Leon Piterman，F(xiàn)iona Judd，Grant Blashki，Hui Yang

案例介紹：在中文中，“心臟”和“心理”兩個詞都共享一個“心”字。從中醫(yī)文化中，我們也了解到“心總統(tǒng)形神功能”和“形神合一”等東方哲學觀點。這些樸素的東方文化提示了心臟和心理的互動關系，以及軀體心病與心理心病的共存現(xiàn)象。一項在中國的研究表明，某醫(yī)院心臟內(nèi)科40%的患者同時患有焦慮，24%的患者同時患有抑郁[1]。另外一個最近的研究發(fā)現(xiàn)，15%～30%的心血管內(nèi)科門診患者和60%～75%的心血管急診患者中存在軀體和心理疾病共患的情況[2]。不過，在高度專科化的醫(yī)院環(huán)境中，醫(yī)務人員很可能主要關注軀體上的心臟問題，而忽略精神上的心理問題。北京大學的劉梅顏[3]認為，“雙心”共病的發(fā)生率高、診出率低這一現(xiàn)象甚為普遍，因此也推斷管理率更低。全科醫(yī)學以病人為中心和整體人的診療策略，通過生理-心理-社會模式，并通過與醫(yī)院和多學科團隊的合作，可以幫助患者管理雙心共病。Piterman教授和同事們通過這個案例，與您討論怎樣發(fā)現(xiàn)、診斷和管理同時患有冠心病和抑郁的患者。

1　病史

湯姆是一位67歲的木工，他妻子2年前死于乳腺癌，現(xiàn)在他自己一個人單獨生活。他的兒子和女兒都已經(jīng)結婚，住在離他不遠的地方。在這次生病前，湯姆整天忙碌于自己的木工和家具制造生意。在妻子去世前，他曾經(jīng)中斷過幾個月的工作。

湯姆的既往病史包括高血壓和高脂血癥，分別服用阿替洛爾(atenolol)50 mg和辛伐他汀(simvastatin)20 mg治療。在這次看病前1個月，他患了心肌梗死，造成局灶性的心血管損傷。醫(yī)生在他的左側和右側冠狀動脈上放置了兩個支架。他在醫(yī)院住了1周，出院后轉入康復服務項目。他剛剛開始接受康復服務。

這次湯姆找你看病的時間是他出院后4周，他主訴自己極端地疲勞、睡眠很差、缺乏食欲、體質(zhì)量降低(4周內(nèi)體質(zhì)量減少4 kg)、缺乏信心、做任何事情都找不到樂趣、不能考慮重新工作。

你給他進行身體檢查，并沒有發(fā)現(xiàn)什么有意義的體征。他的血壓125/80 mm Hg(1 mm Hg=0.133 kPa)，脈搏64次/min，規(guī)律。沒有發(fā)現(xiàn)心臟衰竭或貧血的臨床指征。胸部聽診未發(fā)現(xiàn)異常，神經(jīng)學檢查也沒有發(fā)現(xiàn)異常。目前的服藥情況是每天服用一次如下藥物：阿司匹林100 mg，氯吡格雷(clopidogrel)75 mg，辛伐他汀40 mg，雷米普利(ramipril)20 mg，阿替洛爾25 mg。

2　提問

2.1你的鑒別診斷是什么？

2.2你應該安排哪些實驗室檢查？

2.3你要給湯姆講哪些管理計劃？

3　解答

3.1鑒別診斷即便是沒有臨床指征，某些軀體上的原因也能造成他目前的癥狀，如貧血(他在服用阿司匹林，因此存在胃腸失血的風險)、糖尿病、甲狀腺毒癥、潛在的惡性腫瘤等，這些都需要通過檢查來排除。

抑郁是可能的診斷。雖然他沒有抑郁的既往史，也沒有家族史(有情感障礙的老年人通常有既往史和家族史)；但他既有抑郁的危險因素(妻子去世、一個人獨居、最近患嚴重的軀體疾病)，也有抑郁的生物學因素(疲勞感、失去食欲、體質(zhì)量降低、睡眠紊亂)，還有心理學上的表現(xiàn)(如快感缺乏，即對任何事情都缺乏快樂，失去信心)，這些都與抑郁的表現(xiàn)是一致的。

3.2實驗室檢查首先核對湯姆在住院期間的實驗室檢查結果。如果要考慮周全的話，要讓他再重復進行全血檢查、血沉檢查、C-反應蛋白檢查、血脂檢查、腎功能檢查、肝功能檢查、甲狀腺功能檢查、維生素B12水平檢查、心電圖檢查。如果有必要，可以做超聲心動圖檢查。根據(jù)這些檢查的結果，可能還需要進一步的檢查。比如，如果血涂片檢查發(fā)現(xiàn)他有小細胞低色素性貧血，則懷疑是缺鐵引起，需要做血鐵水平檢查、便隱血檢查，也許還需要做上下胃腸內(nèi)鏡檢查。

3.3管理計劃你要給湯姆解釋，告訴他具有很多抑郁的特征，不過需要排除造成這些癥狀的軀體原因。所以他需要做一些實驗室檢查，并需要在1周后再來診所看結果。服用藥物也可能造成抑郁。對這個案例來講，β-受體阻滯劑是惟一的懷疑藥物，不過他用的劑量很小，而且相對于其他β-受體阻滯劑而言，阿替洛爾的心血管選擇性更強。特別是，他在心肌梗死之前和目前癥狀出現(xiàn)前，就已經(jīng)服用阿替洛爾了。

重要的一點是要評估他癥狀的嚴重程度，以及他是否能恰當?shù)卣疹欁约骸Ｔ跍冯x開診所之前，你必須評估他的自殺風險，并告訴他如果感到活著沒有意義，他應該立刻與你或診所取得聯(lián)系。與有老伴的老年人相比，孤寡老人的自殺風險較高。

4　復診

湯姆1周后再次來到診所看他的檢查結果。這次是他女兒陪他一起來的。他女兒對你表達了她對湯姆情況的擔心。她說湯姆吃得非常少，好像故意地怠慢自己。她3 d前搬來和湯姆住在一起，發(fā)現(xiàn)湯姆的家里凌亂不堪。她說湯姆變得很健忘，而且經(jīng)?？奁吆懿?。她發(fā)現(xiàn)湯姆凌晨3點的時候圍著房子游蕩。湯姆對自己的生意沒有任何興趣，而且好多賬單也沒有付。

在整個看病過程中，湯姆一直沉默寡言。

1周前安排的所有檢查的結果都是正常的。你告訴湯姆和他的女兒，說結果都正常，可是他女兒對你說：“肯定他有些地方不正常！爸爸正常的時候可不是這樣的。即便是媽媽去世的時候，他也沒有孤立和疏忽自己?！?/p>

5　提問

5.1在這個階段，你的可能診斷是什么？

5.2你準備做哪些進一步的評估？

5.3根據(jù)你的可能診斷，你的管理計劃是什么？

6　解答

6.1可能診斷

6.1.1重性抑郁發(fā)作(major depressive episode)湯姆具有很多重性抑郁的特征：心境低落、精力和動機缺乏、快感缺乏、睡眠紊亂、食欲缺乏、體質(zhì)量降低。她女兒描述湯姆的失能程度，提示他處于嚴重的發(fā)作狀態(tài)。

抑郁與心血管疾病之間有很強的雙向關系。抑郁是冠心病的危險因素[4]，而且在患心血管疾病的人群中，特別是經(jīng)歷急性事件(比如心肌梗死或心臟手術)后，重性抑郁是更常見的[5]。對心血管疾病的患者診斷和治療抑郁會給患者的預后以及整體健康帶來影響。抑郁與心血管疾病的生物學關系一直備受研究者關注，各種研究方向包括通過應激激素(如皮質(zhì)醇)的釋放來激活下丘腦-垂體-腎上腺素軸，炎性細胞因子的激活，以及對冠狀血管和血小板凝集的作用[6]。

6.1.2老年癡呆癥(dementia)湯姆生病的很多特征，特別是他女兒描述的很多特征，增加了診斷老年癡呆癥的可能性。興趣缺乏、自我忽視，以及忽視他生活的環(huán)境，想法混淆，夜間游蕩，這些都可能是老年癡呆癥的特征。然而，抑郁和老年癡呆在癥狀學上有很多交叉，因此可能帶來診斷上的困難。有人用“抑郁性假性癡呆”(depressive pseudodementia)來表述老年人的綜合征[7]，這種綜合征主要表現(xiàn)為認知上的問題，容易讓人聯(lián)想到老年癡呆癥(記憶損傷和混淆)，不過實際上應該診斷為抑郁。識別患者是否真的因為抑郁造成臨床表現(xiàn)，關鍵點是這些“真抑郁假癡呆”的患者通常對抗抑郁藥有很好的反應；那些嚴重的抑郁患者對電休克療法(ECT)也有很好的反應。

對湯姆的案例來說，如果發(fā)現(xiàn)他有認知損傷，就需要對腦血管原因造成癥狀的可能性做些考慮。在考慮他的危險因素時，鑒于他做過心臟手術，腦栓塞的可能性總是會有的。

6.2進一步評估在這次看病中，應該做兩個重要的臨床評估，即采用簡易精神狀態(tài)檢查(MMSE)[8]評估患者的認知功能(我們假設在前一次就診的時候沒有做過這個評估)，以及評估患者的自殺風險。如果簡易精神狀態(tài)檢查結果異常，就可以給患者做正式的神經(jīng)心理學測試，并進行腦CT檢查。湯姆的簡易精神狀態(tài)檢查的結果是24/30。

湯姆說在當下的困境中，自己感到生活沒有什么意義。不過，他否認自己有任何自殺計劃。他哭著對你說，如果自殺的話，會讓家人很難過，也玷污對妻子的美好回憶。

6.3管理計劃

6.3.1心理教育給湯姆和他女兒提供教育，告訴他們有關抑郁的知識，并告訴他們需要采取包括藥物在內(nèi)的治療措施，這一點是很重要的。他們應該知道藥物治療需要2～4周才會出現(xiàn)改進效果，不過有些其他的藥物可以幫助患者改善睡眠。他們還應該理解治療措施中包括心理學治療，并需要家庭的社會支持。治療是一個長期的過程，患者可能要服藥6～9個月，甚至更長的時間。治療是由全科醫(yī)生安排的；如果患者對治療的反應很小甚至沒有反應，如果患者的自殺風險加重，則要把患者轉診給精神病學專家。

6.3.2藥物治療選擇性5-羥色胺再攝取抑制劑(SSRIs)是心血管疾病和抑郁患者的治療用藥[9]。應避免使用三環(huán)類抗抑郁藥，因為存在心律失常和用藥過量致命的危險。曲舍林(sertraline)對老年人來說有較好的耐受性，開始劑量為50 mg，然后根據(jù)藥物反應增加到100 mg或150 mg。在1～2個星期內(nèi)夜間使用苯二氮(benzodiazepine)會有助于患者的睡眠。短效藥物如替馬西泮(temazepam)10 mg，適用于有依賴風險的情況。如果讓患者使用苯二氮，一定是在短期內(nèi)使用，一般不要超過2個星期。湯姆需要每2個星期做一次復診。

6.3.3心理治療如果能安排心理治療師給患者做認知行為治療(CBT)治療患者的抑郁，則可以在患者的康復服務項目中安排這個治療。

6.3.4合作服務在針對湯姆的合作性服務中，全科醫(yī)生發(fā)揮著至關重要的作用。全科醫(yī)生采用生物-心理-社會模式，并扮演守門人的角色。全科醫(yī)生通過書面、電話、電子郵件等各種方式，與治療團隊的所有成員保持聯(lián)系。這個團隊包括全科醫(yī)生、湯姆本人、他的家人、心血管病專家、康復團隊、心理學專家、精神病學專家、藥劑師等。在澳大利亞，全科醫(yī)生得到全民醫(yī)療保險計劃的資助(全民醫(yī)療保險的初級保健增強項目)，開展和協(xié)調(diào)為湯姆這樣的患者提供服務。

1葉維菲，徐俊冕.100例住院心臟病人的焦慮抑郁調(diào)查[J].上海精神醫(yī)學，1993，5(4)：253-255.

2夏大勝，盧成志.心血管病人心理障礙特點及其治療[EB/OL].http://www.365heart.com/show/80131.shtml.

3劉梅顏.“雙心”共病：發(fā)生率高 診出率低[EB/OL].http://www.mdweekly.com.cn/doc/2009/12/21501.shtml.

4Rudish BNC.The epidemiology of comorbid coronary artery disease and depression[J].Biol Psychiatry,2003,54:227-240.

5Lichtman JH,Bigger JT,Blumenthal JA,et al.Depression and coronary artery disease:Recommendations for screening,referral and treatment[J].Circulation,2008,118:1768-1775.

6Joynt KE,Whellan DJ,O′Connor CM.Depression and cardiovascular disease:Mechanisms and interaction[J].Biol Psychiatry,2003,54:16-22.

7Bulbena A,Berrios GE.Pseudodementia:Facts and figures[J].Br Jnl Psychiatry,1986,148:87-94.

8Folstein MF,Folstein SE,McHugh PR.Mini-mental state:A practical method for grading the cognitive state of patients for the clinician [J].Jnl Psychiatric Research,1975,12:189-198.

9Roose S.Treatment of depression in patients with heart disease[J].Biol Psychiatry,2003,54:262-268.

·WorldGeneralPractice/FamilyMedicine·

【IntroductionoftheColumn】The Journal presents the Column of Case Studies of Mental Health in General Practice;with academic support from Australian experts in general practice,psychology and psychiatry from Monash University and the University of Melbourne.The Column′s purpose is to respond to the increasing needs of mental health services in China.Through study and analysis of mental health cases,we hope to improve understanding of mental illnesses in Chinese primary health settings,and to build capacity amongst community health professionals in managing mental illnesses in general practice.Patient-centred whole-person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and research.A number of Australian experts from the disciplines of general practice,mental health and psychiatry will contribute to the Column.A/Professor Blashki,Professor Judd and Professor Piterman are authors of General Practice Psychiatry.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will reach new heightsunder this international cooperation.

Introductiontothecasestudy:In Chinese language,heart (Xin Zang,literally physical heart) and mind (Xin Li,literally spirit heart)share a same character of′heart′.It is also known from traditionalChinese medicine that both physical and spirit heart (brain and emotion) governs organs and functions which form human life.The simple belief in oriental culture suggests that the physical and mental heart interact and so there is coexistence of "heart ill and mental ill".One Chinese study found,among heart disease patients admitted into a hospital internal medical ward,40% of them suffered anxiety and 24% of the suffered depression[1].Another recent Chinese study suggested 15%～30% cardiovascular outpatient visitors and 60%～75% of heart disease emergency patients have physical and mental comorbidity[2].However,in highly specialized hospital environment,clinicians might mainly focus only on thephysical heart problem instead of caringfor the ′spirit heart′.Peking University LIU Mei-yan[3]reported ′high comorbidity and low detection′ of the ′double heart condition′.General practitioners who work in thecommunity and the interface between primary care and hospital care have opportunity to help patients applying the principle of whole-person care in partnership with a multi-disciplinary team.In this case study,Professor Leon Piterman and his colleagues discuss with you how to detect,diagnose and management patients with both physical and mental heart disorders.

1　History

Tom is a 67 carpenter who lives on his own following the death of his wife from breast cancer 2 years ago.His son and daughter,both married with families live in close proximity.Until his recent illness,Tom was working fulltime as a carpenter and cabinet maker running his own small business.This was interrupted for a few months during the terminal phases of his wife′s illness.

Tom has a past history of hypertension and hyperlipidaemia treated with Atenolol 50mg and Simvastatin 20mg respectively.A month before his current presentation to you he had a myocardial infarct with minimal cardiac damage.He had 2 coronary artery stents inserted into his left and right coronary arteries.He was in hospital for 1 week and discharged into a rehabilitation program which he is about to commence.

He presents to you 4 weeks after hospital discharge complaining of extreme tiredness,poor sleep,lack of appetite,loss of weight (he has lost 5kg in 4 weeks),lack of confidence,unable to find pleasure in anything,and unable to contemplate return to work.

Physical examination is unremarkable.His BP is 125/80 mm Hg(1 mm Hg=0.133 kPa),Pulse 64/min regular;there are no signs of cardiac failure or anaemia clinically.His chest is clear on auscultation and there are no abdominal signs or neurological signs present.His current daily medication now consists of once daily doses of the following medications:aspirin 100mg,clopidogrel 75 mg,simvastatin 40 mg,ramipril 20 mg and atenolol 25 mg.

2　Questions

2.1What is your differential diagnosis?

2.2What investigations will you do?

2.3What will you tell Tom,about your management plan?

3　Answers

3.1Despite the absence of clinical signs,physical causes of his symptoms such as anaemia(he is taking aspirin so there is a risk of gastro intestinal blood loss),diabetes,thyrotoxicosisand underlyingmalignancy need to be excluded.

Depression is a likely diagnosis.Although he has no past history or family history of depression (both common when an older person presents with a mood disorder),Tom has both risk factors for depression (he is a widower,lives on his own and has experienced recent serious illness) as well as biological(tiredness,loss of appetite and weight loss,sleep disturbance) and psychological manifestations (for example anhedonia which means no pleasure in anything and loss of confidence),which are consistent with depression.

3.2Check the results of the investigationsthat were done in hospital.It would be thorough for him to have a repeat of full blood examination,an ESR or CRP,blood sugar,renal and liver function tests,thyroid function,Vitamin B 12 level,an ECG and if necessary an echocardiogram.Depending on the findings further examination may be required.For example if he is found to be anaemic with a hypochromic microcytic appearance on the blood film,iron deficiency may be suspected and he would need iron levels,faecal occult blood testing and may alsoneed upper and lower GI endoscopy.

3.3You will explain to Tom that he has a number of features of depression but physical causes for his symptoms need to be excluded.Hence he needs to have a number of tests and to be reviewed in one week.Medications can also cause depression.The B Blocker is the only suspect in this case,but he is on a low dose and atenolol which is more cardioselective than other B Blockers.Notably he was taking this medication before his myocardial infarct and before the current symptoms arose.

It is important that you assess the severity of his symptoms,whether he is able to adequately look after himself.You must assess his suicide risk before Tom leaves the clinic and indicate that should Tom feel that life is not worth living he makes contact with you or the clinic immediately.Widowers are at higher risk for suicide than older males in a relationship.

4　Follow up visit

Tom returns one week later to get his results.This time he is accompanied by his daughter who expresses concern about Tom′s condition.She states that Tom is eating very little and seems to be neglecting himself.She has moved into his house for the past 3 days and found it to be in a mess.She indicates that he appears to be forgetful,is often tearful and sleeps poorly.She found him wandering around the house at 3am in the morning.He has not taken any interest in his business and there are unpaid accounts.

Tom appears withdrawn during the consultation.

All the previously performed tests are normal.You inform Tom and his daughter that the tests are normal,to which his daughter replies:"There must be something wrong with him.Dad is not normally like this.Even when mum died he did not withdraw and neglect himself."

5　Questions

5.1What is your probability diagnosis at this stage?

5.2What further assessment would you undertake?

5.3Based on your probability diagnosis,what is your management plan?

6　Answers

6.1Probability diagnosis

6.1.1Major depressive episodeTom has many of the features of major depression:Low mood,loss of energy and motivation,anhedonia,sleep disturbance,loss of appetite and weight loss.The degree of disability described by his daughter indicates he has a severe episode.

There is a strong and bi-directional relationship between depression and cardiovascular disease.Depression is a risk factor for ischaemic heart disease[4]and major depression is more common in people with cardiovascular disease especially following an acute event like a myocardial infarct or cardiac surgery[5].Diagnosing and treating depression in patients with cardiovascular disease may influence the prognosis of that condition as well the well being of the patient as a whole.The biological basis for the relationship between depression and cardiovascular disease is the subject of ongoing research taking a variety of directions including activation of the hypothalamic -pituitary- adrenal axis with release of stress hormones such as cortisol,activation of inflammatory cytokines and their effect on the coronary vessels and platelet aggregation[6].

6.1.2DementiaThere are a number of features of Tom′s illness,particularly those described by his daughter,which raise the possibility of dementia.Loss of interest,self neglect and neglect of his living environment as well as confusion and wandering at night,may all be features of dementia.Depression and dementia symptomatology may overlap which makes diagnosis difficult.The term "Depressive Pseudodementia"[7]is used to describe a syndrome in older people dominated by cognitive features suggestiveof dementia (memory impairment and confusion),but the diagnosis is actually depression.It is critical to identify individuals who actually do have depression as the cause of this presentation as they usually have a good response to antidepressants or in severe cases to electro convulsive therapy (ECT).

In Tom′s case if cognitive impairment is found some consideration should be given to a cerebrovascular cause for his symptoms.Having a cardiac procedure in the context of his risk factors there is always the slim chance that cerebro-thromboembolism may have occurred.

6.2Further assessmentTwo important clinical assessments should be undertaken at this consultation.They include assessment of cognitive function using the mini -mental examination (MMSE)[8](assuming this was not done at the first consultation) and assessment of suicide risk.If the mini-mental examination is abnormal then formal neuropsychological testing should be undertaken and a cerebral CT scan performed.Tom scores 24/30 on the MMSE.

He states that he feels life is hardly worth living in his current predicament but denies any plans to commit suicide and acknowledges tearfully that it would upset his family if he did and would also bring shame to the memory of his late wife.

6.3Management Plan

6.3.1Psycho-educationIt is important to educate Tom and his daughter about the nature ofdepression and the requirement for treatment including medication.They should appreciate that it may take 2-4 weeks before any improvement is noted on the medication,but some additional medication will be used to help sleep.They should also understand that treatment may include psychological therapies and will require social support from the family.Treatment will be long term and he may need to be on medication for 6-9 months or even longer.Although treatment may be undertaken by the GP,should there be little or no response to treatment,or should the risk for suicide exacerbate the referral to a psychiatrist will be sought.

6.3.2MedicationSSRIs are the treatment of choice for patients with cardiovascular disease and depression[9].Tricyclic antidepressants should be avoided due to the risk of arrhythmias and fatal overdose.Sertraline is generally well tolerated in older patients with a starting dose of 50mg building up to 100mg or 150mg depending on the response.It may be helpful to use a benzodiazepine at night for a week or two to help sleep.A short acting medication such as Temazepam 10mg may be suitable with warning about the risk for addiction.If you do prescribe a benzodiazepine this should be for only a short period of time,generally no more than 2 weeks.Tom will need to be reviewed in 2 weeks.

6.3.3PsychotherapyCognitive behavioral therapy for his depression may be offered as part of the cardiac rehabilitation program if this can be organized with a treating psychologist.

6.3.4Care Co-ordinationThe role of the GP is critical in co-ordinating Tom′s care using a bio-psycho-social model.The GP is the gatekeeper of care in this instance so communication in writing,by phone and email is essential with all members of the team which includes Tom,his family,the cardiologist,the rehabilitation team,possibly the psychologist,perhaps a psychiatrist and the local pharmacist.In Australia GPs are specifically funded to undertake and co-ordinate care plans to manage such patients as part of the national universal health insurance,Medicare Enhanced Primary Care Program.

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