it a(terior os!le"i( a! av!t o rat# se+(i$icativ cresc!t# a %olii ische+ice car0 iace4 Mai +!lt3 cre/terea c#tre oza +aAi+# e os!le"i( a $ost asociat# c! cre/terea ratei "e(tr! %olile car iace ische+ice4 I( schi+%3 (! s0a i e(0 ti$icat o cre/tere se+(i$icativ# a acestor a$ec)i!(i "e(tr! a+itri"tili(a3 lo$e0 "ra+i(a /i ISRS4 &=?II% St! iile a! evi e()iat o "ro"or)ie +ai +are e a%a( o( la trata+e(t!l c! ATC chiar +o i$icate Nlo$e"ra+i(aO ceea ce co(stit!ie !( arg!+e(t @( "l!s @( $avoarea !itiliz#rii e ISRS4 &'>3&' 'I% Schi+%area trata+e(t!l!i "acie()ilor e"resivi e "e ATC "e ISRS eter+i(# @+%!(#t#)irea rez!ltatelor "ri( sc#0 erea i(ci e()ei @(trer!"erii trata+e(t!l!i $ar+acologic e c#tre "acie()i3 +e()i(G( @( +are acelea/i cost!ri ge(erale ale @(griHirii s#(#t#)ii4 &';III I( ceea ce "rive/te cre/terea ratei te(tativelor e s!ici 3 a(aliza ISRS vers!s ATC (! a etectat o i$ere()# a ratei te(tativelor e s!ici 4 &=>Ia Co(si erat re"t cel +ai !tilizat ATC3 a+itri"tili(a N>70&>7+g5ziO este la $el e e$icie(t# ca /i sertrali(a ar +ai "rost tolerat#4 &'<I% Co+"arativ c! ve(la$aAi(a3 rata e r#s"!(s la a+itri"tili(# este si+ilar# ar reac)iile a 0
Ghi !ri
e $a+ilie I CNSMF
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verse s!(t +ai $recve(te4 Cele +ai +!lte @(trer!"eri e trata+e(t a+itri"tili(ei a! $ost atorate !sc#ci!(ii g!rii4 &'8I%
i( gr!"!l
Ne$azo o( a este !( a(ti e"resiv triciclic e ge(era)ia a o!a c! e$ecte se ative /i a(Aiolitice4 U( trial cli(ic "lace%o co(trolat a evi e()iat e$icie()a /i sig!ra()a !tiliz#rii (e$azo o(ei @( "reve(irea rec!re()ei la "acie()ii c! e"resie cro(ic#4 Ne$azo o(a @( oz# tera"e!tic# N+aAi+ '77 +g5ziO este %i(e tolerat# /i re"rezi(t# o tera"ie e co(ti(!are e$icie(t# "e(tr! $or+ele cro(ice ale t!l0 %!r#rii e"resive4 Di(tre e$ectele sec!( are3 la "acie()ii trata)i c! (e$azo o(#3 so+(ole()a a $ost se+(i$icativ +ai $recve(t# N&>3?YO @( co+"ara)ie c! "lace%o N?3'YO4 &;7I% =4 I(hi%itorii e reca"tare ai seroto(i(ei /i (ora re(ali(ei NIRSNO
REC2MANDRI
R6? Le(la$aAi(a @( oze e ;> 0 66> +g5zi @( tera"ia e"resiei ca +e ica)ie e a o!a i(te()ie4 R6> Mil(aci"ra( @( oze e &770&>7 +g5zi @( tera"ia e"resiei ca +e ica)ie e a o!a i(te()ie4 R6' D!loAeti(a @( oze e ?70&67 +g5zi @( tera"ia e"resiei ca +e ica)ie e a o!a i(te()ie4
A 9 A
IRSN re"rezi(t# o clas# (o!# e +e ica+e(te a(ti e"resive c! ac)i!(e !al# i( care $ac "arte: ve(la$aAi(a3 +il(aci"ra(!l /i !loAeti(a4 Co($or+ rez!ltatelor !(ei +etaa(alize "!%licate @( 677;3 e$icie()a tera"e!tic# a acestora "are s# $ie co+"ara%il# c! a ISRS4&88Ia Le(la$aAi(a Le(la$aAi(a este !( i(hi%itor (eselectiv e reca"tare a seroto(i(ei care i(hi%# e ase+e(ea reca"tarea (ora re(e rgic#4 &??I% U(ele st! ii a! e+o(strat c# ve(la$aAi(a re"rezi(t# !( trata+e(t e$icace /i sig!r "e(tr! t!l%!rarea e"resiv#4 U( trial co(trolat ra( o+izat a relevat c# a +i(istrarea ve(la$aAi(ei c! eli%erare "rel!(git# @( oze e ;>066>
'7
CNSMF I Ghi !ri
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+g5zi este o tera"ie e co(ti(!are e$icie(t# /i sig!r#4 Ratele e rec# ere la = /i ' l!(i a! $ost e &8 /i 6<Y "e(tr! ve(la$aAi(#3 res"ectiv ?? /i 6<Y "e(0 tr! "lace%o4 &;&I% I(tr0o +etaa(aliz# "!%licat# @( 67763 s0a g#sit c# ve(la$aAi(a "rezi(t# o e$icie()# +ai +are $a)# e ISRS4 I( ra"ort c! alte a(ti e"resive3 s!"eriori0 tatea e$icie()ei este i(cert#4 Aceast# +etaa(aliz# (! $ace re$erire @(s# /i la escitalo"ra+4 &;6Ia Co($or+ alt!i st! i!3 ve(la$aAi(a @( oze e ;>0&>7 +g a $ost la $el e e$i0 cie(t# ca a+itri"tili(a la "acie()ii c! t!l%!rare e"resiv# +o erat# trata)i @( a+%!latori!4 Le(la$aAi(a a ca!zat +ai "!)i(e reac)ii a verse iar a%a( o(!l tera"e!tic a $ost +ai rar4 &'8I% Li+itele tera"iei c! vela($aAi(# s!(t "recizate e (!+eroase st! ii: 0 tolera()a sc#z!t# $a)# e escitalo"ra+ /i e celelalte IRSN eoarece co+0 %i(# e$ectele a verse seroto(i(e rgice Ngrea)#3 co(sti"a)ie /i tra(s"ira)ii a%!(0 e(teO c! $e(o+e(ele car iovasc!lare e"e( e(te e oz# N+ai ales hi"erte(si!(e arterial#O &??3&?>3 &;=I%3 67=III 0 cre/terea risc!l!i s!ici al &;?Ia &>=3 &>' II% 0 cost!ri cresc!te4 &?'I%&;>II% AvG( @( ve ere aceste ezava(taHe ca /i (!+#r!l +are e st! ii ce reco0 +a( # alte s!%sta()e @( tera"ia e"resiei3 ve(la$aAi(a (! "oate $i reco+a(0 at# @( trata+e(t!l e "ri+# li(ie al t!l%!r#rii e"resive @( +e ici(a "ri0 +ar#4 Mil(ac i"ra(! l AvG( ac)i!(e !al# s"eci$ic# clasei3 +il(aci"ra(!l este ove it e$icie(t @( trata+e(t!l e"resiei +o erate /i severe4 677II% Acest +e ica+e(t este +ai %i(e tolerat ecGt a(ti e"resivele triciclice3 avG( +ai "!)i(e e$ecte sec!( are /i @(registrG( o "ro"or)ie +ai +ic# a a%o( o(!l!i tera"e!tic4 67&Ia Utilizat @( oz# e &770&>7 +g5zi +il(aci"ra(!l s0a ove it e$icie(t /i %i(e tolerat @( trata+e(t!l a+%!lator e l!(g# !rat# Ncel "!)i( & a(O la "acie()ii c! t!l%!rare e"resiv#D oza e &>7 +g5zi re"rezi(t# o o")i!(e te0 ra"e!tic# reco+a( at# la "acie()ii care (! r#s"!( satis$acator la oza e &77 +g5zi4 E$ectele a verse +ai $recve(t @(registrate s!(t: grea)#3 se(za)ie e sete3 is!rie3 "al"ita)ii3 tahicar ie3 a+e)eal# /i tra(s"ira)ii4 676II% Co+"arativ c! ve(la$aAi(a3 +il(aci"ra(!l Nal#t!ri e !loAeti(#O este li"sit e e$ecte car0 io0vasc!lare4 67=III
Ghi !ri
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D!loAeti(a D!loAeti(a s0a ove it e$icie(t# @( trata+e(t!l e"resiei i( i$ere(t e gra !l e severitate al acesteia4 De/i !(ele st! ii o reco+a( # +ai ales @( caz!rile +o erate /i severe3 eAista /i st! ii care s!s)i( e$icie()a !loAeti(ei @( caz!rile e e"resie !/oar#4 67'36& 6I% D!loAeti(a este e$icie(t# atGt @( trata+e(t!l "ri+!l!i e"iso e"resiv ar /i al e"isoa elor !lterioare i( i$ere(t e !rata e"iso !l!i c!re(t "rec!+ /i @( $aza e co(ti(!are a trata+e(t!l!i4 6&&I%67;II% E$ectele a verse +ai $recve(t @(registrate s!(t: !sc#ci!(ea g!rii3 grea)a /i iareea ar acestea (! eter+i(a @(trer!"erea trata+e(t!l!i +ai $recve(t ecGt "lace%o4 67>I% I( ti+"!l trata+e(t!l!i c! !loAeti(# (! s0a @(registrat cre/terea risc!l!i e co+"orta+e(t sa! i ea)ie s!ici ar#4 &;'Ia I( ceea ce "rive/te ozele !z!ale3 oza e ?7 +g !loAeti(# "e zi are e$icie()# +i(i+#D ozele e '70&67 +g5zi s!(t e$icie(te @( tratarea e"re0 siei4 2 oz# i(i)ial# +ai +ic# e '7 +g5zi ar "!tea co( !ce c#tre o +ai %!(# tolera()# a !loAeti(ei la !(ii "acie()i4 6&7I% St! iile co+"arative e+o(streaz# @(s# c# !loAeti(a: 0 "are +ai "!)i( e$icie(t# avG( o tolera()# si+ilar# c! a ve(la$aAi(ei 6&=Ia 0 este +ai "!)i( e$icie(t#3 +ai r#! tolerat# /i +ai costisitoare ecGt esci0 talo"ra+!l4 67?367<367 8I% ?4 A(ti e"resive ati"ice Mirtaza "i(a Mirtaza"i(a este !( a(ti e"resiv i(tro !s i( &88? @( trata+e(t!l e"re0 siei +o erate /i severe4 U( trial cli(ic ra+ o+izat co( !s e /i cola%oratorii a evi e()iat c# te0 ra"ia c! +irtaza"i(# N&>0?> +g5ziO @( $aza e co(ti(!are a trata+e(t!l!i este e$icie(t# /i %i(e tolerat#4 Fa)# e "lace%o3 +irtaza"i(a re !ce rata rec# e0 rilor e"iso !l!i e"resiv c! +ai +!lt e H!+#tateD rata e @(trer!"ere a trata0 +e(t!l!i atorat# e$ectelor a verse a $ost e &&3<Y "e(tr! tera"ia activ# c! +irtaze"i(# vers!s 63>Y "e(tr! "lace%o iar cre/terea @( gre!tate e0a l!(0 g!l celor ?7 e s#"t#+G(i a $ost oar e &3? Tg4&;;I% >4 I(hi%itorii e +o(oa+i(oAi aza NIMA2O Me ica+e(tele i( aceast# clas# a! ca e$ect sec!( ar s"eci$ic .reac)ia la %rG(z#J Q criza hi"erte(siv# la i(gestia e ali+e(te care co()i( tira+i(#
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Ncare este e ase+e(ea +eta%olizat# "ri( MA2O4 Ali+e(tele /i %#!t!rile %ogate @( tira+i(# care tre%!ie evitate @( ti+"!l trata+e(t!l!i c! IMA2 s!(t: aO c! co()i(!t $oarte ri icat e tira+i(#: 0 %rG(zet!ri $er+e(tate Ns!(t "er+ise %rG(za e vaci /i %rG(za c! s+G(0 tG(#O3 0 %#!t!ri alcoolice3 @( s"ecial %ere /i vi( ro/! Neste "er+is# o ca(titate +ic# e gi(3 votc#3 FhisT- sa! lichiorO3 0 $asole3 0 "ortocale3 0 "e/te3 "!i /i car(e a$!+ate sa! +ari(ate3 cGr(a)i /i +ezel!ri co(ser0 vate3 $icat e vac# sa! "!i3 0 s!"e co(servate3 0 roH ie4 %O c! co()i(!t relativ ri icat e tira+i(#3 "er+ise (! +ai +!lt e !(a 0 o!# ori "e zi: sos e soia3 s+G(tG(#3 %a(a(e3 avoca o3 vi(ete3 "r!(e3 sta$i e3 s"a(ac3 ro/ii3 ia!rt4 Aceste restric)ii ali+e(tare vor $i i( icate (! (!+ai @( ti+"!l trata+e(t!0 l!i c! IMA23 /i @(c# o!# s#"t#+G(i !"# sistarea sa3 cG( orga(is+!l este ca"a%il s# resi(tetizeze e(zi+a MA24 Selegili(a: !tilizat# i(i)ial @( tera"ia %olii ParTi(so(3 este !( i(hi%itor selectiv 9 e +o(oa+i(oAi az# care "oate $i !tilizat /i @( trata+e(t!l e"re0 siei4 A +i(istrarea tra(s er+ic# NSTSO este "re$erat# eoarece re !ce risc!l reac)iei la tira+i(# /i "oate cre/te co+"lia()a la trata+e(t4 Dozele e '0 67+g5zi a! $ost %i(e tolerate /i e$icie(te @( +e()i(erea !(!i r#s"!(s s!s)i(0 !t la "acie()ii c! t!l%!rare e"resiv# $#r# a (ecesita restric)ii ietetice4 I( a +i(istrare tra(s er+ic#3 selegili(a ar "!tea $i o sol!)ie tera"e!tic# e l!(g# !rat#4 &<73&< 6I%&;<3&; 8III Alte e$ecte sec!( are i(cl! : rata !/or cresc!t# "e(tr! hi"ote(si!(e orto0 static#3 i(so+(ia /i cel +ai $recve(t3 reac)iile c!ta(ate la loc!l e a"licare4 N! a! $ost i e(ti$icate e$ecte se+(i$icative as!"ra gre!t#)ii sa! e$ecte sec!(0 are seA!ale4 Prezi(t# i(terac)i!(i +e ica+e(toas e c!: car%a+aze"i(a 3 ISRS3 si+"ato+i+etice i( irecte3 a(algezice N+e"eri i(aO4&;8Ia I(tr0o a(aliz# sis0 te+atic# s0a! i e(ti$icat &?> i(terac)i!(i c! se+(i$ica)ie cli(ic# +aHor#4 Acestea a! $ost @( "ri(ci"al !rge()ele hi"erte(sive /i si( ro+!l seroto(i(ic4
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Cele +ai +!lte i(tre +e ica+e(tele c! i(terac)i!(i "reze(ta! activitate "e siste+!l (ervos ce(tral NSNCO4 A/a c!+ era e a/te"tat3 IMA2 "are s# $ie $a+ilia c! cele +ai +!lte "ro%le+e @( "rivi()a "ote()ial!l!i !(or i(terac)i0 !(i +e ica+e(toase serioase4 &<&Ia Phe(elzi( e /i Moclo%e+i e : ovezile eAiste(te @( literat!r# a! evi e()iat e$i0 cie()a s!"erioar# a acestor i(hi%itori ireversi%ili e +o(oa+i(oAi az # $a)# e a(ti e"resivele triciclice @( trata+e(t!l $or+elor ati"ice e e"resie4 &<=Ia
EFECTE SECUNDAR E
ALE ANTIDEPRESILE L2R
Me ica)ia a(ti e"resiv# "oate $i asociat# c! +!lti"le e$ecte sec!( are Nvezi ta%elO i(tre care se+(i$icative s!(t !r+#toarele: Risc!l "e(tr! co+"orta+e(t s!ici ar este cresc!t @( "ri+a l!(# e la @(ce"erea trata+e(t!l!i c! a(ti e"resive3 @( s"ecial @( "ri+ele 8 zile4 Risc!l s!ici ar sa! e a!tov#t#+are (eletal# la a !l)ii trata)i c! ISRS este si+ilar celor trata)i c! ATC4 &<?3&<> II% Si( ro+!l seroto(i(ergic Nhi"er"ireAie3 agita)ie /i co($!zieO a"are la aso0 cierea ISRS @(tre ele sa! c! alte a(ti e"resive NeA: ATC /i liti!O Si( ro+!l e sevraH a"are la @(trer!"erea %r!sc# a a +i(istr#rii a(ti e0 "resivelor $ii( eter+i(at e !( re%o!( coli(ergic ar /i e i+"licarea sis0 te+elor (ora re(e rgice /i seroto(i(e rgice4 Cea +ai $recve(t# ca!z# a si( ro+!l!i e sevraH o co(stit!ie (o(0co+"li0 a()a4 I( i$ere(t e (at!ra chi+ic# a a(ti e"resivelor Ntriciclice3 ISRS3 IMA2 etc4O3 o"rirea %r!sc# !ce la a"ari)ia !(!i si( ro+ e sevraH c! $e(o+e(e e +a(i$estare @( "la( so+atic /i "sihic4 Fe(o+e(ele so+ato0$izice s!(t "oli+or$e3 c! ac!ze igestive Ngre)!ri3 v#rs#t!ri3 !reri a% o+i(ale3 iareeO3 t!l%!r#ri circ!latorii cere%rale NvertiH3 ce$alee3 t!l%!r#ri +otoriiO4 I( "la( "sihic se o%serv# $recve(t st#ri e a(Aietate3 i(so+ie3 risc cresc!t e rea"ari)ie a $e(o+e(elor e"resive +aHore3 viraHe hi"o+a(iacale sa! chiar accese +a(iacale3 iar @( caz!l sevraH!l!i IMA23 stare e co($!zie +e(tal#4 I( caz e sevraH c! $e(o+e(e severe se reco+a( # rei(tro !cerea a(ti e0 "resiv!l!i res"ectiv /i a"oi i+i(!area "rogresiv# a ozelor3 "e "aliere e "osologie escrescG( #3 %i(e +o(itorizate4 Me ica)ia a(ticoli(e rgic# "oate $i e$icie(t# "e(tr! t!l%!r#rile igestive3 !(eori $oarte era(Ha(te4 &<'III
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INTERACKIUN I
MEDICAMENT2ASE &<;III
I(terac)i!(i +e ica+e(toase ale a(ti e"resivelor A(ti e"resiv I(terac)i!(i E$ect cli(ic Fl!oAeti(a Var$ari(a Risc cresc!t e sG(gerare ATC3 car%a+aze"i(a3 $e(itoi(a Sertrali(a ATC Cre/terea co(ce(tra)iei sa(g!i(e3 c! "osi%il e$ect toAic Cre/terea co(ce(tra)iei sa(g!i(e3 c! "osi%il e$ect toAic N(!+ai la oze +ariO Risc cresc!t e sG(gerare Cre/terea co(ce(tra)iei sa(g!i(e3 c! "osi%il e$ect toAic Posi%il risc e sG(gerare Cre/terea co(ce(tra)iei sa(g!i(e3 c! "osi%il e$ect toAic U( si(g!r caz e !rge()# hi"erte(siv# Si( ro+!l seroto(i(e rgic: +o i$ic#ri ale stat!s!l!i +e(tal3 agita)ie3 +ioclo(ii3 re$leAe vii3 tra(s"ira)ii eAcesive3 tre+o r3 iaree3 li"sa coor o(#ri i 3 $e%r#D "oate a+e(i()a via)a4
ParoAeti(a
Var$ari(a ATC
Fl!voAa+i(a
Var$ari(a ATC3 theo$ili(a
Mirtaza"i(a Toate a(ti e"resivele Ni(cl!siv Citalo"ra+3 Escitalo"ra+3 Le(la$aAi(aO
Clo(i i(a 2rice +e ica+e( t care cre/te co(ce(tra)ia seroto(i(ei3 i(cl!zG( IMA23 tra+a ol si%!tra+i(a3 +e"eri i(e3 s!+atri"ta(3 lithi!+3 H-"eric!+ "er$orat!+3 gi(Tgo %ilo%a /i age()ii a(ti"sihotici ati"ici
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CLASIFICAREA ANTIDEPRESILEL2R CI
NFoo a( Drog A +i(istratio(O: A(ti e"resivele "ot cre/te risc!l Cre/te "rogresiv oza i(i)ial# !"# s!ici al la a !l)ii /i co"iii c! t!l%!0 "ri+ele ?0; zile e trata+e(t Nc! eAce")ia rare e"resiv# sa! alte t!l%!r#ri "si0 Fl!oAeti(ei care (ecesit# !( i(terval e =0 hice4 2rici(e !tilizeaz# a(ti e"r e0 ? s#"t#+G(iO4 sive tre%!ie s# "!(# @( %ala()# risc!l c! %e(e$ici!l cli(ic4 Mo(itorizeaz# c! ate(tie "acie()ii Mo(itorizeaz# "acie()ii s#"t#+G(al care "ri+esc a(ti e"resive "e(tr! o "e(tr! a a"recia e$ectele a verse "osi%il# agravare a e"resiei sa! a"ari)iei risc!l!i s!ici ar @( s"ecial /i a ere()a tera"e!tic#4 la @(ce"!t!l trata+e(t!l!i sa! cG( se cresc 5 sca ozele4
Me ica+e(t ISRS Citalo"ra+& Escitalo"ra+ Fl!oAeti(a Fl!voAa+i(a ParoAeti(a ParoAeti(a CR Sertrali(a Mil(aci"ra( Le(la$aAi(a UR D!loAeti(a 9!"ro"io( SR Mirtaza"i(a Ne$azo o(a A+itri"tili(a A+oAa"i(a Clo+i"ra+i(a Desi"ra+i(a DoAe"i( I+i"ra+i(a Ma"rotili(a Nortri"tili(a Protri"tili(a Trazo o(e Tri+i"ra+i(a
Doza
e start
Doza e$icie(t# 67 Q '7 +g5zi &7 Q 67 +g5zi 67 Q '7 +g5zi &77 Q =77 +g5zi 67 Q '7 +g5zi 6> Q '63> +g >7 Q 677 +g5zi &77 Q &>7 +g5i ;> Q 66> +g5zi '7 Q &67 +g5zi &>7 Q 677 +g %i &? Q ?> +g5zi &>7 Q '77 +g5zi &>7 +g Shs &77 Q ?77 +g &77 Q 6>7 +g5zi &77 Q =77 +g5zi &77 Q =77 +g5zi &77 Q =77 +g5zi &77 Q 66>+g5zi >7 Q &>7 +g5zi 67 Q '7 +g5zi &>7 Q '77 +g5zi &77 Q =77 +g5zi ^ 0 ^^ ^^ ^ 0 ^^^ ^ 0 ^^^ ^ 0 ^^ ^^ 0 ^^^ ^^ ^^ ^^ ^^^ ^ 0 ^^^ ^^ 0 ^^^ ^^ ^ ^^ ^^ ^ ^ ^ ^ ^ ^ ^^ ^^
7 Q 67 +g S __ &7 +g S &7 Q 67 +g S _ 6> +g %i __ &7 Q 67 +g S _ &63> Q 6> +g S 6> Q >7 +g S &77 +g5zi =;3> +g S ?7 Q '7 +g5zi ;> +g S Q ;> +g %i ;3> Q &> +g S 6> Q >7 +g %i 6> Q >7 +g Shs ___ >7 +g %i 6> Q ;> +g Shs 6> Q ;> +g Shs 6> Q ;> +g Shs 6> Q ;> +g Shs 6> Q ;> +g Shs 6> Q >7 +g Shs &> +g S >7 +g Shs 6> Q ;> +g Shs
IRSN
Ati"ice
ATC /i al)i age(ti +ai vechi
Nota: _S ] o at# "e ziD __%i ] e 6 ori "e ziD ___Shs ] o at# "e zi3 la c!lcareD _ ] st! iile evi e()iaz# o cre/tere @( gre!tate la a +i(istrarea acestor +e ica+e(teD
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Cost Relativ
N^O
Ate()io(are FDA
D2WELE REC2MANDATE LA ADULKI6=;

E$ecte a verse
7 ] a%se(te sa! rareD ? ] relative co+!(e
e co(( !cere5 a$ect
Co(trai( ica)ii
NU ] (! se reco+a( #O Risc s!ici al Ns!"ra ozele letaleO Hi"ote(si!(e ortostatic# Acci e(te vasc!lare ac!te T!l%!r#ri ale a"etit!l!i Gla!co+
SNC
I(so+(ie 5 Agita)ie A(ticoli(ergice Se are
T!l%!r#ri Gastro0I(testi(ale
Hi"ote(si!(e ortostatic#
T!l%!r#ri SeA!ale
Arit+ii
Cre/teri @( gre!tate NZ ' TgO
7 7 7 7 7 7 7 & & & 7 & & ? 6 ? & = = 6 6 6 & ?
6 6 & 6 6 & 6 & & & 7 ? 6 ? 6 0 & ? = = 6 & ? ?
6 & = 6 6 6 6 6 6 7 6 0 0 7 6 0 & 7 & 7 7 & 7 7
7 7 7 7 7 7 7 7 7 7 7 7 7 ? 6 0 6 6 ? 6 & 6 = =
7 7 7 7 7 7 7 7 & 7 & 7 7 = 6 0 6 6 = 6 6 = & =
= = = = = 6 = = = = 7 7 & & 7 0 7 7 & 7 7 7 & 7
& & 6 & = = 6 6 6 6 & & & 0 0 0 0 0 0 0 0 0 0 0
M M M M M M M 7 7 7 M = M ? 6 0 & ? ? 6 & 7 6 ?
Hi"ertro$ie %e(ig(#
e "rostat#
Car io0 Lasc!lar
Altele
coro(arelor T!l%4
A A A A
A A A A A A A A A
A A A A A A A A A A
A A A A A A A A A
A A A A A A A A A A A
A A A A A A A A A A
A A A A A A A A A A A
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Alegerea a(ti e"resiv!l!i Trata+e(t!l e "ri+# li(ie: e"i( e e "ro$il!l e$ectelor sec!( are3 e si0 g!ra()a /i tolera()a acest!ia3 e "reze()a a$ec)i!(ilor co+or%i e3 e aso0 cierile +e ica+e(toase3 e cost!ri3 e istoric!l "acie(t!l!i "rivi( r#s"!(0 s!l la a(ti e"resivele $olosite a(terior /i risc!l letal la s!"ra oz#4 Dac# "acie(t!l a r#s"!(s %i(e la !( a(!+it +e ica+e(t /i e$ectele sec!(0 are a! $ost +i(i+e3 at!(ci este "re$erat# acea +e ica)ie4 I( schi+%3 ac# "acie(t!l (! a r#s"!(s la !( trata+e(t a(terior a ecvat sa! ac# e$ectele sec!( are ale !(!i a(!+it +e ica+e(t (! a! $ost tolerate3 acea +e ica)ie ar tre%!i @( ge(eral evitat#4 <<IL Este i$icil# alegerea cel!i +ai "otrivit age(t tera"e!tic "e(tr! "acie(t4 E$icie()a /i tolera()a a(ti e"resivelo r e a o!a ge(era)ie Ncitalo"ra+3 esci0 talo"ra+3 $l!oAeti(#3 $l!voAa+i(#3 "aroAeti(# 3 sertrali(#3 +irtaza"i(# 3 %!"ro0 "io(3 !loAeti(# 3 (e$azo o(# 3 trazo o( /i ve(la$aAi(#O $a)# e a(ti e"resivele e "ri+a ge(era)ie ca /i $a)# e "lace%o este rec!(osc!t# 4 Co+"arG( a(ti e0 "resivele e a o!a ge(eratie @(tre ele3 o +etaa(aliz # "!%licat# @( 677< (! a i e(ti$icat i$ere()e s!%sta()iale @(tre e$icie()a acestora4 EAist# @(s# i$ere()e @( ceea ce "riveste e$ectele a verse /i e%!t!l ac)i!(ii iar aceste as"ecte ar "!tea re"reze(ta 3 @( o"i(ia a!torilor3 !( criteri! e alegere4 &<<Ia Rez!ltate co(tra ictorii a"ar @(s# @(tr0o +etaa(aliz# "!%licat# @( 6778 care arat# c#: 0 +irtaza"i(a3 escitalo"ra+!l3 ve(la$aAi(a /i sertrali(a a! $ost se+(i$icativ +ai e$icie(te ecGt !loAeti(a3 $l!oAeti(a3 $l!voAa+i(a3 "aroAeti(a /i re%oAeti(aD 0 re%oAeti(a a $ost se+(i$icativ +ai "!)i( e$icie(t# ecGt toate celelalte +e ica+e(te a(ti e"resive l!ate @( st! i!D 0 escitalo"ra+!l /i sertrali(a a! "reze(tat cel +ai %!( "ro$il e tolera()# co( !cG( +!lt +ai rar la @(trer!"rerea trata+e(t!l!i ecGt !loAeti(a3 $l!voAa+i(a3 "aroAeti(a3 re%oAeti(a /i ve(la$aAi(a4 EAist# i$ere()e i+"orta(te @(tre e$icie()a celor +ai "rescrise a(ti e"re0 sive4 Cele +ai e$icie(te /i %i(e tolerate s!(t escitalo"ra+!l /i sertrali(a4 S0ar "!tea ca sertrali(a s# $ie cea +ai %!(# o")i!(e e i(i)iere a tera"iei @( e"re0 sia +o erat# /i sever# eoarece "rezi(t# cel +ai %!( ra"ort @(tre %e(e$icii3 acce"ta%ilitate /i "re)!l e achizi)ie4 6?6Ia U( alt arg!+e(t i+"orta(t @( $avoarea alegerii "ri+ei li(ii tera"e!tice @l co(stit!ie cost0e$icie()a4 U( trial co(trolat ra( o+izat a st! iat cost0e$icie()a a trei clase e a(ti e0
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CNSMF I Ghi !ri
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"resive: ATC3 ATC +o i$icate Nlo$e"ra+i(aO /i ISRS ca tera"ie e "ri+# i(te()ie a t!l%!r#rii e"resive @( +e ici(a "ri+ar#4 C!r%ele e cost0e$icie()# realizate a! s!gerat c# ISRS ar $i o")i!(ea cea +ai cost0e$icie(t# /i ar tre%!i "re$erate4 &'>3&' 'I% Alegerea !(!i ISRS ar "!tea @+%!(#t#)i rez!ltatele trata0 +e(t!l!i /i "ri(tr0o "erioa # e re+isie +ai @( el!(gat#4 &8=III Utilizarea ISRS re !ce cost!rile ge(erale "e(tr! s#(#tate co+"arativ c! ATC "ri( @+%!(#t#)irea co+"lia()ei /i sc# erea (evoii e !tilizare a altor servicii e @(griHire +e ical#4 Cost0e$icie()a "ote()ial# a ISRS $a)# e ATC "oate $i co+"ro+is# e !tilizarea a(ti e"resivelor @( alte sit!a)ii +e icale ecGt e"resia4 &'7III St! iile care a! a(alizat cost!rile trata+e(t!l!i c! escitalo"ra+ co+"ara0 tiv c! re"reze(ta()i ai clasei IRSN Nve(la$aAi(a /i !loAeti(aO a! ar#tat ca escitalo"ra+!l re"rezi(t# o")i!(ea cea +ai cost Q e$icie(t#4 &??3&?'367? I% A(alizG( cost0e$icie()a celor +ai $recve(t ISRS !tiliza)i3 o cohort# e &;;& "acie()i (! a i e(ti$icat i$ere()e se+(i$icative @( "rivi()a cost!rilor totale "e(tr! @(griHirile e s#(#tate @(tre $l!oAeti(#3 "aroAeti(# /i sertrali(#D @( ceea ce "rive/te cost!rile legate strict e t!l%!rarea e"resiv#3 s0a! o%ser0 vat tot!/i i$ere()e3 cost!rile "e(tr! $l!oAeti(# $ii( +ai +ari ecGt cele "e(tr! sertrali(# sa! "aroAeti(#4 I( acest st! i! (! s0a i e(ti$icat (ici o leg#0 t!ra @(tre @(trer!"erea trata+e(t!l!i /i cost!rile cresc!te N$ie chelt!ielile totale3 $ie cost!rile legate strict e e"resieO4 &8?II% D!"# alegerea a(ti e"resiv!l!i3 trata+e(t!l se @(ce"e c! o oz# +ic# /i se cre/te "rogresiv "G(# la oza tera"e!tic#3 !r+#ri( starea +e(tal# a "acie(t!l!i /i a"ari)ia e$ectelor sec!( are4 Frecve()a +o(itoriz#rii va e"i( e e severitatea e"resiei3 risc!l e s!ici 3 coo"erarea "acie(t!l!i /i is"o(i%ilitatea s!"ort!l!i social4 <<IL Pote()area +e ica)iei a(ti e"resive: re"rezi(t# o strategie e cre/tere a e$icie()ei +e ica)iei a(ti e"resive "ri( asocieri c! alte s!%sta()e Ncare (! s!(t rec!(osc!te re"t age()i a(ti e"resiviO c!+ ar $i: lithi!3 hor+o(i tiroi0 ie(i3 %!s"iro(a sa! "i( olol4 Se !tilizeaz# @( caz!l "acie()ilor care "rezi(0 t# !( r#s"!(s sla% la oze !z!al e$icie(te e a(ti e"resive /i este "re$erat# asocierii e a(ti e"resive care este grevat# e cre/terea risc!l!i e$ectelor sec!( are4 EAist# ovezi care s!s)i( e$icie()a "ote()#rii4 De eAe+"l!3 o +etaa(aliz# a 8 trial!ri cli(ice ra( o+izate a co+"arat e$icie()a /i tolera(0 )a co+%i(a)iei "i( ol 0 ISRS vers!s "lace%o 0 ISRS4 Pi( olol "are s# accele0 reze r#s"!(s!l la ISRS @( "ri+ele 6 s#"t#+G(i ar (! /i @( i(terval!l ?0' s#"0 t#+G(i4 &<8Ia Acela/i l!cr! s0a "!t!t co(stata /i @(tr0!( trial cli(ic ra( o+i0
Ghi !ri
e $a+ilie I CNSMF
'8
zat3 !%l! or%3 "lace%o co(trolat care a relevat c# asocierea +il(aci"ra(!0 l!i N>7 +g e o!a ori "e zi O c! "i( olol N63> +g5zi O este sig!r#3 e$icie(t# /i %i(e tolerat#3 avG( re"t e$ecte sec!( are +ai $recve(t @(tGl(ite grea)a3 v#rs#t!rile3 tra(s"ira)iile /i %!$e!rile e c#l !r#4 Co+%i(a)ia +il(aci"ra( /i "i( olol re"rezi(t# o strategie ra)io(al# "e(tr! o "osi%il# accelerare ori "ote()are a acti!(ii a(ti e"resive4 &87I% Trata+e(t!l e a o!a li(ie este e$i(it ca o @(loc!ire a clasei e a(ti e0 "resive alese i(i)ial c! o alta clas#3 @( ec!rs!l "ri+!l!i a( e la iag(osti0 carea e"resiei4 I( alegerea altei clase e a(ti e"resive tre%!ie l!ate @( co(0 si erare criteriile ge(erale e(!+erate a(terior4 I( ceea ce "rive/te cost!rile3 acestea a! $ost si+ilare "ri(tre "acie()ii care a! "ri+it ve(la$aAi(#3 ISRS3 ATC sa! !( alt a(ti e"resiv @( trata+e(t!l e a o!a li(ie al e"resiei ti+" e !( a(4 &8&II% De"resia re$ractar# la trata+e(t este o "ro%le+# e s#(#tate "!%lic# i+"orta(t#3 +otiv "e(tr! care este (evoie e trial!ri +ari3 realiste care sa i($or+eze "ractica cli(ic# 4 2 rece(zie siste+atic# care a c!"ri(s &' trial!ri cli(ice ra( o+izate a ar#tat c# eAist# "!)i(e ovezi care s# ghi eze +a(0 age+e(t!l e"resiei ce (! a r#s"!(s la o c!r# e a(ti e"resive4 &86Ia
PARTICULARITKI TERAPEUTICE Pacie(t!l vGrst(ic

REC2MANDRI
R6; La "acie(t!l vGrst(ic c! e"resie !/oar# /i +e ie se reco+a( # asocierea !(!i a(ti e"resiv N e "re$erat ISRSO c! "sihotera"ie4 R6< La "acie(t!l vGrst(ic c! e"resie /i co+or%i it#)i se reco0 +a( # tratarea si+!lta(#3 e la @(ce"!t3 a t!t!ror a$ec)i!(ilor4 R68 Pe(tr! a cre/te e$ect!l tera"e!tic la "acie(t!l vGrst(ic se reco+a( # "sihotera"ie /i @(griHiri la o+icili! asig!rate e o echi"# e asiste()# co+!(itar# s"ecializat#4 R=7 Se reco+a( # la "acie(t!l vGrst(ic co(ti(!area trata+e(t!l!i c! +e ica)ie a(ti e"resiv# @( oza care a "ro !s re+isia e"iso !l!i ac!t "e(tr! cel "!)i( = a(i "e(tr! "reve(irea rec# erilo r4
C C
;7
CNSMF I Ghi !ri
e $a+ilie
De"resia vGrst(ic!l!i este o t!l%!rare $recve(t# c! co(seci()e i+"orta(te as!"ra "acie(t!l!i3 $a+iliei sale /i societ#)ii4 Pacie()ii vGrst(ici "rezi(t# o rat# cresc!t# a reziste()ei la trata+e(t /i +ortalitate ri icat# ca !r+are a !(!i co+"leA e $actori ce c!"ri( : co+or%i it#)i +e icale3 a a"tarea la +o i$ic#rile e stat!t @( $a+ilie /i societate3 eces!l celor a"ro"ia)i3 co(0 strG(gerile sociale /i stres!l i(ter"erso(al4 I(tr0o rece(zie "!%licat# @( 67763 se evi e()iaz# $a"t!l c# rec# erile "ot $i "reve(ite sa! a+G(ate at!(ci cG( "acie()ii ia! +e ica)ie a(ti e"resiv# c! oza i(i)ial# N oza (ecesar# "e(tr! a "ro !ce rec!"erarea !"# !( e"iso ac!tO "e(tr! cel "!)i( = a(i sa! chiar "e ter+e( (e e$i(it4 At!(ci cG( este "osi%il3 "e(tr! a cre/te e$ect!l ter0 a"e!tic3 "acie()ii ar tre%!i s# %e(e$icieze e ase+e(ea e "sihotera"ie /i @(griHiri la o+icili! asig!rate e o echi"# e asiste()# co+!(itar# s"eciali0 zat#4 &8>Ia MaHoritatea trial!rilor cli(ice care st! iaz# trata+e(tele a(ti e"resive c!0 "ri( "acie()i ti(eri4 Di( acest +otiv3 cli(icie(ii s!(t (evoi)i s# eAtra"oleze atele !(or st! ii e$ect!ate "e s!%iec)i care (! "rezi(t# caracteristici si+i0 lare "acie()ilor vGrst(ici4 De eAe+"l!3 "acie()ii @( vGrsta "rezi(t# a$ec)i!(i +e icale grave coeAiste(te care "ot co(tri%!i la a"ari)ia e"resiei /i care co+"lic# alegerea trata+e(t!l!i4 De reg!l#3 "acie()ii vGrst(ici (ecesit# trata+e(te c! +ai +!lte +e ica+e(te3 iar !(ele i(tre acestea "ot co(tri%!i la a"ari)ia e"resiei /i5sa! i(terac)io(eaz# c! +e ica)ia a(ti e"resiv#4 I( $i(e3 "acie()ii @( vGrsta +eta%olizeaz# +e ica+e(tele +ai le(t /i s!(t +ai se(si%ili la e$ectele a verse ecGt cei ti(eri4 U( gr!" e eA"er)i care a! ela%orat !( ghi e $ar+acotera"ie a t!l0 %!r#rilor e"resive la "acie()ii vGrst(ici a! s!%li(iat i+"orta()a i e(ti$ic#rii coeAiste()ei !(or a$ec)i!(i +e icale care ar "!tea co(tri%!i la a"ari)ia e"resiei sa! ar "!tea co+"lica trata+e(t!l4 Pe(tr! e"resia !(i"olar# (o(0 "sihotic#3 trata+e(t!l e elec)ie este asocierea !(!i a(ti e"resiv NISRS sa! ve(la$aAi(e URO c! "sihotera"ie4 Pe(tr! e"resia !(i"olar# "sihotic#3 trata0 +e(t!l e elec)ie este asocierea !(!i a(ti e"resiv NISRS sa! ve(la$aAi(e URO c! !(!l i(tre (oile a(ti"sihotice ati"iceD tera"ia electroco(v!lsiva(t# este e ase+e(ea e "ri+a li(ie4 Pe(tr! t!l%!rarea isti+ic# sa! "e(tr! e"resia !/oar# "ersiste(t#3 eA"er)ii reco+a( # asocierea !(!i a(ti e"resiv N e "re$erat ISRSO c! "sihotera"ie4 Dac# "acie(t!l "rezi(t# o a$ec)i!(e +e ical# coeAiste(t# N e eA4 hi"otiroi0 ieO care co(tri%!ie la e"resie3 eA"er)ii reco+a( # tratarea si+!lta(# a a+%elor a$ec)i!(i e la i(ce"!t4 ISRS a! $ost co(si erate ca a(ti e"resivele
Ghi !ri
e $a+ilie I CNSMF
;&
e elec)ie "e(tr! toate $or+ele e e"resie4 Di(tre ele3 eA"er)ii a! cotat cel +ai %i(e citalo"ra+!l /i sertrali(a "e(tr! e$icie()a /i tolera()a lor4 &=&IL Sertrali(a $olosit# @( oz# tera"e!tic# (! o$er# @(s# o "rotec)ie se+(i$icativ# @+"otriva rec!re()ei e"resiei4 &>8I% ParoAeti(a a $ost e ase+e(ea co(si erat# e "ri+# alegere iar $l!oAeti(a a $ost cotat# ca cel +ai i( icat "e(tr! li(ia a o!a4 Teh(icile e "sihotera"ie "re$erate "e(tr! trata+e(t!l e"resiei la "acie()ii vGrst(ici s!(t tera"ia cog0 (itiv0co+"orta+e(tal#3 "sihotera"ia e s!sti(ere3 "sihotera"ia "ri( re0 zolvarea e "ro%le+e /i "sihotera"ia i(ter"erso(al#4 EA"er)ii a! acor at o i+"orta()# eose%it# i(cl! erii !(or i(terve()ii "sihosociale cores"!(z#0 toare @( "rogra+!l e trata+e(t NeA: "sihoe !ca)ie3 co(siliere $a+ilial#3 vizite la o+icili! e$ect!ate e "erso(al +e ical +e i!O4 &=&IL SeA!l $e+i(i(
REC2MANDRI
R=& La $e+eia c! e"resie !/oar# N@( "erioa a e co(ce")ie3 sarci(# ori al#"tareO se reco+a( # "sihotera"ie ca trata+e(t e "ri+a li(ie4 R=6 La $e+eia c! e"resie sever# se reco+a( # asocierea +e ica)iei a(ti e"resive c! alte tera"ii N@( ge(eral "sihotera"ieO4 R== ISRS ca "ri+a alegere i(tre clasele e a(ti e"resive4
C C
Fe+eile re"rezi(t# o!# trei+i i(tre "acie()ii e"resivi4 Trata+e(t!l e"resiei la $e+ei este e aceea o i+"orta(t# "reoc!"are e s#(#tate "!0 %lic#4 St! iile e calitate es"re t!l%!r#rile e"resive s"eci$ice $e+eilor s!(t "!)i(e4 Di( acest +otiv (! eAist# ghi !ri e "ractic# +e ical# %azate "e ovezi care s# reco+a( e cel +ai %!( trata+e(t4 Ca !r+are3 !( gr!" e eA"er)i a aH!(s la co(se(s @( ceea ce "riveste trata+e(t!l a "atr! co( i)ii e"resive s"eci$ice $e+eii: t!l%!rarea is$oric# "re+e(str!al# NTDPMO3 e"resia @( sarci(#3 e"resia "ost"art!+ la $e+eia care al#"teaz# /i e"re0 sia legat# e "eri5+e(o"a!z#4 Pe(tr! $e+eile c! si+"to+e severe3 reco0 +a( area e "ri+# li(ie a $ost asocierea +e ica)iei a(ti e"resive c! alte tera"ii N@( ge(eral "sihotera"ieO3 reco+a( are si+ilar# c! cea i( ghi !rile ce se a reseaz# "o"!la)iei ge(erale4 Pe(tr! e"resia !/oar# (! a eAistat !(
;6
CNSMF I Ghi !ri
e $a+ilie
co(se(s "rivi( reco+a( area e a(ti e"resive4 Pe(tr! trata+e(t!l i(i)ial al si+"to+elor +ai !/oare eA"er)ii a! reco+a( at $ie alte tera"ii N"rec!+ a%or #ri (!tri)io(ale sa! "siho0co+"orta+e(tale @( TDPM3 s!%stit!)ie hor0 +o(al# @( "eri+e(o"a!z#O3 $ie a! "re$erat "sihotera"ia @( loc!l +e ica)iei N@( "erioa a e co(ce")ie3 sarci(# ori al#"tareO4 2ric!+3 @( toate caz!rile e e"resie !soar#3 a(ti e"resivele a! $ost reco+a( ate ca o")i!(e e li(ia a o!a4 Di(tre a(ti e"resive3 clasa ISRS a $ost reco+a( at# ca trata+e(t e "ri+# li(ie @( toate sit!a)iile4 I( $!(c)ie e "artic!laritatea sit!a)iei cli(ice se reco+a( # alegerea !(!i ISRS s"eci$ic4 A(ti e"resivele triciclice re"rezi(t# o %!(# alter(ativ# a ISRS3 @( sarci(# /i al#"tare4 &'?IL U( trial cli(ic s!ge0 reaz# c# o strategie $oarte e$icie(t# la $e+eile $ertile c! t!l%!rare e"resiv# !(i"olar# rec!re(t# este re"reze(tat# e !( trata+e(t %azat i(i)ial (!+ai "e "sihotera"ie i(ter"erso(al# /i !lterior3 @( a%se()a re+isi!(ii3 asocierea c! +e ica)ia a(ti e"resiv#4 &8'IIa
84?4 ALTE INTERLENKII TERAPEUTICE

z EUERCIKIULFIWIC IN TERAPIADEPRESIEI
REC2MANDRI
R=? Pacie()ii c! e"resie "ot %e(e$icia e tera"ie "ri( eAerci)i! $izic4 R=> Se reco+a( # !( "rogra+ e eAercit)ii e = ori "e s#"t#+G(#3 c! !rat# e ?>0 '7 +i(!te "e se i()# ti+" e &70&6 s#"t#+G(i4 Persoa(ele vGrst(ice /i cele c! s!$eri()e so+atice vor avea reco+a( #ri e e$ort $izic a a"tate co( i)iei lor4
EAist# ovezi care arat# c# eAerci)i!l $izic @( trata+e(t!l e"resiei "oate $i %e(e$ic4 I(tr0!( trial co(trolat ra( o+izat "!%licat @( 67773 e$ect!at "e &>' a !l)i iag(ostica)i c! e"resie +aHor# NDSM ILO care a! $ost trata)i $ie c! ? l!(i e eAerci)i! aero%ic3 $ie c! sertrali(a $ie "ri( co+%i(a)ia celor o!#3 toate = gr!"ele a! "reze(tat o a+eliorare se+(i$icativ#4 Rec# erile !"# &7 l!(i a! av!t o $recve()# +ai sc#z!t# @( gr!"!l celor care a! e$ect!at eAerci)ii $izice ecGt @( gr!"!l celor care a! "ri+it sertrali(#4 A!torii co(cl!zio(eaz# c#
Ghi !ri
e $a+ilie I CNSMF
;=
tera"ia $izic# la "acie()ii c! e"resie este asociat# c! e$ecte %e(e$ice se+0 (i$icative @( s"ecial ac# se co(ti(!# e0a l!(g!l ti+"!l!i4 6&?I% La "acie()ii vGrst(ici3 !"# c!+ arat# co(cl!ziile !(!i trial co(trolat ra(0 o+izat "!%licat @( &8883 c! !( esig( si+ilar3 tera"ia e"resiei "ri( eAer0 ci)ii $izice "oate $i co(si erat# o alter(ativa c! rez!ltate $i(ale co+"ara%ile c! tera"ia +e ica+e(toas# ar c! !( r#s"!(s tera"e!tic i(i)ial +ai le(t4 Cei c! $or+e +ai !/oare e e"resie i( gr!"!l c! tera"ie co+%i(at# a! av!t !( r#s"!(s +ai ra"i ecGt cei c! $or+e severe4 6&>I% C! toate acestea3 o +etaa(aliz# i( 677& al c#r!i sco" a $ost e a eter0 +i(a e$icie()a eAerci)i!l!i $izic @( +a(age+e(t!l e"resiei arat# c# s!(t (ecesare st! ii cli(ice c! o !r+#rire a ecvat#4 Metaa(aliza a l!at @( co(si0 erare &? st! ii la care s0a! i e(ti$icat e$icie()e +eto ologice ar /i i$e0 re()e "rivi( ra( o+izarea3 sta%ilirea iag(ostic!l!i3 "erioa a e !r+#rire care $ac i+"ro"rie co+"ararea rez!ltatelo r4 Co+"arativ c! "acie()ii care (! !r+at trata+e(t3 cei care a! e$ect!at eAerci)ii $izice a! "reze(tat a+elior#ri si+ilare celor care a! !r+at tera"ie cog(itiv#4 E$ect!l %e(e$ic a $ost +ai i+"orta(t @( st! iile c! !r+#rire sc!rt#4 6&'Ia I( ge(eral se reco+a( # !( "rogra+ e eAerci)ii e = ori "e s#"t#+G(#3 c! !rat# e ?>0 '7 +i(!te "e se i()# ti+" e &70&6 s#"t#+G(i4 Persoa(ele vGrst(ice /i cele c! s!$eri()e so+atice vor avea reco+a( #ri e e$ort $izic a a"tate co( i)iei lor4'<IL z TERAPIAELECTR2C2NLULSILANT NTECO
REC2MANDRI
R=' Se reco+a( # tera"ia electroco(v!lsiva(t# @( trata+e(t!l e"resiei severe4
Tera"ia electroco(v!lsiva(t# NTECO este o o")i!(e @( trata+e(t!l e"resiei severe4 I(tr0o +etaa(aliz# "!%licat# @( 677? s0a co+"arat e$icie()a tera"iei elec0 troco(v!lsiva(te c! TEC si+!lat#3 c! "lace%o /i c! tera"ie +e ica+e(toas# Na(ti e"resiv# @( ge(eral3 ATC /i IMA2O4 Tera"ia electroco(v!lsiva(t# a $ost s!"erioar# t!t!ror acestora /i "oate $i co(si erat# o varia(t# vali # e trata0 +e(t "e(tr! e"resie i(cl!siv "e(tr! $or+ele severe /i reziste(te4 6&;36&< Ia Tera"ia electroco(v!lsiva(t# este o varia(t# "e ter+e( sc!rt a trata+e(t!0
;?
CNSMF I Ghi !ri
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l!i e"resiei "ro%a%il +ai e$icie(t# ecGt tera"ia +e ica+e(toas#4 TEC %ilateral# este +o erat +ai e$icie(t# ecGt cea !(ilateral# /i ozele +ari s!(t +ai e$icie(te ecGt cele +ici4 6&8Ia Dovezi li+itate s!gereaz# c# TEC este s!"erioar# /i sti+!l#rii +ag(etice tra(scra(ie(e4 A(ti e"resivele triciclice "ar s# @+%!(#t#)easc# e$ect!l TEC4 Co(ti(!area $ar+acotera"iei c! triciclice co+%i(ate c! liti! la "ersoa(ele care a! r#s"!(s la TEC a sc#z!t rata rec# erilo r4 EAist# "!)i(e ovezi ale e$icacit#)ii TEC "e ter+e( l!(g4 S!(t (ecesare cercet#ri s!"li+e(tare care s# arate ce i($or+a)ii s!(t (ecesare "acie()ilor "e(tr! a eci e acce"tarea sa! (! a TEC 0!l!i4 66=Ia A(alizG( e$ect!l TEC "e(tr! "reve(irea rec# erii @( e"resie3 !( trial co(trolat ra( o+izat "!%licat @( 677' a co+"arat e$ectele TEC co(ti(!e N&7 trata+e(teO c! tera"ia +e ica+e(toas# Nliti! /i (ortri"tili(aO ' l!(i4 Rec#0 erile (! a! $ost se+(i$icativ i$erite @( cele 6 gr!"!ri iar rez!ltatele a! $ost s!"erioare co+"arativ c! "lace%o4 A+%ele +eto e a! ar#tat @(s# o e$icaci0 tate li+itat# e a "reve(i rec# erile N"este >7Y i(tre "acie()i a! av!t rec# eri sa! a! "#r#sit st! i!lO4 S!(t (ecesare strategii +ai e$icie(te e "re0 ve(ire a rec# erii4 66&I% z TERAPIANATURIST H-"eric!+ "er$orat!+ a $ost !tilizat# e0a l!(g!l ti+"!l!i @( +e ici(a tra i)io(al# "e(tr! trata+e(t!l e"resiei4 Pla(ta este c!(osc!t# s!% iverse e(!+iri "o"!lare: s!(#toare3 "oHar(i)#3 %!r!ia(a0 e0(# !$3 %!r!ia(a0 e0 "e0r#zor3 cr!cea0voi(ic!l!i3 ro%i/or3 $loarea0l!i0Ioa(3 he+ei0 e0"#+G(t3 le+(ie3 @(cheg#toare3 os!l0ie"!rel!i3 "oHar3 s%!r#toare3 s!(aica3 sovGrvari)#4 U(ele st! ii a! ar#tat c# eAtract!l e s!(#toare este +ai e$icie(t ecGt "lace%o /i la $el e e$icie(t ca a(ti e"resivele triciclice /i ISRS @( trata+e(0 t!l "e ter+e( sc!rt N' s#"t#+G(iO al e"resiei !/oare /i +o erate4 Doza zil0 (ic# $olosit# a $ost e 877 +g N=77 +g A =5ziO4 66736=7 III I( trial!rile care co+"ar# H-"eric!+ c! alte a(ti e"resive3 $olosirea eA0 tract!l!i (! a $ost asociat# c! (ici !( e$ect a vers sever3 rata total# a e$ectelor sec!( are $ii( e 63?Y4 Di(tre acestea se +e()io(eaz#: t!l%!r#ri gastro0i(testi(ale3 cre/terea a(Aiet#)ii3 "al"ita)ii3 $otose(si%ilitate3 o%oseal#3 (eli(i/te3 !sc#ci!(ea g!rii3 ce$alee /i !(eori chiar acce(t!area e"resiei4 EAtract!l e H-"eric!+ "rezi(t# i(terac)i!(i se+(i$icative c! !(ele +e0 ica+e(te Nco(trace"tive3 a(ticoag!la(te /i a(tico(v!lsiva(teO4 N! se reco0
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+a( # asocierea c! ISRS atorit# "osi%ilit#)ii a"ari)iei si( ro+!l!i sero0 to(i(ic4 667III I( ci! a ovezilor citate3 @( literat!ra e s"ecialitate a +i(istrarea e eA0 tract e H-"eric!+ r#+G(e co(troversat#4 2 +etaa(aliz# "!%licat# @( 677> arat# c# ovezile c!re(te "rivi( eAtract!l e H-"eric!+ s!(t i(co(siste(te /i "ro !c co($!zie4 La "acie()ii c! e"resie3 !(ele RCT0!ri rece(te s!ge0 reaz# c# eAtractele e H-"eric!+ $olosite a! e$ecte %e(e$ice +i(i+e @( ti+" ce alte trial!ri s!gereaz# c# H-"eric!+ /i a(ti e"resivele sta( ar a! e$ecte %e(e$ice si+ilare4 AvG( @( ve ere c# "re"aratele is"o(i%ile "e "ia)# "ot varia co(si era%il @( ceea ce "rive/te calitatea $ar+ace!tic#3 rez!ltatele acestei +etaa(alize se a"lic# oar "ro !selor la care $ace re$erire4 6=&Ia Di(tre "re"aratele eAiste(te @( Ro+G(ia +e()io(#+: Stres Sto" Nco+%i0 (a)ie e "la(te care co()i(e ?77 +g eAtract e r# #ci(a e H-"eric!+ "er ca"s!l#O3 Passi$lora0H-"erici0Me(tol N&77 +g e eAtract sta( ar izat e s!(#toare "e c"4O3 Re+otiv N6>7+g eAtract !scat e H-"erici her%a "e c"4O4 z ADMINISTRAREADE 2MEGA = NACIWI GRACI P2LINESATURAKIO 2 +etaa(aliz# i( 677' a i(cl!s toate RCT /i rece(ziile siste+atice care a! cercetat e$ect!l o+ega = sa! a !lei!l!i e "e/te as!"ra e"resiei4 A! $ost i e(ti$icate &< RCT i( care &6 a! $ost l!ate @( co(si erare4 Datorit# hetero0 ge(it#)ii acestora a $ost i$icil e s!+arizat co(cl!zii4 St! iile arat# !( %e(0 e$ici! re !s al !tiliz#rii o+ega = @( @+%!(#t#)irea si+"to+elor e"resiei4 S!(t (ecesare trial!ri a ecvate "e(tr! a e"ista %e(e$icii cli(ice4 666Ia N! eAist# s!$icie(te ovezi care s# s!s)i(# !tilizarea e r!ti(# a o+ega = @( trata+e(t!l e"resiei4 66>Ia z F2T2TERAPIA 2 +etaa(aliz # i( 677> a eval!at e$icie()a tera"iei "ri( l!+i(# @( t!l%!r#rile e is"ozi)ie4 EAist# re !ceri se+(i$icative ale severit#)ii si+"to+elo r e"resiei !"# eA"!(ere a la l!+i(# "!ter(ic str#l!citoare @( t!l%!r#ril e a$ective sezo(iere /i @( e"resiile (esezo(iere 4 Utilizarea $ototera"iei ca a H!va(t al +e ica)iei a(ti e"resiv e @( e"resia (esezo(ier # (! a a !s a+elior#ri4 Ar $i (ecesare st! ii a ecvate care sa sta%ileasc# "ara+etrii /i criterii ri0 g!roase "e(tr! a a(aliza corect e$ect!l $ototera"iei as!"ra t!l%!r#rilor e is"ozi)ie4 66'Ia
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z STIMULAREAMAGNETIC TRANSCRANIAN Se "are c# sti+!larea +ag(etic# re"etitiv# ra"i # tra(scra(ia(# (! a !ce %e(e$icii @( trata+e(t!l e"resiei +aHore NDSM ILO4 66;Ia z H2ME2PATIA IN TERAPIA DEPRESIEI C#!tarea siste+atic# a st! iilor a e+o(strat c# ovezile "rivi( e$icie()a ho+eo"atiei @( trata+e(t!l e"resiei s!(t li+itate atorit# li"sei trial!rilor cli(ice e %!(# calitate4 66<Ia z ACUPUNCTURA IN TERAPIA DEPRESIEI S!(t i(s!$icie(te ovezile care "ot eter+i(a e$icie()a ac!"!(ct!rii co+0 "arativ c! +e ica)ia sa! c! lista e a/te"tare sa! $alsa ac!"!(ct!r# @( +a(0 age+e(t!l e"resiei4 St! iile s!(t (esatis$#c#toare ca esig( /i c!"ri( !( (!+#r re !s e s!%iec)i4668Ia
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&74 M2 N T I 2 R IW A R E A TUL9UR ID RE I P R E S IL E
REC2MANDRI
R=; E$ect!area +o(itoriz#rii e"resiei "e %aza chestio(ar!l!i MDI N2MSO R=< Mo(itorizare s#"t#+G(al# sa! %il!(ar# N@( $!(c)ie e severitateO @( $aza ac!t# e $ar+acotera"ie "G(# cG( a"are o @+%!(#t#)ire cli(ic#D !lterior vizitele "ot $i s"a)iate la o l!(#4 R=8 Mo(itorizare l!(ar# sa! %il!(ar# a "acie()ilor care s!(t i(cl!/i @( "rogra+e e a!to0co(trol Nsel$ +a(age+e(tO4 R?7 Mo(itorizarea "acie()ilor care !r+eaz# "sihotera"ie e c#tre "sihotera"e!t4
C C C
Evol!G( @( e"isoa e3 t!l%!rarea e"resiv# este a esea o a$ec)i!(e rec!0 re(t# sa! cro(ic# ce (ecesit# o +o(itorizare i()ial# s!s)i(!t# "G(# la is"ari0 )ia si+"to+elor !r+at# e o reeval!are "erio ic# "e(tr! a e"ista eve(t!0 ala rec# ere sa! rec!re()#4 87IL Pacie()ii tre%!ie !r+#ri)i i(i)ial s#"t#+G(al sa! %is#"t#+G(al @( $!(c)ie e severitatea e"iso !l!i e"resiv "G(# cG( a"are o @+%!(#t#)ire cli(ic#4 Ulterior vizitele "ot $i s"a)iate la o l!(# sa! +ai rar @( $!(c)ie e "artic!lari0 t#)ile i( ivi !ale4 La $iecare vizit# se vor eval!a: 0 r#s"!(s!l la i(terve()ia tera"e!tic# N+e ica)ie3 "sihotera"ie sa! alte +eto e tera"e!ticeO 0 a"ari)ia /i i(te(sitatea e$ectelor sec!( are 0 risc!l s!ici ar No "arte a "acie()ilor trata)i c! a(ti e"resive "ot ezvolta 0 @( s"ecial @( $azele i(i)iale ale trata+e(t!l!i ar /i la +o i$icarea o0 zelor 0 agita)ie3 a(Aietate3 ostilitate ceea ce cre/te risc!l e s!ici O 0 evol!)ia cli(ic# /i "aracli(ic# a co+or%i it#)ilo r4&8;IL R#s"!(s!l la i(terve()ia tera"e!tic# se eval!eaz# o%iectiv "ri( chestio(are4 N! eAist# "e "la( i(ter(a)io(al !( co(se(s "rivi( chestio(ar!l cel +ai a ecvat "e(tr! +o(itorizarea trata+e(t!l!i t!l%!r#rii e"resive4
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Ca /i @( caz!l iag(ostic!l!i3 @( literat!r# s!(t escrise o +!ltit! i(e e i(str!+e(te "e(tr! +o(itorizare: Patie(t Health ,!estio((aire08 NPH,08O Q ANEUA ' 0 /i varia(ta sa PH,063 Str!ct!re Cli(ical I(tervieF $or DSM0IL NSCIDO3 Mo(tgo+er-0`s%e rg De"ressio( Rati(g Scale NMADRSO3 Geriatric De"ressio( Scale NGDS&>O3 Ha+ilto( e"ressio( rati(g scale NHDRSO3 9ecT De"ressio( I(ve(tor- N9DI3 9DI0IIO3 Ho"Ti(s S-+"to+ ChecTlist NSCL067O3 Sheeha( Disa%ilit- Scale3 VH20Five Vell0%ei(g I( eA NVH20FiveO4 8&36=636==36=?36=>36=' Co($or+ reco+a( #rilor 2MS3 chestio(ar!l a!toa +i(istrat "ro"!s "e(0 tr! iag(ostic NMDI ] .MaHor De"ressio( I(ve(tor-JO se "oate !tiliza /i ca i(str!+e(t "e(tr! +o(itorizare4 8&IL I( ti+"!l trata+e(t!l!i c! a(ti e"resive evol!)ia "oate @+%r#ca !r+#0 toarele $or+e: 0 o @+%!(#t#)ire !/oar# a si+"to+elor i(i)iale NeA4 "este 67Y @+%!(#t#)ire "!(ctaH MDIO @( "ri+ele 60? s#"t#+G(i 0 !( r#s"!(s cli(ic %!( NeA4 "este >7Y @+%!(#t#)ire "!(ctaH MDIO @( ?0< s#"t#+G(i 0 re+isia si+"to+elor N"!(ctaH MDI s!% >O @( <0&6 s#"t#+G(i4 Re+isia si+"to+elor !"# &60&' s#"t#+G(i este !( sco" realist "e(tr! circa '>Y i(tre "acie()ii c! t!l%!rare e"resiva4 Rec!"erarea co+"let# "oate sa !reze +ai +!lt4 0 evol!)ie (e$avora%il#: rec# ere3 rec!re()#3 viraH +a(iacal3 agravarea e"resiei3 a"ari)ia co+"lica)iilor Nte(tativ# e s!ici sa! s!ici realizatO4 Pacie()ii care !r+eaz# "sihotera"ie sa! care s!(t i(cl!/i @( "rogra+e e a!to0@(griHire tre%!ie e ase+e(ea +o(itoriza)i la i(tervale l!(are sa! e o!# ori "e l!(#4 Pe(tr! "sihotera"ie3 se a/tea"t# o @+%!(#t#)ire !"# '0< s#"t#+G(i e trata+e(t /i re+isia si+"to+elor !"# &60&' s#"t#+G(i4 87IL Ghi !l U(iversit#)ii i( Michiga( "!%licat @( 677> "ro"!(e !r+#tor!l +o el e +o(itorizare a e"resiei &8; :
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CLASIFICAREA TUL9URRIIDEPRESILE0 CIM &7& F=6 E"iso ! l e"resiv G&4 E"iso !l e"resiv tre%!ie s# !reze cel "!)i( 6 s#"t#+G(i G64 N! s!(t s!$icie(te si+"to+e e hi"o+a(ie sa! +a(ie care s# @(tr!(easc# criteriile "e(tr! e"iso hi"o+a(iacal sa! +a(iacal NF=740O @( oricare +o+e(t i( via)a !(!i i( ivi 4 G=4 Cel +ai a esea este $olosit iag(ostic!l e eAcl! ere: e"iso !l (! este legat e $olosirea !(ei s!%sta()e "sihoactive NF&7 Q F&8O sa! e vreo t!l%!0 rare +e(tal# orga(ic# N@( se(s!l celor e la F77 Q F78O4 Si( ro+!l so+atic U(ele si+"to+e e"resive s!(t @( ge(eral co(si erate ca avG( o se+(i$i0 ca)ie cli(ic# eose%it#3 $ii( e aceea (!+ite.so+aticeJ Nter+e(i ca %iolo0 gic3 vital3 +ela(colic3 e( oge(o+or$ic s!(t $olosi)i "e(tr! acest si( ro+ @( alte clasi$ic#riO4 U( al ci(cilea caracter N"rec!+ cel i( icat la F=&4=D F=64&D F==47 /i F==4&O "oate $i $olosit "e(tr! a s"eci$ica "reze()a sa! a%se()a si( ro+!l!i so+atic4 Pe(tr! a e$i(i si( ro+!l so+atic3 tre%!ie s# $ie "reze(te ? i( !r+#0 toarele si+"to+e: N&O "ier ere i+"orta(t# a i(teres!l!i sa! "l#cerii "e(tr! activit#)i care s!(t (or+al "l#c!teD N6O li"sa reac)iilor e+o)io(ale la eve(i+e(te sa! activit#)i care "ro !c @( +o (or+al !( r#s"!(s e+o)io(alD N=O trezirea i+i(ea)a c! cel "!)i( 6 ore @(ai(te e ora o%i/(!it#D N?O e"resia este +ai acce(t!at# i+i(ea)aD N>O ova a o%iectiv# e retar "siho+otor evi e(t sa! agita)ie Nre+arcat# e "ersoa(a @( ca!z# sa! eA"ri+at# e alte "ersoa(eOD N'O a"etit sc#z!t evi e(tD N;O sc# ere "o( eral# N> Y sa! +ai +!lt i( gre!tatea cor"oral# @( !lti+a l!(#OD N<O sc# erea evi e(t# a li%i o!l!i4 I( .Clasi$icarea CIM Q &7 a t!l%!r#rilor +e(tale /i co+"orta+e(tale: Descrierile cli(ice /i ghi !rile e iag(osticJ3 "reze()a sa! a%se()a si( ro0
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+!l!i so+atic (! este s"eci$icat# "e(tr! e"iso !l e"resiv sever3 i( +o0 +e(t ce se "res!"!(e c# este "reze(t @( cele +ai +!lte caz!ri4 Tot!/i3 @( sco" e cercetare este reco+a( a%il s# se o"teze "e(tr! co i$icarea a%0 se()ei si( ro+!l!i so+atic @( e"iso !l e"resiv sever4 F=647 E"iso ! l e"resiv !/or A4 Este (ecesar# "reze()a criteriilor ge(erale care e$i(esc e"iso !l e"re0 siv NF=6O 94 Cel "!)i( o!# i( !r+#toarele trei si+"to+e tre%!ie s# $ie "reze(te: N&O stare e"resiv# la !( gra care este evi e(t a(or+al "e(tr! i( ivi 3 "reze()a @( cea +ai +are "arte a zilei /i a"roa"e zil(ic3 @( +are +#s!r# (ei($l!e()at# e circ!+sta()e /i !rG( e cel "!)i( o!# s#"t#+G(iD N6O "ier erea i(teres!l!i sa! "l#cerii "e(tr! activit#)ile care era! @( +o o%i/(!it "l#c!teD N=O i+i(!area e(ergiei sa! $atiga%ilitate cresc!t#4 C4 Este (ecesar# "reze()a !(!ia sa! +ai +!ltor si+"to+e a i)io(ale i( !r+#toarea list#3 "e(tr! a rez!lta !( total e cel "!)i( "atr!: N&O "ier erea @(cre erii /i a res"ect!l!i e si(eD N6O se(ti+e(te (eH!sti$icate e a!to0ac!zare ori e c!l"a%ilizare eAcesiv# /i i(a ecvat#D N=O gG( !ri rec!re(te e +oarte sa! s!ici 3 sa! orice co+"orta+e(t si(!0 ciga/D N?O ac!ze sa! ovezi "rivi( i+i(!area a%ilit#)ii e a gG( i sa! e a se co(ce(tra3 ca e eAe+"l! (esig!ra()a sa! ezitareaD N>O +o i$icarea activit#)ii "siho+otorii3 c! agita)ie sa! retar N$ie s!%iecti v3 $ie o%iectivOD N'O t!l%!r#ri e so+( e orice $elD N;O +o i$icarea a"etit!l!i Nsc# ere sa! cre/tereO c! +o i$icarea core"!(0 z#toare a gre!t#)iiD U( al ci(cilea caracter "oate $i $olosit "e(tr! a s"eci$ica "reze()a sa! a%0 se()a .si( ro+!l!i so+aticJ: F=6477 $#r# si( ro+ so+atic F=647& c! si( ro+ so+atic F=64& E"iso ! l e"resiv +o erat A4 Este (ecesar# "reze()a criteriilor ge(erale care e$i(esc e"iso !l siv NF=6O4 e"re0
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94 Tre%!ie s# $ie "reze(te cel "!)i( o!# i( cele trei si+"to+e listate "e(0 tr! F=6473 criteri!l 94 C4 Tre%!ie s# $ie "reze(te si+"to+ele a i)io(ale e la F=6473 criteri!l C3 "e(tr! a rez!lta !( total e cel "!)i( /ase4 U( al ci(cilea caracter "oate $i $olosit "e(tr! a s"eci$ica "reze()a sa! a%0 se()a .si( ro+!l!i so+aticJ e$i(it la "agi(a AA: F=64&7 $#r# si( ro+ so+atic F=64&& c! si( ro+ so+atic F=646 E"iso ! l e"resiv sever $#r# si+"to+e "sihotice Not#: ac# se o%serv# si+"to+e i+"orta(te c!+ ar $i agita)ia sa! retar !l3 "acie(t!l "oate s# (! oreasc# sa! s# $ie i(ca"a%il s# escrie @( etali! +!lte i(tre si+"to+e4 I(ca rarea @( e"iso e"resiv sever "oate $i tot!/i H!sti$icat# @( ast$el e caz!ri4 A4 Este (ecesar# "reze()a criteriilor ge(erale care e$i(esc e"iso !l e"re0 siv NF=6O4 94 Este (ecesar# "reze()a a celor trei si+"to+e re!(ite eA"!se la criteri!l 93 F=647 C4 Este (ecesar# "reze()a si+"to+elor a i)io(ale e la F=6473 criteri!l C3 "e(tr! a rez!lta !( total e cel "!)i( o"t4 D4 N! tre%!ie s# eAiste hal!ci(a)ii3 elir!ri sa! st!"or e"resi v4 F=64= E"iso ! l e"resiv sever c! si+"to+e "sihotice A4 Este (ecesar# "reze()a criteriilor ge(erale care e$i(esc e"iso !l e"re0 siv NF=6O4 94 Este (ecesar# "reze()a si+"to+elor e"iso !l!i e"resiv $#r# si+"to+e "sihotice NF=646O c! eAce")ia criteri!l!i D4 C4 N! tre%!ie s# $ie "reze(te criteriile "e(tr! schizo$re(ie N F6740O sa! "e(0 tr! t!l%!rare schizoa$ectiv# e ti" e"resiv NF6>4&O4 D4 2ricare i( !r+#toarele criterii tre%!ie s# $ie "reze(te: N&O elir!ri sa! hal!ci(atii 3 altele ecGt acelea listate ca ti"ice "e(tr! schizo0 $re(ie @( F673 criteri!l G&N&O%3c /i N e eAe+"l! elir!ri3 altele ecGt cele co+0 "let i+"osi%ile sa! (e"otrivite stat!s!l!i c!lt!ral al "ersoa(ei /i hal!ci(a)ii care (! s!(t la "ersoa(a a treia /i (! se +a(i$est# ca !( co+e(tari ! (e@(trer!"tOD cele +ai co+!(e eAe+"le s!(t acelea c! co()i(!t e"resiv3 e vi(ov#)ie3 i"o0 ho( riac3 (ihilistic3 re$eritor la "ro"ria "ersoa(# sa! "ersec!tori!D N6O st!"or e"resiv
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U( al ci(cilea caracter "oate $i $olosit "e(tr! a s"eci$ica ac# si+"to+ele "sihotice s!(t co(gr!e(te sa! (eco(gr!e(te c! is"ozi)ia: F=64=7 C! si+"to+e "sihotice co(gr!e(te c! is"ozi)ia NeAe+"l! elir!ri c! se(ti+e(te vi(ov#)ie3 li"sa e valoare3 %oli $izice3 se(ti+e(t!l ezastr!0 l!i i+i(e(t3 hal!ci(a)ii a! itive ac!zatoare sa! co( a+(atoriiO F=64=& C! si+"to+e "sihotice (eco(gr!e(t e c! is"ozi)ia N elir!ri "ersec!0 torii sa! c! re$erire la "ro"ria "ersoa(# /i hal!ci(a)ii $#r# !( co()i(!t a$ectivO F=64< Alte e"isoa e e"resive E"isoa ele ce tre%!ie i(cl!se aici s!(t cele ce (! se "otrivesc escrierii e"i0 soa elor e"resive e la F=647 Q F=64=3 ar "e(tr! care i+"resia ge(eral# e iag(ostic i( ic# $a"t!l c# ele s!(t e"resive "ri( (at!ra lor4 EAe+"lele i(cl! a+estec!ri $l!ct!a(te e si+"to+e e"resive N+ai ales cele ale si( ro+!l!i so+aticO c! si+"to+e (o( iag(ostic e c!+ ar $i te(si!(ea 3 @(griHorarea3 e"!i0 zarea /i a+estec!ri e si+"to+e e"resive so+atice c! !rere "ersiste(t# sa! o%oseal# $#r# ca!ze orga(ice N@(tGl(ite !(eori @( serviciile s"italice/tiO4 F=648 E"iso e"resiv3 (es"eci$icat
F== T!l%!rare e"resiv# rec!re(t# G&4 "reze()a a(teroar# a cel "!)i( !(!i e"iso 3 !/or NF=647O3 +o erat NF=64&O sa! sever NF=646 sa! F=64=O ce a !rat +i(i+ o!# s#"t#+G(i /i se0 "arat e e"iso !l c!re(t "ri( cel "!)i( o!# l!(i $#r# (ici !( si+"to+ se+0 (i$icativ "rivi( is"ozi)ia4 G64 N! s0a @(registrat @( trec!t (ici !( e"iso care s# @(tr!(easc# criteriile "e(tr! e"iso hi"o+a(iacal sa! +a(iacal NF=7O4 G=4 Cel +ai a esea este $olosit iag(ostic!l e eAcl! ere: e"iso !l (! "oate $i atri%!it $olosirii e s!%sta()e "sihoactive NF&O sa! oric#rei t!l%!r#ri +e(tale orga(ice3 @( se(s!l l!i F74 Se reco+a( # s# se s"eci$ice ti"!l "re o+i(a(t al e"isoa elor a(terioare N!/or3 +o erat3 sever3 (e"recizatO4 F==47 T!l%!rarea e"resiv# rec!re(t#3 e"iso c!re(t !/or A4 Este (ecesar# "reze()a criteriilor ge(erale ale t!l%!r#rii e"resive rec!0 re(te NF==O4 94 E"iso !l c!re(t @( e"li(e/t e criteriile "e(tr! e"iso e"resiv !/or NF=647O U( al ci(cilea caracter "oate $i $olosit "e(tr! a s"eci$ica "reze()a si( ro0 +!l!i so+atic3 e$i(it ca la F=63 @( e"iso !l c!re(t:
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F==477 $#r# si( ro+ so+atic F==47& c! si( ro+ so+atic F==4& T!l%!rarea e"resiv# rec!re(t#3 e"iso c!re(t +o erat A4 Este (ecesar# "reze()a criteriilor ge(erale "e(tr! t!l%!rare e"resiv# rec!re(t# NF==O 94 E"iso !l c!re(t @( e"li(e/te criteriile e"iso !l!i +o erat NF=647O U( al ci(cilea caracter "oate $i $olosit "e(tr! a s"eci$ica "reze()a sa! a%se()a si( ro+!l!i so+atic3 e$i(it ca la F=63 @( e"iso !l c!re(t: F==4&7 $#r# si( ro+ so+atic F==4&& c! si( ro+ so+atic F==46 T!l%!rare e"resiv# rec!re(t#3 e"iso c!re(t sever $#r# si+"to+e "sihotice A4 Este (ecesar# "reze()a criteriilor ge(erale ale t!l%!r#rii e"resive rec!re(te NF==O 94 E"iso !l c!re(t @( e"li(e/te criteriile e"iso !l!i e"resiv sever $#r# si+"to+e "sihotice NF=646O F==4= T!l%!rare e"resiv# rec!re(t#3 e"iso c!re(t sever c! si+"to+e "sihotice A4 Este (ecesar# "reze()a criteriilor ge(erale "e(tr! t!l%!rare e"resiv# rec!re(t# NF==O 94 E"iso !l c!re(t @( e"li(e/te criteriile e"iso !l!i e"resiv sever c! si+"to+e "sihotice NF=64=O U( al ci(cilea caracter "oate $i $olosit "e(tr! a s"eci$ica ac# si+"to+ele "sihotice s!(t sa! (! s!(t co(gr!e(te c! is"ozi)ia: F==4=7 c! si+"to+e "sihotice co(gr!e(te c! is"ozi)ia F==4=& c! si+"to+e "sihotice (eco(gr!e(te c! is"ozi)ia F==4? T!l%!rare e"resiv# rec!re(t#3 a$lat# @( "reze(t @( re+isie A4 Criteriile ge(erale "e(tr! t!l%!rare e"resiv# rec!re(t# NF==O a! $ost @(tGl(ite @( trec!t4 94 Starea "reze(t# (! @( e"li(e/te criteriile "e(tr! e"iso e"resiv NF=640O e orice severitate sa! "e(tr! orice alt# t!l%!rare i( F= N"acie(t!l "oate s# "ri+easc# trata+e(t "e(tr! re !cerea risc!l!i !(!i viitor e"iso O F==4< Alte t!l%!r#ri rec!re(te e"resive F==48 T!l%!rare e"resiv# rec!re(t#3 (es"eci$icat#
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Criteriile DSM0IL "e(tr! e"iso !l e"resiv +aHor /i t!l%!rarea e"resiv# +aHor#6
DIAGN2STIC CRITERIU5 DESCRIEREA SIMPT2ME L2R E"iso A4 Cel "!)i( > i( !r+#toarele si+"to+e a! $ost "reze(te e"resiv @( ti+"!l aceleia/i "erioa e e 6 s#"t#+G(i /i re"re0 +aHor zi(t# o schi+%are $a)# e $!(c)io(area a(terioar#D este "reze(t cel "!)i( !( si+"to+ i( "ri+ele 6 N(! se i(cl! si+"to+e clar atorate !(ei a$ec)i!(i so+atice sa! il!zii /i hal!ci(a)ii i(co(gr!e(te c! is"ozi)iaO &4 Dis"ozi)ie e"resiv# @( cea +ai +are "arte a zilei3 a"roa"e @( $iecare zi3 i( icat# s!%iectiv sa! o%servat# e al)ii 64 Pier erea i(teres!l!i sa! "l#cerii @( toate sa! a"roa"e toate activit#)ile @( cea +ai +are "arte a zilei3 a"roa"e @( $iecare zi3 i( icat# s!%iectiv sa! o%servat# e al)ii =4 Sc# ere sa! cre/tere se+(i$icativ# @( gre!tate N"este >Y @(tr0o l!(#O sa! sc# erea5cre/tere a a"etit!l!i a"roa"e zil(ic ?4 I(so+(ie sa! hi"erso+(ie a"roa"e zil(ic >4 Agita)ie "siho+otorie sa! retar a"roa"e zil(ic No%servat# e al)ii3 (! (!+ai se(za)ia s!%iectiv# e (eli(i/te sa! le(0 toareO '4 2%oseal# sa! li"s# e e(ergie a"roa"e zil(ic ;4 Se(ti+e(te e i(!tilitate sa! c!l"a%ilizare eAcesiv# sa! (e0 "otrivit# Ncare "oate $i elira(t#O a"roa"e zil(ic N(! (!+ai a!to ac!zare "rivi( starea e %oal#O <4 Di+i(!are a a%ilit#)ii e gG( ire /i co(ce(trar e sa! i( ecizia a"roa"e zil(ic Ns!%iectiv# sa! o%servat# e al)iiO 84 GG( !ri rec!re(te e +oarte N(! oar $rica e +oarteO sa! i ea)ie c! co()i(!t s!ici ar sa! te(tativ# e s!ici sa! eAis0 te()a !(!i "la( s"eci$ic e s!ici 94 Si+"to+ele (! @(tr!(esc criteriile "e(tr! e"iso !l +iAt C4 Si+"to+ele "ro !c isa%ilitate cli(ic se+(i$icativ# socia0 l#3 oc!"atio(al# sa! @( alte o+e(ii D4 Si+"to+ele (! se atoreaz # e$ectelor irecte ale !(or s!%0 sta()e N rog!ri3 +e ica)ie e4g4O sa! !(or %oli Nhi"otiroi ie e4g4O E4 Si+"to+ele (! s!(t eA"licate e oli! N e/i acesta "oate co+"lica e"resia +aHor#O
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T!l%!rare e"resiv# +aHor#3 e"iso !(ic
T!l%!rare e"resiv# +aHor# rec!re(t#
A4 Preze()a !(!i e"iso +aHor e"resiv !(ic 94 E"iso !l +aHor e"resiv (! aco+"a(iaz# o t!l%!rare schizoa$ectiv# /i (! coeAist# c! schizo$re(ia3 t!l%!r#ri schizo$re(i$or+e sa! elira(te sa! "sihotice (es"eci$icate C4 N! a eAistat (icio at# !( e"iso +a(iacal3 +iAt sa! hi"o0 +a(iac A4 Preze()a a 6 sa! +ai +!lte e"isoa e +aHore e"resive Nse"arate e cel "!)i( 6 l!(i @( care criteriile e iag(ostic a! li"sitO 94 E"iso !l +aHor e"resiv (! aco+"a(iaz# o t!l%!rare schi0 zoa$ectiv# /i (! coeAist# c! schizo$re(ia3 t!l%!r#ri schizo0 $re(i$or+e sa! elira(te sa! "sihotice (es"eci$icate C4 N! a eAistat (icio at# !( e"iso +a(iac3 +iAt sa! hi"o+a0 (iac
E"iso !l e"resiv +aHor "oate $i clasi$icat ca !/or3 +o erat /i sever $!(c)ie e (!+#r!l si+"to+elor "reze(te /i e re"erc!rsi!(ile lor as!"ra activi0 t#)ilor !z!ale ale i( ivi !l!i4 I( e"isoa ele !/oare eAist# (!+#r!l +i(i+ e si+"to+e (ecesare iag0 (ostic!l!i iar $!(c)io(area i( ivi !l!i este iscret alterat#4 E"isoa ele severe se iag(osticheaz# cG( eAist# +aHoritatea si+"to+elor care i(ter$er# +aHor sa! chiar total c! activitatea social# /i oc!"a)io(al#4 I( DSM IL e"resia +i(or# (! este @(c# i(tro !s# ca /i iag(ostic4 De"resia +i(or# "oate $i l!at# @( co(si erare cG( eAist# @(tre 6 /i ? si+"0 to+e i(tre cele e(!+erate i(tre care o%ligatori! tre%!ie s# $ie "reze(te "ri+!l N is"ozi)ia e"resiv#O sa! al oilea Na(he o(iaO "e(tr! o !rat# e +#car 6 s#"t#+G(i4
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DSM IL Se+(i$ica)ie Si+"to+ele "ro !c stres se+(i0 cli(ic# $icativ sa! isa%ilitatese+(i $icativ# social#3 oc!"a)io(al# sa! e alt# (at!r#4 ICD0&7 I( e"iso !l e"resiv !/or a"ar !(ele i$ic!lt#)i @( es$#/!rarea +!(cii /i a activit#)ilor sociale o%i/(!it e ar acestea (! vor $i "ert!r%ate co+"letD I( e"iso !l e"resiv +o era t a"ar i$ic!lt#)i co(si era%il e @( es$#/!rarea activit#)ilor o+es0 tice3 sociale /i oc!"a)io(aleD I( e"iso !l e"resiv seve r eAist# s!$eri()# acce(t!at # sa! agita)ie cel +ai "ro%a%il i(co+"ati%il e c! es$#/!rare a activit#)ilor sociale3 o+estice /i oc!"a)io(ale c! eAce")ia e"isoa elo r e"resive e $oarte sc!rt# !rat#4 D!rat a I( cea +ai +are "arte a zilei3 Pe(tr! iag(ostic! l e"isoa elor si+"to+elor a"roa"e zil(ic "e(tr ! cel "!)i( e"resiv e i( i$ere(t e gra !l 6 s#"t#+G(i4 e severitate este (ecesar# o !rat# e cel "!)i( 6 s#"t#+G(i4 Criterii e Cel "!)i( !( si+"to + i( Cel "!)i( o!# i( !r+#toarele iag(ostic !r+#toarele o! # tre%!ie trei si+"to+ e tre%!ie s# $ie s# $ie "reze(te: "reze(te: N&O Stare e"resiv# N&O stare e"resiv# N6O Pier erea i(teres!l!i N6O "ier ere i(teres!l!i sa! "l#cerii N=O i+i(!are a e(ergiei sa! Este (ecesar# "reze()a a @(c# $atiga%ilitate cresc!t#4 trei si+"to+e i( !r+#toarea Este (ecesar# "reze()a !(!ia sa! list# "e(tr! a rez!lta !( total +ai +!ltor si+"to+ e a i)io(ale e cel "!)i( ci(ci: i( !r+#toare a list#3 "e(tr! a N=O Sc# ere5 cre/ter e se+(i$ica0 rez!lta !( total e cel "!)i( "atr!: cativ# @( gre!tat e sa! sc# ere5 cre/ter e se+(i$icativ# a a"etit!l!i N&O "ier ere a @(cre erii /i a res"ect!l!i e si(eD N?O I(so+(ie sa! hi"erso+(ie N6O se(ti+e(te (eH!sti$icate e N>O agita)ie "siho+otori e sa! a!to0ac!zare ori e c!l"a%ilizare le(toare eAcesiv# /i i(a ecvat#D N'O Fatiga%ilitate sa! "ier erea e(ergiei
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N;O Se(ti+e(te e i(!tilitate sa! vi(# eAagerat#5 i(a ecvat # N<O Sc# erea ca"acit#)ii e co(ce(trar e sa! (ehot#rGre4 N8O GG( !ri rec!re(te e +oarte3 e s!ici $#r# !( "la( s"eci$ic5 @(cercare e s!ici 5 "la( s"eci$ic
N=O gG( !ri rec!re(te e +oarte sa! s!ici 3 sa! orice co+"orta+e( t si(!ciga/D gG( ire5 N?O ac!ze sa! ovezi "rivi( i+i(!are a a%ilit#)ii e a gG( i sa! e a se co(ce(tra 3 ca e eAe+"l! (esig!ra()# sa! ezitareD N>O +o i$icare a activit#)ii "siho+otorii 3 c! agita)ie sa! retar N$ie s!%iectiv3 $ie o%iectivOD N'O t!l%!r#ri e so+( e orice $elD N;O +o i$icare a a"etit!l! i Nsc# ere sa! cre/tereO c! +o i$icare a core0 "!(z#toar e a gre!t#)iiD
ANEUA?
ASEMNRICIM &70 DSM IL= Ase+#(#rile i(tre cele o!# clasi$ic#ri ale t!l%!r#rilor e"resive NDSM Q IL /i CIM Q &7O z Pe(tr! sta%ilirea iag(ostic!l!i este o%ligatorie "reze()a !(ei t!l%!r#ri $!( a+e(tale a is"ozi)iei3 e o%icei is"ozi)ie e"resiv#3 "ier erea i(0 teres!l!i ori a "l#cerii4 z Criteriile e iag(ostic /i clasi$icare se %azeaz# eAcl!siv "e si+"to+eD (ici etiologia3 (ici r#s"!(s!l /i rez!ltatele trata+e(t!l!i (! re"rezi(t# criterii e clasi$icare4 z Criteriile e iag(ostic /i clasi$icare c!"ri( o"t si+"to+e co+!(e: &4 is"ozi)ie e"resiv#3 64 "ier erea i(teres!l!i3 =4 sc# erea e(ergiei sa! cre/terea $atiga%ilit#)ii3 ?4 t!l%!rarea so+(!l!i3 >4 t!l%!rarea a"etit!l!i3 '4 gG( !ri s!ici are rec!re(te3 ;4 i(ca"acitatea "e(tr! co(ce(trare sa! @( a l!a ecizii3 <4 agita)ie "siho+otorie sa! retar are4
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DE2SE9IRICIM&70DSM IL= Deose%iril e ese()iale i(tre cele 6 siste+e e clasi$icare rezi # @( $a"t!l c#: "e lG(g# cele < si+"to+e co+!(e 3 CIM &7 +ai co()i(e o!# criterii @( "l!s: 0 re !cerea res"ect!l!i e si(e /i a @(cre erii @( si(e 0 i eea e c!l"a%ilizare /i (e"!ti()#4 DSM0IL co+%i(# c!l"a%ilizarea eAcesiv# /i i(a ecvat# c! se(ti+e(t!l e i(!tilitate Ncare i( "!(ct e ve ere calitativ este +ai sever ecGt "ier erea sa! re !cerea res"ect!l!i e si(e /i a @(cre erii @( si(eO4 z Str!ct!ra algorit+!l!i e iag(ostic este i$erit#: 0 CIM &7 are criterii gr!"ate @( o!# set!ri: !( set co()i(e = criterii N is0 "ozi)ie e"resiv#3 "ier erea i(teres!l!i /i sc# erea e(ergieiO i(tre care tre%!ie sa $ie "reze(te +#car o!# iar cel#lalt set co()i(e rest!l e ; cri0 terii4 Co($or+ CIM &73 iag(ostic!l e severitate se sta%ile/te @( $!(c)ie e (!+#r!l e criterii "reze(te4 0 DSM IL "rezi(t# !( si(g!r set e (o!# criterii /i i+"!(e "reze()a a ci(ci i(tre ele "e(tr! a sta%ili iag(ostic!l e e"iso e"resiv +aHorD is"ozi0 )ia e"resiv# sa! "ier erea i(teres!l!i este o%ligatorie4 z EAist# i$ere()e e !tilizare a ter+e(ilor4 I( CIM &7 se isc!t# es"re t!l0 %!rarea e"resiv# /i e"isoa e e"resive care "ot $i !/oare3 +e ii /i severe @( $!(c)ie e (!+#r!l e criterii "reze(te4 I( DSM0IL se vor%e/te (!+ai e . t!l%!rare e"resiv# +aHor# J care se s!"ra"!(e @( totalitate "este e"resia +e ie /i sever# i( CIM &7 ar c!"ri( e /i !(ele $or+e e e"resie !/oar# i( aceasta clasi$icare4 T!l%!rarea e"resiv# +aHor# i( DSM IL "oate $i3 e ase+e(ea3 !/oar#3 +e ie sa! sever#4 z I( CIM &7 (! este i(cl!s !( criteri! cli(ic se+(i$icativ3 @( ti+" ce DSM0 IL solicit# ca si+"to+ele s# "rovoace isco($ort ori s# a$ecteze cli(ic se+(i$icativ i( "!(ct e ve ere social3 oc!"a)io(al ori alte zo(e i+"orta(te ale $!(c)io(#rii i( ivi !l!i4 z CIM &7 (! $ace re$erire la oli! @( criteriile e iag(ostic3 @( ti+" ce DSM0IL eAcl! e !( iag(ostic e e"resie +aHor# ac# si+"to+ele e"iso !l!i e"resiv "ot $i atorate oli!l!i4 z Preze()a .si( ro+!l!i so+aticJ @( CIM &7 care c!"ri( e si+"to+e "re0 c!+: N&O "ier ere i+"orta(t# a i(teres!l!i sa! "l#cerii "e(tr! activit#)i care
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s!(t (or+al "l#c!teD N6O li"sa reac)iilor e+o)io(ale la eve(i+e(te sa! activit#)i care "ro !c @( +o (or+al !( r#s"!(s e+o)io(alD N=O trezirea i+i(ea)a c! cel "!)i( 6 ore @(ai(te e ora o%i/(!it#D N?O e"resia este +ai acce(t!at# i+i(ea)aD N>O ova a o%iectiv# e retar "siho+otor evi e(t sa! agita)ie Nre+arcat# sa! ra"ortat# la alte "ersoa(eOD N'O a"etit sc#z!t evi e(tD N;O sc# ere "o( eral# N> Y sa! +ai +!lt i( gre!tatea cor"oral# @( !lti+a l!(#OD N<O sc# erea evi e(t# a li%i o!l!i4 z Criteri!l ce e$i(e/te rec!re()a e"resiei este se+(i$icativ i$erit @( cele 6 siste+e4 CIM &7 cere ca i( ivi !l s# ai%# cel "!)i( 6 l!(i $#r# (ici !( si+"0 to+ se+(i$icativ al is"ozi)iei3 @( ti+" ce DSM0IL cere !( i(terval e cel "!)i( 6 l!(i co(sec!tiv e @( care criteri!l "e(tr! e"iso e"resiv +aHor s# (! $ie @( e"li(it N > sa! +ai +!lte si+"to+eO4 Pri( !r+are3 CIM &7 este +!lt +ai strict3 cerG( o re+isie co+"let# @(tre e"isoa e @( ti+" ce DSM0 IL co(si er# c# i( ivi !l "oate s# $i av!t e"isoa e se"arate e e"resie3 chiar ac# si+"to+ele s!(t re !se e la > la ?3 @(tr0o "erioa # e 6 l!(i4 Aceste i$ere()e s!gereaz# c# ar "!tea $i "reze(te sit!a)ii @( care criteri!l e iag(ostic "e(tr! e"resie ar "!tea $i @(tr!(ite @(tr0!( siste+3 ar (! /i @( cel#lalt4 I( co(cl!zie3 cele 6 siste+e "!( la is"ozi)ie +!lte si+ilarit#)i @( e$i(irea !(!i e"iso 3 ar str!ct!ra "ri( care e"iso !l este iag(osticat3 este oarec!+ i$erit#4 DSM0IL se aAeaz# +ai +!lt "e criterii e iag(ostic3 @( ti+" ce CIM &7 co(ce"t!alizeaz# e"iso !l e"resiv +aHor i( DSM IL ca @(ca rG( !0se e la !/or la sever3 c! gra e i$erite e severitate a si+"to+elo r4 DSM0IL "!(e la is"ozi)ie criterii e i(cl! ere /i eAcl! ere s"eci$ice3 care (! s!(t co()i(!te @( CIM &74
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Nr4 +e ici e $a+ilie care !tilizeaz # algorit+! l 2MS5 Nr4 +e ici e $a+ilie Nr4 "ersoa(e c! e"resie iag(osticate c! aH!tor!l algorit+!l!i 2MS5 Nr4 "ersoa(e c! e"resie a$late @( evi e()# Eval!area risc!l!i Eval!area risc!l!i Nr4 "ersoa(e c! e"resie la care s!ici ar la $iecar e vizit# s!ici ar la $iecar e vizit# s0a eval!at risc!l s!ici ar 5 Nr4 (! co(stit!ie o r!ti(# "ersoa(e c! e"resie a$late @( evi e()# I( "reze(t3 +aHoritatea I(i)ierea +e ica)iei Nr4 "ersoa(e c! e"resie la care caz!rilor i e(ti$icat e s!(t a(ti e"resive s0a i(i)iat +e ica)ie5 Nr4 tri+ise la +e ic!l "ersoa(e c! e"resie a$late @( "sihiatr! evi e()# Nr4 "ersoa(e c! e"resi e tri+ise la +e ic! l "sihiatr!5Nr4 "ersoa0 (e c! e"resie a$late @( evi e()#
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Nr4 "ersoa(e c! e"resi e tri+ise la +e ic!l "sihiatr ! co($or+ criteriilor e tri+itere5 Nr4 "ersoa(e c! e"resie tri+ise la +e ic! l "sihiatr! Nr4 "ersoa(e c! e"resie "la(i$icate la vizitele e co(trol5 Nr4 "ersoa(e c! e"resie a$late @( evi e()# Chestio(are e eval!ar e a satis$ac)iei "acie()ilor
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I"oho( rie: "reoc!"ar e eAagerat# a !(!i s!%iect @( ceea ce "rive/te s#(#tatea sa3 eA"ri+at# "ri( cre i()e /i atit! i(i ira)io(ale $a)# e cor"!l s#!3 "ri( tea+a e a avea o +ala ie grav#3 ca /i "ri(tr0o rela)ie e s$i are $a)# e +e ic4 I(terval e @(cre er e: re"rezi(t# li+itele i(terval!l!i @( ca r!l c#r!ia se a$l# +#ri+ea real# a e$ect!l!i N(icio at# c!(osc!t eAactO3 c! !( a(!+it gra e sig!ra()#4 Se isc!t# eseori es"re i(terval!l e @(cre ere e 8>Y Nsa! li+itele e @(cre ere e 8>YO4 Aceasta re"rezi(t# i(terval!l care i(cl! e valoarea real# @( 8>Y i( caz!ri4 Ma(ie: stare e agita)ie caracterizat # "ri(tr0o eAaltare a is"ozi)iei /i "ri(tr0o s!rescitare "siho+otori e "er+a(e(t# 4 Se +a(i$est# "ri( hi"eractivitate3 accelerare a gG( irii3 $l!A i(e"!iza%i l e c!vi(te3 e!$orie3 "!tere /i (eo0 %oseal#3 te( i()# la %!li+ie /i i(so+(ii4 Me ici(a %azat# "e ovezi: re"rezi(t# !tilizarea co(stie(t# 3 eA"licit# /i H! i0 cioas# a celor +ai %!(e ovezi @( l!area eciziilor legate e @(griHirea "acie()ilor i( ivi !ali4 Me li(e NMe lars o(li(eO: este o %az# e ate electro(ic # ce rez!+# s!te e +ii e articole i( literat!ra +e ical# 3 "!%licate @( reviste selec)io(ate4 Este is"o(i%il# @( ca r!l %i%liotecilor +e icale 3 "!tG( $i accesat# e "e CD0 R2M sa! irect "ri( i(ter(et4 MEDINET : re)ea e is"e(sar e sa(ti(el# ce a @(registrat ate statistice i( activ0 itatea +e icilor e $a+ilie i( Ro+G(ia @( "erioa a 67770677 = N"roiect al Ce(tr!l!i Na)io(al e St! ii "e(tr! Me ici(a Fa+iliei @( cola%orar e c! Societatea Na)io(al# e Me ici(a Fa+iliei5Me ici( a Ge(eral# /i .I+"rovi(g ,!alit- o$ Health Care @( Ro+a(ia Fo!( atio(J O4 Metaa(aliz# N+eta0a(al-s-sO: este o teh(ic# statistic# ce i(tegreaz# rez!ltatele "rove(ite i(tr0o serie e st! ii @(tr0o si(g!r# esti+are3 "!(G( acce(t "e rez!ltatele "rove(ite i( st! ii e a+"loare4 Nivel!l ovezii: re"rezi(t# !( siste+ e c!a(ti$icare a valorii ovezilor /tii()i0 $ice rez!ltate i( cercet#ri e i$erite ti"!ri4 I( "reze(t! l +aterial este acce"tat siste+!l NICE e clasi$icare al (ivel!l!i ovezilor /i este etaliat @( ca"itol!l =4 Di$erite orga(iza)ii !tilizeaz# siste+e e c!a(ti$icare i$erite4 Psihoso+atic: se s"!(e es"re ceea ce "rive/te @( acela/i ti+" cor"!l /i s"iri0 t!l3 +ai ales @( leg#t!r# c! a$ec)i!(i viscerale orga(ice sa! $!(c)io(ale "rovocate "ar)ial sa! total e c#tre $actori "sihoa$ectivi4 Psihotera"ie: orice +iHloace "sihologice !tilizate "e(tr! a trata o +ala i e +e(0 tal# sa! o t!l%!rare "sihoso+atic#4 Psihotic: care )i(e e o "sihoz#D care caracterizeaz # o "sihoz#4 Psihoza: +ala ie +e(tal# grav# care a$ecteaz# @( +o glo%al "ero(alitatea "acie(t!l!i4
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P!terea reco+a( #ri i: re"rezi(t# !( siste+ e c!a(ti$icare a reco+a( #rilo r @( $!(c)ie e (ivel!l ovezilor st! iilor "e %aza c#rora a! $ost $or+!late4 Tre%!ie av!t @(s# @( ve ere c#3 !(eori reco+a( #r i %azate "e st! ii e cal0 itate %!(# /i a ecvate ca esig( "e(tr! "ro%le+a cli(ic# st! iat#3 "ot avea !( gra *i($eriorJ3 @(tr!cGt st! i!l "e care se %azeaz # are !( ra(g +ic @( ierarhia ovezilo r4 Ra"t!s: co+"orta+e( t "aroAistic3 c! caracter e esc#rcare irezisti%il# /i %r!0 tal#3 @( c!rs!l c#reia s!%iect!l3 @+"i(s e o stare e+o)io(al# i(te(s#3 risc# s# treac# la act @(tr0!( +o !(eori ra+atic3 e evitare N$!gaO sa! e agre0 sivitate Nco(tra se+e(!l! i sa! a l!i i(s!/iO 4 Rece(zie siste+atic#: co()i(e i e(ti$icarea 3 esti+area /i rez!+are a siste+atic# a !(ei ovezi @( co($or+itate c! criteriile "resta%ilite N!(ii o (!+esc a(al0 iz# ge(eral#O4 Scree(i(g: re"rezi(t# +eto ele e i e(ti$icare a "reze()ei !(ei a$ec)i!(i @( sta ii i(ci"ie(te @( "o"!la)ia a"are(t s#(#toas#4 Se(si%ilitatea !(!i test: ca"acitate a !(!i test e a i e(ti$ica corect "e cei "ozi0 tivi Nc! a ev#rat %ol(aviO4 S"eci$icitatea !(!i test: ca"acitate a !(!i test e a i e(ti$ica corect "e cei (eg0 ativi Ncei care s!(t s#(#to/iO4 Trial co(trolat ra( o+izat Nra( o +ise co(trolle trialO: re"rezi(t# st! i!l @( care "acie()ii s!(t @+"#r)i) i aleatori! @( 6 gr!"!ri: !(!l Ncel eA"eri+e(talO care s!"orta i(terve()ia testat#3 iar cel#lalt Ngr!"!l e co+"ara)ie sa! e co(trolO care "ri+e/te !( trata+e(t alter(ativ4 Cele o!# gr!"!ri s!(t !r+#rite "e(tr! o%servarea oric#rei i$ere()e care a"are @(tre acestea4 St! i!l este !til "e(tr! esti+area e$icie()ei trata+e(t!l!i4 St! i!l e cohort#: i+"lic# 6 gr!"!ri NcohorteO e "acie()i3 !( gr!" care este s!"!s !(!i a(!+it $actor /i !( gr!" care (! este s!"!s acel!i $actor3 gr!"!rile $ii( !r+#rite "ros"ectiv sa! retros"ectiv "e(tr! o%servarea rez!l0 tatelo r4 St! i!l tra(sversal: o%servarea !(ei "o"!la)ii @(tr0!( a(!+it +o+e(t sa! i(ter0 val e ti+"4 EA"!(erea /i rez!ltatele s!(t eter+i(at e si+!lta(4 U(i"olar: se s"!(e es"re o t!l%!rare "sihic# c! evol!)ie @( "!see3 orie(tat# @(tot ea!(a s"re acela/i "ol e"resiv sa! +a(iac4 Lali itatea: se re$er# la rig!rozitatea /i i(tegritatea !(!i st! i!4 U( st! i! este vala%il ac# +o !l e co(ce")ie /i realizare co( !c e la co(cl!zi a c# rez!ltatele (! s!(t ero(ateD ceea ce echivaleaz # c! esti+area real# a e$i0 cie()ei cli(ice4
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i(ter(atio(al literat!re3 a revieF4P Me(t Health Polic- Eco(4 6777 Mar &D=N&O:=0&74 674 Vaghor( G3Cha(t D4 La%o!r $orce activit- %- "eo"le Fith e"ressio( a( a(Aiet- isor ers: a "o"!latio(0leve l seco( 0or e r a(al-sis4Acta Ps-chiatr Sca( 4 677> DecD &&6N'O:?&>06?4 6&4 Ld"i(e PP3 Gast"ar M3 Me( leFic z P3 T-lee A4 De"ressio( @( the co++!(it- : the $irst "a(0 E!ro"ea( st! DEPRES NDe"ressio( Research @( E!ro"ea( Societ-O4I(t Cli( Ps-cho"har+acol4 &88; Pa(D&6N&O:&80684 664A ler DA3 McLa!ghli( TP3 Rogers VH3 Cha(g H3 La"itsT- L3 Ler(er D4Po% "er$or+a(ce e$icits !e to e"ressio(4A + P Ps-chiatr-4 677 ' Se"D&'=N8O:&>'80;'4 6=4Ler(er D3 A ler DA3 Cha(g H3 La"itsT- L3 Hoo MR3 Perissi(otto C3Ree P3 McLa!ghli( TP3 9er( t ER3 Rogers VH4U(e+"lo-+e(t 3 Ho% rete(tio(3 a( "ro !ctivit- loss a+o(g e+"lo-ees Fith e"ressio( 4 Ps-chiatr Serv4 677 ? DecD>>N&6O:&=;&0<4 6?4 Levi(so( DF3 W!%e(To GS3 CroFe RR3 DePa!lo RP3 Sche$t(e r VS3Veiss+a( MM3 Hol+a(s P3 W!%e(To VN3 9o!telle S3 M!r"h-0E%ere( z 13 Mac1i((o( D3 McI((is MG3 Marta DH3 A a+s P3 Sassoo( S3 1(oFles PA3 Tho+as P3 Chellis P4 Ge(etics o$ rec!rre(t earl-0o(set e"ressio( NGe(REDO: esig( a( "reli+i(ar- cli(ical characteristic s o$ a re"ositor- sa+"le $or ge(etic li(Tage st! ies4 A+ P Me Ge(et 9 Ne!ro"s-chiat r Ge(et4 677= Ma- &>D&&8N&O:&&<0=74 6>4 1lei( DN3 Sha(T+a( SA3 LeFi(soh( PM3 Roh e P3 Seele- PR Fa+il- st! - o$ chro(ic e"res0 sio( @( a co++!(it- sa+"le o$ -o!(g a !lts4 A+ P Ps-chiatr-4 677? A"rD&'&N?O:'?'0>=4 6'4 1e( ler 1S3 Gatz M3 Gar (er C23 Pe erse( NL4 Perso(alit- a( +aHo r e"ressio(: a SFe ish lo(git! i(al 3 "o"!latio(0%ase tFi( st! -4 Arch Ge( Ps-chiatr-4 677' 2ctD'=N&7O: &&&=0674 6;4 Pelissolo A3 Corr!%le E4 Perso(alit- $actors @( e"ressive isor ers : co(tri%!tio ( o$ the "s-0 cho%iologi c +o el evelo"e %- Clo(i(ge r4 E(ce"hale 4 6776 P!l0A!gD6<N?O:='=0;=4 6<4 Co(soli SM4 De"ressio( a( 2rga(ic Diseases St! -4De"ressio ( a( associate orga(ic "athologies3 a still !( er0esti+ate co+or%i it-4 Res!lts o$ the DIAL2GUE st! -4Presse Me 4 677= Pa( &&D=6N&O:&706&4 684 Patte( S94 Lo(g0ter+ +e ical co( itio( s a( +aHor e"ressio( @( a Ca(a ia( "o"!latio( st! - at Faves & a( 64 P A$$ect Disor 4 677& MarD'=N&0=O:=>0?&4 =74 Si+o( GE3 1ato( VP3 Li( EH3 R!tter C3 Ma((i(g VG3 Lo( 1or$$ M3 Ciecha(oFsT i P3 L! +a( EP3 Ro!(g 9A4 Cost0e$$ective(ess o$ s-ste+ati c e"ressio( treat+e(t a+o(g "eo"le Fith ia%etes +ellit!s4 Arch Ge( Ps-chiatr-4 677; Pa(D'?N&O:'>0;64 =&4 9l!+el 93 Gi%%o(s A3 1a(acri A3 1erriga( N3 Flore(za(o R4 De"ressiv e s-+"to+s a$ter a( ac!te +-ocar ial i($arctio(4 Rev Me Chil4 677> Se"D&==N8O:&76&0;4 =64 PacTa FN3 Pasco PA3 McCo((ell S3 Villia+s LP3 1otoFicz MA3 Nicholso ( GC3 9erT M4 Sel$0 re"orte e"ressio( a( car iovasc!la r risT $actors @( a co++!(it- sa+"le o$ Fo+e(4 Ps-choso+atics 4 677 ; Pa(0Fe%D?<N&O:>?084 ==4 Patte( S93 9ecT CA3 1assa+ A3 Villia+s PL3 9ar%!i C3 Metz LM4 Lo(g0ter+ +e ical co( i0 tio(s a( +aHor e"ressio(: stre(gth o$ associatio ( $or s"eci$ic co( itio( s @( the ge(eral "o"!la0 tio(4 677> MarD>7N?O:&8>06764 =?4 Roha((es AM3 9al Fi( RC3 Co((oll- MP4 Pre ictors o$ &0-ear +ortalit- @( "atie(ts is0 charge $ro+ hos"ital $olloFi(g ac!te eAacer%atio ( o$ chro(ic o%str!ctive "!l+o(ar- isease4 Age Agei(g4 677> Se"D=?N>O:?8&0'4 =>4 Vo(g SR3 Voo P3 L-(( HS3 Le!(g P3 Ta(g RN3 Le!(g PC4 RisT o$ e"ressio( @( "atie(ts Fith chro(ic res"irator- iseases: res!lts $ro+ tFo large cohort st! ies @( Chi(ese el erl- $ro+ Ho(g 1o(g4I(t P Geriatr Ps-chiatr -4 677' MarD6&N=O:6==0<4 ='4 Ner- FG3 9or%a EF3 Hatch PP3 Soares PC3 9o($a E3 Neto FL4 MaHor e"ressive isor er a( is0 ease activit- @( s-ste+ic l!"!s er-the+atos!s 4 Co+"r Ps-chiatr-4 677; Pa(0Fe%D?<N&O:&?084 =;4 Patte( S93 9ecT CA3 Villia+s PL3 9ar%!i C3 Metz LM4 MaHor e"ressio( @( +!lti"le sclerosis: a "o"!latio(0%ase "ers"ective 4 Ne!rolog-4 677= Dec 8D'&N&&O:&>6?0;4 =<4 Hegel MT3 Moore CP3 Colli(s ED3 1eari(g S3 GillocT 1L3 Riggs RL3Cla- 1F3 Ahles TA4 Distress3
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"s-chiatric s-( ro+es3 a( i+"air+e( t o$ $!(ctio( @( Fo+e( Fith (eFl- iag(ose %reast ca(cer4 Ca(cer4 677' Dec &>D&7;N&6O:686?0=&4 =84 Vo(g SR3 Ho(g A3 Le!(g P3 1FoT T3 Le!(g PC3 Voo P4LoFer !ri(ar - tract s-+"to+s a( e"ressive s-+"to+s @( el erl- +e(4P A$$ect Disor 4 677' NovD8'N&06O:<=0< 4 E"!% 677' P!l &&4 ?74 Rai(er M13 M!cTe HA3 Wehet+a-e r S3 1ra+"la V3 1!sel%a!er T3 Veissgra+ S3 P!(gFirth S3 Tragl 1H3 Fischer P4 Data $ro+ the LITA St! - o (ot s!""ort the co(ce" t o$ vasc!lar e"ressio(4A+ P Geriatr Ps-chiatr-4 677 ' P!(D&?N'O:>=&0;4 ?&4 1oiTe A13 U(!tzer P3 Vells 194 I+"rovi(g the care $or e"ressio( @( "atie(ts Fith co+or%i +e ical ill(ess4A+ P Ps-chiatr-4 677 6 2ctD&>8N&7O:&;=<0?>4 ?64 HeisTa(e( TH3 NisTa(e( L13 Hi(tiTTa PP3 1oiv!+aa0Ho(Ta(e ( HT3 Ho(Tala+" i 1M3 Haatai(e ( 1M3 Lii(a+aTi HT4 Meta%olic s-( ro+e a( e"ressio(: a cross0sectio(a l a(al-sis4P Cli( Ps-chiatr-4 677' Se"D';N8O:&?660;4 ?=4 1i( er LS3 Car(etho( MR3 Pala(ia""a ( LP3 1i(g AC3 Fort+a(( SP4 De"ressio( a( the +eta0 %olic s-( ro+e @( -o!(g a !lts: $i( i(gs $ro+ the Thir Natio(al Health a( N!tritio( EAa+i(atio( S!rve-4Ps-choso+ Me 4 677 ? Ma-0P!(D''N=O:=&'0664 ??4 2(itilo AA3 Nietert PP3 Ege e LE4 E$$ect o$ e"ressio( o( all0ca!s e +ortalit- @( a !lts Fith ca(cer a( i$$ere(tial e$$ects %- ca(cer site4Ge( Hos" Ps-chiatr-4 677' Se"02ctD6<N>O:=8'0?764 ?>4 Vassertheil0S+olle r S3 Sh!+aTer S3 2cTe(e P3 Talavera GA3 Gree(la( P3 Cochra(e 93 Ro%%i(s P3 AragaTi A3 D!(%a r0Paco% P4 De"ressio ( a( car iovasc!la r seS!elae @( "ost+e(o"a!sal Fo+e(4 The Vo+e(c s Healt h I(itiative NVHIO4Arch I(ter( Me 4 677? Fe% 8D&'?N=O:6<808<4 ?'4 1ato( V3 Ca(trell CR3 SoTol MC3 Chiao E3 G ovi( PM4 I+"act o$ a(ti e"ressa( t r!g a her0 e(ce o( co+or%i +e icatio ( !se a( reso!rce !tilizatio(4Arch I(ter( Me 4 677> Nov 6<D&'>N6&O:6?8;0>7=4 ?;4 2ha-o( MM3 Schatz%erg AF4 Usi(g chro(ic "ai( to "re ict e"ressiv e +or%i it- @( the ge(0 eral "o"!latio( 4 Arch Ge( Ps-chiatr-4 677= Pa(D'7N&O:=80?;4 ?<4 Dic"i(igaitis PL3 Tso R3 9a(a!ch G4 Prevale(ce o$ e"ressive s-+"to+ s a+o(g "atie(ts Fith chro(ic co!gh4 Chest4 677' DecD&=7N'O:&<=80?=4 ?84 2ha-o( MM3 Le+oi(e P4 A co((ectio ( %etFee( i(so+(ia a( "s-chiatri c isor ers @( the Fre(ch ge(eral "o"!latio( 4 E(ce"hale4 6776 Se"02ctD6<N> Pt &O:?670<4 >74 Portella AT3 Haaga DA3 Roha( 1P4 The associatio( %etFee( seaso(al a( "re+e(str!a l s-+"0 to+s is co(ti(!o! s a( is (ot $!ll- acco!(te $or %- e"ressive s-+"to+s4 P Nerv Me(t Dis4 677' NovD&8?N &&O:<==0;4 >&4 Patte( S93 Lavorato DH4 Me icatio( !se a( +aHor e"ressiv e s-( ro+ e @( a co++!(it"o"!latio( 4 Co+"r Ps-chiatr-4 677& Mar0A"rD?6N6O:&6?0=&4 >64 Patte( S93 Char(e- DA4 Alcohol co(s!+"tio ( a( +aHor e"ressio( @( the Ca(a ia( "o"!0 latio(4 Ca( P Ps-chiatr-4 &88< P!(D?=N>O:>760'4 >=4 L-(sTe- MT3 GloFi(sTi AL3 To orov AA3 9!cholz 113 Ma e( PA3 Nelso( EC3 Statha+ DP3 Marti( NG3 Heath AC4 MaHor e"ressive isor e r3 s!ici al i eatio(3 a( s!ici e atte+"t @( tFi(s iscor a( t $or ca((a%i s e"e( e(c e a( earl-0o(set ca((a%is !se4 Arch Ge( Ps-chiatr-4 677? 2ctD'&N&7O:&76'0=64 >?4 Dege(har t L3 Hall V3 L-(sTe- M4 EA"lori(g the associatio( %etFee ( ca((a%is !se a( e"ressio( 4 A ictio(4 677= NovD8<N &&O:&?8=0>7?4 >>4 Va(g PL4 R!ral0!r%a( i$$ere(ces @( the "revale(c e o$ +aHo r e"ressio( a( associate i+"air+e(t 4 Soc Ps-chiatr- Ps-chiatr E"i e+iol 4 677? Pa(D=8N&O:&806>4 >'4 1oster A3 9os+a H3 1e+"e( GI3 Pe((i(A 9V3 9eeT+a( AT3 Deeg DP3 va( EiHT PT4 Socioeco(o+i c i$$ere(ces @( i(ci e(t e"ressio( @( ol er a !lts: the role o$ "s-chosocia l $actors3 "h-sical health stat!s3 a( %ehaviora l $actors4 P Ps-choso+ Res4 677' NovD'&N>O:'&806;4 >;4 Marti( CR3 9o((er A3 9rooT A3 L!sco+%e C4 Factor str!ct!re a( !se o$ the hos"ital a(Aieta( e"ressio( scale @( the ho+eless a( sociall - +argi(alize 4 Ps-chol Health Me 4 677'
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Ma-D&&N6O:&870;4 ><4 MossaToFsTi 1N4 Co"i(g Fith "erceive iscri+i(atio( : oes eth(i c i e(tit- "rotect +e(0 tal healthM P Health Soc 9ehav4 677= Se"D??N=O:=&<0=&4 >84 Va(g P4 VorT stress as a risT $actor $or +aHor e"ressive e"iso eNsO 4 Ps-chol Me 4 677> P!(D=>N'O:<'>0;&4 '74 Ts!ts!+i A3 1a-a%a 13 Theorell T3 Siegrist P4 Associatio( %etFee( Ho% stress a( e"ressio( a+o(g Pa"a(ese e+"lo-ees threate(e %- Ho% loss @( a co+"ariso ( %etFee( tFo co+"le+e(tarHo%0stress +o els4 Sca( P VorT E(viro( Health4 677& A"rD6;N6O:&?'0>=4 '&4 Sta(s$el SA3 Hea P3 F!hrer R3 Var le P3 Cattell L Social i(eS!alities @( e"ressive s-+"to+s a( "h-sical $!(ctio(i(g @( the Vhitehall II st! -: eA"lori(g a co++o( ca!se eA"la(atio( 4 P E"i e+iol Co++!(it- Health 4 677= Ma-D>;N>O:='&0;4 '64 Vi o+ CS3 D!Mo(t 13 CzaHa SP4 A "ros"ective i(vestigatio( o$ +aHo r e"ressive isor er a( co+or%i it- @( a%!se a( (eglecte chil re ( groF( !"4 Arch Ge( Ps-chiatr-4 677; Pa(D'?N&O:?80>'4 '=4 Perso( C3 Trac- M3 Galea S4 RisT $actors $or e"ressio( a$ter a isaster4 P Nerv Me(t Dis4 677' Se"D&8?N8O:'>80''4 '?4 Cole MG3 De( !T!ri N4 RisT $actors $or e"ressio( a+o(g el erl - co++!(it- s!%Hects: a s-ste+atic revieF a( +eta0a(al-sis 4 A+ P Ps-chiatr -4 677= P!(D&'7N'O: &&?;0>'4 '>4 H!sai( MM3 R!sh AP3 SacTei+ HA3 Vis(ieFsTi SR3 McCli(tocT SM3 Crave( N3 Holi(er P3 Mitchell PR3 9alas!%ra+a( i G13 Ha!ger R4 Age0relate characteristic s o$ e"ressio(: a "reli+i(arSTAR_D re"ort4 A+ P Geriat r Ps-chiatr-4 677> 2ctD&=N&7O:<>60'74 ''4 Hollo( SD3 Shelto( RC3 Vis(ieFsTi S3 Var e( D3 9iggs MM3 Frie +a ( ES3 H!sai( M3 1!"$er DP3 Niere(%erg AA3 Peterse( TP3 Shores0Vilso( 13R!sh AP4 Prese(ti(g characteristic s o$ e"resse o!t"atie(ts as a $!(ctio( o$ rec!rre(ce : "reli+i(ar- $i( i(gs $ro+ the STAR_D cli(ical trial4 P Ps-chiat r Res4 677' Fe%D?7N&O:>80'84 ';41e( ler 1S3 Prescott CA4 A "o"!latio(0%ase tFi( st! - o$ li$eti+e +aHo r e"ressio( @( +e( a( Fo+e(4 Arch Ge( Ps-chiatr-4 &888 Pa(D>'N&O:=80??4 '<4 NICE4 De"ressio( : Ma(age+e( t o$ e"ressio( @( "ri+ar- a( seco( ar- care4 677? htt":55FF F4(ice4o rg4!T5(ice+e ia5" $5CG6=$!llg!i eli(e4" $ '84 S"iHTer P3 e Graa$ R3 9iHl RL3 9eeT+a( AT3 2r+el P3 Nole( VA4 D!ratio ( o$ +aHor e"res0 sive e"iso es @( the ge(eral "o"!latio( : res!lts $ro+ The Netherla( s Me(tal Health S!rve- a( I(ci e(ce St! - NNEMESISO49 r P Ps-chiatr-4 6776 Se"D&<&:67<0&=4 ;74 Cole MG3 9ellava(ce F3 Ma(so!r A4 Prog(osis o$ e"ressio( @( el erl - co++!(it- a( "ri0 +arcare "o"!latio(s : a s-ste+atic revieF a( +eta0a(al-sis4A + P Ps-chiatr-4 &888 A!gD&>'N<O: &&<6084 ;&4 L-(ess PM3 Heo M3 Datto CP3 Te( Have TR3 1atz IR3 Dra-er R3 Re-(ol s CF r 3 AleAo"o!los GS3 9r!ce ML42!tco+es o$ +i(or a( s!%s-( ro+a l e"ressio( a+o(g el erl"atie(ts @( "ri+arcare setti(gs4 A(( I(ter( Me 4 677' A"r ?D&??N;O:?8'0>7?4 ;64 A+erica( Ps-chiatric Associatio(4Practic e G!i eli(e $or the Treat+e(t o$ Patie(ts Fith MaHor De"ressive Disor er3 6777 4 htt":55FF F4"s-chiatr-o(li(e4co+5"racG!i e5"racG!i e To"ice;4as"A4 ;=4 Gerar A3 Pelissolo A3 Falissar 93 Go!ssia!+ e G3 Millet L4 Patie(ts Fith a co+"lete or "ar0 tial re+issio( o$ MaHor De"ressive E"iso e as "art o$ Rec!rre(t MaHor De"ressive Disor er: escri"tio( o$ ECLAI R st! - "o"!latio( 4 E(ce"hale4 677> Mar0A"rD=&N6O:&;?0<&4 ;?4 9ocTti(g CL3 S"i(hove( P3 1oeter MV3 Vo!ters LF3 Sche(e AHD De"ressio( Eval!atio( Lo(git! i(al Thera"- Assess+e(t St! - Gro!" 4 Pre ictio( o$ rec!rre(c e @( rec!rre(t e"ressio( a( the i($l!e(ce o$ co(sec!tiv e e"iso es o( v!l(era%ilit- $or e"ressio(: a 60-ear "ros"ective st! -4P Cli( Ps-chiatr-4 677' Ma-D';N>O:;?;0>>4 ;>4 N!(es EL3 Li! U3 Sa+et S3 Matseoa(e 13 Hasi( D4 I( e"e( e( t vers!s s!%sta(ce0i( !ce +aHor e"ressive isor er @( s!%sta(ce0 e"e( e( t "atie(ts : o%servatio(a l st! - o$ co!rse !ri(g
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&?<4Ra"a"ort MH3 9ose A3 Whe(g H Escitalo"ra+ co(ti(!atio ( treat+e( t "reve(ts rela"se o$ e"ressive e"iso es4 P Cli( Ps-chiatr-4 677? Pa(D'>N&O:??084 &?84Azori( PM3 Llorca PM3 Des"iegel N3 Ler"illat P4 Escitalo"ra+ is +ore e$$ective tha( citalo0 "ra+ $or the treat+e(t o$ severe +aHor e"ressiv e isor er4 E(ce"hale4 677? Mar0A"rD=7N6O:&><0 ''4 &>74Le"ola U3 Va e A3 A( erse( HF Do eS!ivale( t oses o$ escitalo"ra + a( citalo"ra+ have si+ilar e$$icac-M A "oole a(al-sis o$ tFo "ositiv e "lace%o0co(trolle st! ies @( +aHor e"ressive isor er4 : I(t Cli( Ps-cho"har+acol 4 677? Ma-D&8N=O:&?80>> &>&41l-s(er R3 9e(t0Ha(se( P3 Ha(se( HL3 L!( e M3 Plei r!" E3 Po!lse ( DL3 A( erse( M3 Peterse( HE4 E$$icac- o$ citalo"ra+ @( the "reve(tio( o$ rec!rre(t e"ressio( @( el erl"atie(ts: "lace%o0co(trolle st! - o$ +ai(te(a(c e thera"-4 9r P Ps-chiatr-4 6776 P!lD&<&:680=>4 &>64Les"era(c e F3 Fras!re0S+ith N3 1osz-cTi D3 Lali%erte MA3 va( W-l LT3 9aTer 93 SFe(so( PR3 Ghatavi 13 A%ra+so( 9L3 Doria( P3 G!erti( MCD CREATE I(vestigators4 E$$ects o$ citalo"ra+ a( i(ter"erso(a l "s-chothera" - o( e"ressio( @( "atie(ts Fith coro(ar- arter- isease: the Ca(a ia( Car ia c Ra( o+ize Eval!atio( o$ A(ti e"ressa(t a( Ps-chothera" - E$$icacNCREATEO trial4 PAMA4 677; Pa( 6?D68;N?O:=';0;84 &>=4R!%i(o A3 RosTell N3 Te((is P3 Mi(es D3 Veich S3 A( reFs E RisT o$ s!ici e !ri(g treat0 +e(t Fith ve(la$aAi(e3 citalo"ra+ 3 $l!oAeti(e3 a( othie"i( : retros"ective cohort st! -4 9MP4 677; Fe% =D==?N;><;O:6?64 &>?4Rossi A3 9arraco A3 Do( a P4 Fl!oAeti(e: a revieF o( evi e(ce %ase +e ici(e 4 A((als o$ Ge(eral Hos"ital Ps-chiatr- 677?3 =:64 htt":55FF F4ge(eral0hos"ital0"s-chiatr -4co+5co(te(t5=5&56 &>>4Sch+i t ME3 Fava M3 Ro%i(so( PM3 P! ge R4 The e$$icac- a( sa$et- o$ a (eF e(teric0coat0 e $or+!latio( o$ $l!oAeti(e give( o(ce FeeTl- !ri(g the co(ti(!atio ( treat+e(t o$ +aHor e"res0 sive isor er4 P Cli( Ps-chiatr-4 6777 NovD'&N &&O:<>&0;4 &>'4Tiiho(e ( P3 Lo((Svist P3 Vahl%ecT 13 1la!TTa T3 Ta(sTa(e( A3 Ha!TTa P4 A(ti e"ressa(ts a( the risT o$ s!ici e3 atte+"te s!ici e3 a( overal l +ortalit- @( a (atio(Fi e cohort4 Arch Ge( Ps-chiatr-4 677' DecD'=N&6O:&=><0'; &>;4Ra"a"ort MH3 Sch(ei er LS3 D!((er DL3 Davies PT3 Pitts CD4 E$$icac- o$ co(trolle 0 release "aroAeti( e @( the treat+e(t o$ late0li$e e"ressio( 4 P Cli( Ps-chiatr-4 677= Se"D'?N8O:&7'>0 ;?4 &><4Sch(ei e r LS3 Nelso( PC3 Clar- CM3 NeFho!s e P3 1rish(a( 1R3 Shiovitz T3 Veihs 1D Sertrali(e El erl- De"ressio( St! - Gro!"4 A( <0Fee T +!ltice(te r3 "arallel0gro!" 3 o!%le0 %li( 3 "lace%o0co(trolle st! - o$ sertrali( e @( el erl- o!t"atie(ts Fith +aHor e"ressio( 4 A+ P Ps-chiatr -4 677= P!lD&'7N;O:&6;;0<>4 &>84Vilso( 1C3 Mottra+ PG3 AshForth L3 A%o!0Saleh MT4 2l e r co++!(it- resi e(ts Fith e"ressio(: lo(g0ter+ treat+e(t Fith sertrali(e 4 Ra( o+ise 3 o!%le0%li( 3 "lace%o0 co(trolle st! -4 9r P Ps-chiatr-4 677 = 2ctD&<=:='>4 &'74Ch!(g S4 Does the !se o$ SSRIs re !ce +e ical care !tilizatio( a( eA"e( it!res M P Me(t Health Polic- Eco(4 677> Se"D<N=O:&&8068 &'&4F!r!TaFa TA3 McG!ire H3 9ar%!i C4 Meta0a(al-sis o$ e$$ects a( si e e$$ects o$ loF osage tric-clic a(ti e"ressa(t s @( e"ressio(: s-ste+atic revieF4 9MP4 6776 Nov 6D=6>N;=;&O:88&4 &'64 Serra(o09la(co A3 Ga%arro( E3 Garcia09a-o I3 Soler0Lila M3 Cara+es E3 Pe(arr!%ia0 Maria M T3 Pi(to0Meza A3 Haro P M3 De"ressio e( Ate(ci o Pri+aria e Gava gro!"4 E$$ective(ess a( cost0e$$ective(ess o$ a(ti e"ressa( t treat+e(t @( "ri+ar- health care: a siA0+o(th ra( o+ise st! - co+"ari( g $l!oAeti(e to i+i"ra+i(e 4 Po!r(al o$ A$$ective Disor ers3 677'3 vol4 8&N60=O3 "ag4 &>=0 &'= &'=4A( erso( IM4 Selective seroto(i( re!"taTe i(hi%itors vers!s tric-cli c a(ti e"ressa(ts : a +eta0a(al-si s o$ e$$icac- a( tolera%ilit-4 P A$$ect Disor 4 6777 A"rD><N&O:&80='4 &'?4Altsh!ler LL3 Cohe( LS3 Moli(e ML3 1ah( DA3 Car"e(ter D3 Dochert- PPD EA"ert Co(se(s!s Pa(el $or De"ressio( @( Vo+e(4 The EA"ert Co(se(s!s G!i eli(e Series4 Treat+e(t o$ e"ressio(
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o$ +aHor e"ressive "atie(ts4 Cli( Ne!ro"har+acol 4 677' Pa(0Fe%D68N&O:'08 67&4 NaTagaF a A3 Vata(a% e N3 2+ori IM3 9ar%!i C3 Ci"ria(i A3 McG!ir e H3 Ch!rchill R3 F!r!TaFa TAD M!lti"le Meta0A(al-ses o$ NeF0Ge(eratio ( A(ti e"ressa(ts NMANGAO St! Gro!"E$$icac- a( tolera%ilit- o$ +il(aci"ra ( @( the treat+e(t o$ +aHor e"ressio( @( co+"ariso( Fith other a(ti e"ressa(t s : a s-ste+atic revieF a( +eta0a(al-sis 4 CNS Dr!gs4 677<D66N;O:><;0 '764 6764 2T!+!ra 13 F!r!TaFa TA4 Re+issio( rates Fith +il(aci"ra ( &77 +g5 a - a( &>7 +g5 a@( the lo(g0ter+ treat+e(t o$ +aHor e"ressio( 4 Cli( Dr!g I(vestig4 677'D6'N=O:&=>0?6 67=4Stahl SM3 Gra - MM3 Moret C3 9rile- M SNRIs: their "har+acolog -3 cli(ical e$$icac-3 a( tolera%ilit- @( co+"ariso ( Fith other classes o$ a(ti e"ressa(ts 4 CNS S"ectr4 677> Se"D&7N8O:;=60 ?; 67?4 Va e AG3 Fer(b( ez PL3 Fra(iois C3 Ha(se( 13 Da(che(T o N3 Des"iegel N4Escitalo"ra+ a( !loAeti( e @( +aHor e"ressive isor er: a "har+acoeco(o+i c co+"ariso ( !si(g U1 cost ata4 Phar+acoeco(o+ics 4 677<D6'N &&O:8'80<&4 67>4 RasTi( P3 Viltse CG3 Di(Tel PP3 ValTer DP3 Desaiah D3 1ato(a C4 Sa$et- a( tolera%ilito$ !loAeti( e at '7 +g o(ce ail- @( el erl- "atie(t s Fith +aHor e"ressive isor er4 P Cli( Ps-cho"har+acol 4 677< Fe%D6<N&O:=60<4 67'4 Shelto( RC3 A( or( AC3 Malli(cTro t CH3 Vohlreich MM3 RasTi( P3 VatTi( PG3 DetTe MP4Evi e(ce $or the e$$icac- o$ !loAeti( e @( treati(g +il 3 +o erate 3 a( severe e"ressio(4I( t Cli( Ps-cho"har+acol 4 677; NovD66N'O:=?<0>>4 67;4 D!((er DL3 Vilso( M3 Fava M3 1or(stei( S3 M!(oz R3 2cRear o ( P3 Trive i M3 Vohlreich M4Lo(g0ter+ tolera%ilit- a( e$$ective(ess o$ !loAeti( e @( the treat+e(t o$ +aHor e"ressive isor0 er4De"ress A(Aiet-4 677<D6>N>O:E&0<4 67<4 1ha( A3 9ose A3 AleAo"o!los GS3 Go++oll C3 Li D3 Ga( h i C4Do!%le0%li( co+"ariso( o$ escitalo"ra + a( !loAeti( e @( the ac!t e treat+e(t o$ +aHor e"ressive isor er4Cli( Dr!g I(vestig4 677;D6;N;O:?<&0864 6784 Va e A3 Ge+%ert 13 Florea I4A co+"arativ e st! - o$ the e$$icac- o$ ac!te a( co(ti(!atio( treat+e(t Fith escitalo"ra + vers!s !loAeti( e @( "atie(ts Fith +aHor e"ressive isor er4C!rr Me Res 2"i(4 677 ; P!lD6=N;O:&'7>0&?4 6&74 Pritchett RL3 Marci(iaT MD3 Core-0Lisle P13 9erzo( RA3 Desaiah D3 DetTe MP4Use o$ e$$ect size to eter+i(e o"ti+al ose o$ !loAeti( e @( +aHo r e"ressive isor er4P Ps-chiatr Res4 677; A"r0 P!(D?&N=0?O:= &&0<4 6&&4 Perahia DG3 1aH asz D13 Ro-er MG3 ValTer DP3 RasTi( P4D!loAeti( e @( the treat+e(t o$ +aHor e"ressive isor er: a( assess+e(t o$ the relatio(shi " %etFee( o!tco+es a( e"iso e char0 acteristics4I(t Cli( Ps-cho"har+acol 4 677' Se"D6&N>O:6<>08>4 6&64 Perahia DG3 1aH asz D13 ValTer DP3 RasTi( P3 T-lee A4 D!loAeti(e '7 +g o(ce ail- @( the treat+e(t o$ +il er +aHor e"ressive isor er4 I(t P Cli( Pract4 677' Ma-D'7N>O:'&=0674 6&=4 Lis PM3 va( 9aar eFiHT M3 Ei(arso( TRD!loAeti(e a( ve(la$aAi(e0UR @( the treat+e(t o$ +aHor e"ressive isor er: a +eta0a(al-si s o$ ra( o+ize cli(ical trials4A(( Phar+acothe r4 677> NovD=8N &&O:&;8<0<7;4 6&?4 9a%-aT M3 9l!+e(thal PA3 Her+a( S3 1hatri P3 DoraisFa+- M3 Moor e 13 Craighea VE3 9al eFicz TT3 1rish(a( 1R4 EAercise treat+e(t $or +aHor e"ressio(: +ai(te(a(c e o$ thera"e!tic %e(e$it at &7 +o(ths4Ps-choso + Me 4 6777 Se"02ctD'6N>O:'==0<4 6&>4 9l!+e(thal PA3 9a%-aT MA3 Moore 1A3 Craighea VE3 Her+a( S3 1hatri P3 Va!gh R3 Na"olita( o MA3 For+a( LM3 A""el%a!+ M3 DoraisFa+- PM3 1rish(a( 1R4 E$$ects o$ eAercise trai(i(g o( ol er "atie(t s Fith +aHor e"ressio( 4 Arch I(ter( Me 4 &888 2ct 6>D&>8N&8O:6=?80>'4 6&'4 LaFlor DA3 Ho"Ter SV4 The e$$ective(ess o$ eAercise as a( i(terve(tio ( @( the +a(age+e(t o$ e"ressio(: s-ste+atic revieF a( +eta0regressio ( a(al-sis o$ ra( o+ise co(trolle trials4 9MP4 677& Mar =&D=66N;6<8O:;'=0;4
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6&;4 Pag(i( D3 e ,!eiroz L3 Pi(i S3 Cassa(o G94 E$$icac- o$ ECT @( e"ressio(: a +eta0a(al-t0 ic revieF4 P ECT4 677? MarD67N&O:&=0674 6&<4 1ho 1H3 va( LreesFiHT MF3 Si+"so( S3 WFi( er+a ( AH4 A +eta0a(al-si s o$ electroco(v!l0 sive thera"- e$$icac- @( e"ressio(4P ECT4 677= Se"D&8N=O:&=80?;4 6&84 U1 ECT RevieF Gro!"4 E$$icac- a( sa$et- o$ electroco(v!lsiv e thera" - @( e"ressive is0 or ers: a s-ste+atic revieF a( +eta0a(al-sis4La(cet 4 677 = Mar <D='&N8='7O:;880<7<4 6674 Ha++er(es s P3 9asch E3 Ul%richt C3 9arrette EP3 Fo""a I3 9asch S3 9e(t S3 9oo( H3 Er(st ED Nat!ral Sta( ar Research Colla%oratio( 4 St Poh(cs Fort: a s-ste+atic revieF o$ a verse e$$ects a( r!g i(teractio(s $or the co(s!ltatio ( "s-chiatrist4 Ps-choso+atics 4 677= P!l0A!gD??N?O:6;&0 <64 66&4 1ell(er CH3 1(a"" RG3 Petri es G3 R!++a(s TA3 H!sai( MM3 Ras+!sse( 13 M!eller M3 9er(stei( HP3 2cCo((o r 13 S+ith G3 9iggs M3 9aili(e SH3 Mal!r C3 Ri+ E3 McCli(tocT S3 Sa+"so( S3 Fi(T M4 Co(ti(!atio ( electroco(v!lsiv e thera"- vs "har+acothera" - $or rela"se "reve(tio( @( +aHor e"ressio(: a +!ltisite st! - $ro+ the Co(sorti!+ $or Research @( Electroco(v!lsive Thera"- NC2REO4Arch Ge( Ps-chiatr-4 677' DecD'=N&6O:&==;0??4 6664 A""leto( 1M3 Ha-Far RC3 G!((ell D3 Peters TP3 Rogers PP3 1essler D3 Ness AR E$$ects o$ (0= lo(g0chai( "ol-!(sat!rate $att- aci s o( e"resse +oo : s-ste+atic revieF o$ "!%lishe tri0 als4 A+ P Cli( N!tr4 677' DecD<?N'O:&=7<0&'4 66=4 Gree(halg h P3 1(ight C3 Hi( D3 9everle- C3 Valters S4 Cli(ical a( cost0e$$ective(ess o$ electroco(v!lsiv e thera"- $or e"ressive ill(ess 3 schizo"hre(ia 3 catato(ia a( +a(ia: s-ste+atic revieFs a( eco(o+i c +o elli(g st! ies4 Health Tech(olog- Assess+e(t 677> Lol48: No48 "g4 &;74 66?4 1ras(iT C3 Mo(tori LM3 G!-att GH3 Heels0A(s ell D3 9!sse PV4 The e$$ect o$ %right light thera"- o( e"ressio( associate Fith "re+e(str!a l -s"horic isor e r4 A+ P 2%stet G-(ecol4 677> Se"D&8=N= Pt &O:'><0'&4 66>4 Schachter H3 1o!ra 13 Merali W3 L!+% A3 Tra( 13 Mig!elez M3 et al4 E$$ects o$ o+ega0= $att- aci s o( +e(tal health4 RocTville: Age(c- $or Healthcar e Research a( ,!alit- NAHR,O 677>: 66> 66'4 Gol e( RN3 Ga-(es 9N3 ETstro+ RD3 Ha+er RM3 Paco%se( FM3 S!""es T3 Vis(er 1L3 Ne+ero$$ C94 The e$$icac- o$ light thera"- @( the treat+e(t o$ +oo isor ers: a revieF a( +eta0 a(al-sis o$ the evi e(ce 4 A+ P Ps-chiatr-4 677> A"rD&'6N?O:'>'0'64 66;4 Co!t!rier PL4 E$$icac- o$ ra"i 0rate re"etitive tra(scra(ia l +ag(eti c sti+!latio( @( the treat0 +e(t o$ e"ressio(: a s-ste+atic revieF a( +eta0a(al-sis4 P Ps-chiatr- Ne!rosci4 677> MarD=7N6O:<=0874 66<4 PilTi(gto( 13 1irTFoo G3 Ra+"es H3 Fisher P3 Richar so( P4 Ho+eo"ath - $or e"ressio(: a s-ste+atic revieF o$ the research evi e(ce4Ho+eo"ath -4 677> P!lD8?N=O:&>=0'=4 6684 S+ith CA3 Ha- PP4 Ac!"!(ct!r e $or e"ressio(4Cochra( e Data%as e S-st Rev4 677> A"r &<DN6O:CD77?7?'4 6=74 1as"er S3 Die(el A4 Cl!ster a(al-sis o$ s-+"to+s !ri(g a(ti e"ressa( t treat+e(t Fith H-"eric!+ eAtract @( +il l- to +o eratel - e"resse o!t0"atie(ts 4 A +eta0a(al-si s o$ ata $ro+ three ra( o+ize 3 "lace%o0co(trolle trials4 Ps-cho"har+acolog - N9erlO4 6776 NovD&'?N=O:=7&0<4 6=&4 Li( e 13 M!lroF CD3 9er(er M3 Egger M4St Poh(cs Fort $or e"ressio( 4 Cochra(e Data%ase S-st Rev4 677> A"r &<DN6O:CD777??<4 6=64 LoFe 93U(!tzer P3Callaha( CM3PerTi(s AP31roe(Te 14Mo(itori(g e"ressio( treat+e(t o!t0 co+es Fith the "atie(t health S!estio((aire08 4 Me Care4 677? DecD ?6N&6O: &&8?067&4 6==4 LoFe 93 1roe(Te 13 Gra$e 14Detecti(g a( +o(itori(g e"ressio( Fith a tFo0ite+ S!es0 tio((aire NPH,06O4 P Ps-choso+ Res4 677> Fe%D><N6O:&'=0;& 6=?4 Arth!r AP3 Pagger C3 Li( esa- P3 MattheFs RP4Eval!ati(g a +e(tal healt h assess+e(t $or ol er "eo"le Fith e"ressive s-+"to+s @( ge(eral "ractice: a ra( o+ise co(trolle trial4 9r P Ge( Pract4 6776 MarD>6N?;'O:6760;4
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6=>4 He ricT SC3 Cha(e- EF3 FelTer 93 Li! CF3 Hase(%erg N3 Heagert- P3 9!cha(a( P3 9agala R3 Gree(%e rg D3 Pa e( G3 Fih( SD3 1ato( V4E$$ective(ess o$ colla%orativ e care e"ressio( treat+e(t @( Letera(sc A$$airs "ri+ar- care4 P Ge( I(ter( Me 4 677= Pa(D&<N&O:80&'4 6='4 Ara-a R3 RoHas G3 Fritsch R3 Gaete P3 RoHas M3 Si+o( G3 Peters TP4Treati(g e"ressio( @( "ri0 +arcare @( loF0i(co+ e Fo+e( @( Sa(tiago 3 Chile: a ra( o+ise co(trolle trial4 La(cet4 677= Mar 66D='&N8='6O:88>0&7774 6=;4 Colora o Cli(ical G!i eli(es Colla%orative 4 MaHor De"ressio ( Disor er @( A !lts4 Diag(ostica Treat+e(t G!i eli(es 4 htt":55FF F4colora og!i eli(es4o rg5" $5g!i eli(es5 e"ressio(5 e"ressio(eg!i eli(eeshort4" $ 6=<4 Mari(esc! L4As"ecte cli(ice @( e"resia reziste(ta la trata+e( t a(ti e"resiv4 Revista Psihiatr!4ro (r4 ;3 UII 677' N htt":55"sihiatr!4"!ls+e ia4ro5article00Cli(icaY6Cesi+"to+atologie0 As"ecteecli(iceei(e e"resiaereziste(taelaetrata+e(tea(ti e"resiv0066784ht+l O 6=841lei( DN3 LeFi(soh( PM3 Roh e P3 Seele- PR3 Sha(T+a( SA4 Fa+il- st! - o$ co0 +or%i it- %etFee( +aHor e"ressive isor er a( a(Aiet - isor ers 4 Ps-chol Me 4 677= Ma-D==N?O:;7=0&?4 6?74 Ci"ria(i A3 La Ferla T3 F!r!TaFa TA3 Sig(oretti A3 NaTagaF a A3 Ch!rchill R3 McG!ire H3 9ar%!i C4 Sertrali(e vers!s other a(ti e"ressiv e age(ts $or e"ressio( 4 Cochra(e Data%ase o$ S-ste+atic RevieFs 6778 3 Iss!e 64 Art4 No4: CD77' &&;4 D2I: &74&7765&?'>&<><4CD77' &&;4 "!%64 6?&4 Ci"ria(i A3 F!r!TaFa TA3 Ge es PR3 Malvi(i L3 Sig(oretti A3 McG!ire H3 Ch!rchill R3 NaTagaF a A3 9ar%!i CD MANGA St! - Gro!" 4 Does ra( o+ize evi e(ce s!""ort sertrali(e as $irst0li(e a(ti e"ressa( t $or a !lts Fith ac!te +aHor e"ressio(M A s-ste+atic revieF a( +eta0 a(al-sis 4 P Cli( Ps-chiatr-4 677< NovD'8N &&O:&;=60?6 4 E"!% 677< Nov ?4 6?64 Ci"ria(i A3 F!r!TaFa TA3 Sala(ti G3 Ge es PR3 Higgi(s PP3 Ch!rchill R3 Vata(a% e N3 NaTagaFa A3 2+ori IM3 McG!ire H3 Ta(sella M3 9ar%!i C4 Co+"arative e$$icac- a( acce"ta%il0 it- o$ &6 (eF0ge(eratio ( a(ti e"ressa(ts : a +!lti"le0treat+e(t s +eta0 a(al-sis4La(cet 4 6778 Fe% 6<D=;=N8''>O:;?'0><4 6?=4 Ci"ria(i A3 Sa(tilli C3 F!r!TaFa TA3 Sig(oretti A3 NaTagaF a A3 McG!ir e H3 Ch!rchill R3 9ar%!i C4 Escitalo"ra+ vers!s other a(ti e"ressiv e age(ts $or e"ressio( 4 Cochra(e Data%ase o$ S-ste+atic RevieFs 6778 3 Iss!e 64 Art4 No4: CD77'>=6 4 D2I: &74&7765&?'>&<><4 CD77'>=64"!%64 6??4 e Maat SM3 DeTTer P3 Schoevers RA3 e Po(ghe F4Relative e$$icac- o$ "s-chothera" - a( co+%i(e thera"- @( the treat+e(t o$ e"ressio(: a +eta0a(al-sis4E!r Ps-chiatr-4 677; Pa(D66N&O:&0 <4 E"!% 677' Dec 6;4
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