双相情感障碍增加身体疾病提前死亡的风险

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患精神疾病不光要关注精神
双相情感障碍增加生理疾病提前死亡的风险

首次系统化的研究报告发现双相患者多达两倍的风险提前死亡

Caroline Cassels

2009年2月6日

双相情感障碍会提高由于生理疾病导致的提前死亡，这包括心血管疾病、脑血管疾病、内分泌疾病以及慢性阻塞性肺病。

首部系统性研究报告经过审查双相情感障碍的死亡率，发现患者会有1.5到2倍的高风险由于这些常见的生理疾病而提前死亡。

“双相情感障碍有着和吸烟一样的巨大风险会提前死亡。这是项重大的发现，我们要使之深入内心，作为精神科医师，我们要定期监控我们慢性精神疾病患者的身体状况。”首席研究员，华盛顿大学医学院西雅图分校Wayne Katon博士认为。

惊人的发现

据Katon博士说，多项研究已经揭示了重性抑郁症和由于普通生理疾病导致的高风险的提前死亡之间的联系。最新的精神分裂症方面的文献研究证据也表明了类似的结果。

在过去，双相情感障碍的过量死亡常常认为是向自杀，谋杀，意外伤害等非自然因素。但是，新增的文献表明了这些只能说明一部分患者的提前死亡。

研究者回顾了17项研究涉及了331000名患者，其中包括双相情感障碍、情感性精神病、需要入院治疗或锂盐治疗的情感障碍或分裂情感性障碍。

相比于没有精神疾病的同年龄同性别的控制组，实验组的自然死亡与普遍特定生理疾病的死亡率都非常的高，这包括心脏病、吸烟、糖尿病和慢性阻塞性肺炎。

研究者们指出，在超过2500个双相情感障碍患者的更大型研究中，这项发现是尤为惊人的。

危险的循环

虽然机制并不明朗。Katon博士说他的小组进行的关于重性抑郁症和心脏病、骨关节炎和糖尿病之类的生理状况之间的联系，研究调查表明在慢性精神疾病和身体疾病间有双向的有害交互。

患有重性精神疾病如双相情感障碍会增加得上生理疾病的可能性，这会通过各种原因，如不良饮食习惯、吸烟、缺乏锻炼、物质依赖、社会剥夺以及尤其缺乏医疗护理实现。

另外，他指出患有重性生理疾病固有的慢性压力会影响下丘脑一垂体一肾上腺轴，提高可的松水平并导致交感神经系统的活跃，可能使生理疾病发病更早。（译者注：怀疑第一个生理疾病是笔误，应为精神疾病）

一旦患者有精神疾病的同时又有身体疾病，调整他们自己身体状况通常将是一个更为艰巨的挑战。患者有糖尿病，需要大量的自我保健，不良的调整会引起更多并发症，这会反馈并同时恶化精神状况。

“那确实会变成一种危险的循环。”Katon博士说。

非典型抗精神病药物的角色

另一项潜在的因素是广泛使用的第二代或非典型抗精神病药物和心境稳定剂。它们会导致身体疾病并造成双相情感障碍患者的过早死亡。

研究者暗示，虽然这些药物比第一代有包括包括锥体外系症状在内的更少的副作用，但是，它们与肥胖和代谢紊乱有关，这恐怕会增加糖尿病和心血管疾病的发病率和死亡率。

“所以最近我们会观察到对心境稳定剂和非典型抗精神病药物研究的新起，虽然它们在治疗精神疾病方面很有效，但是它们也带来新问题。”

“人们确实需要注意这些并且提高意识，以全新的方式面对——作为精神科医师，我们需要更注重我们病人的身体健康。如果只是眼看他们过早死于生理疾病，那么治疗他们的精神问题，难道有多大意义吗？”Katon博士表示。

试图减少精神疾病患者的过早死亡率的工作已经在进行，这包括增加训练精神科住院医师对普通生理疾病的认识和告知其风险因素的重要性。

我们需要治疗的新模型

另外，他指出治疗的新模型当前正在开发测试中——它是基层医疗健康服务和社区精神健康治疗的结合的产物。

“如今，在编的精神科医师隶属于正在成长的专业医疗的诊所，如糖尿病、心脏病、癌症中心和基层医疗中心如家庭医生”Katon博士说。

“精神健康专业人士与提供生理疾病治疗的医师并肩作战。许多地方，卫生保健和身心健康方案的新方法正在测试以发现预防双相患者和其他精神疾病患者过早死亡的有效模型”他补充道。
Katon博士坦言自己已经收到了来自礼来公司，辉瑞公司，森林实验室和惠氏公司的谢礼。他同时也是礼来公司的咨询会的成员。Roshanei-Moghaddam博士中立报道。
译者注：
social deprivation 社会剥夺
指因自幼父母过分保护，或因自幼生活环境过份孤立，致使个体无从参与社会性活动。无法获得社会经验与能力，终而影响其个性发展的情形。社会性剥夺与生活贫穷无关。自幼生活艰苦的孩子，其社会经验可能远较自幼娇生惯养者更为丰富。


Bipolar Disorder Increases Risk for Premature Death from Medical IllnessBipolar Disorder Increases Risk for Premature Death From Medical Illness
First Systematic Review Reveals Bipolar Patients Have up to 2-Fold Increased Risk for Early Death

Caroline Cassels

February6, 2009 — Bipolar disorder appears to increase the risk for prematuredeath due to medical illness, including cardiovascular andcerebrovascular disease, endocrine disorders, and chronic obstructivepulmonary disease.
The first systematic review to examinemortality data in bipolar disorder shows that affected individuals havebetween a 1.5- and 2-fold increased risk for premature death due tothese common medical conditions.
"It appears bipolar disorder is asbig a risk factor for premature mortality as smoking. This is a majorfinding and drives home the message that as psychiatrists we should beregularly monitoring the physical status of our patients with chronicmental illness," principal investigator Wayne Katon, MD, from theUniversity of Washington School of Medicine, in Seattle, said.
With first author Babak Roshanaei-Moghaddam, MD, the study is published in the February issue of Psychiatric Services.
Striking Findings
Accordingto Dr. Katon, several studies have shown a link between majordepression and an increased risk for early mortality due to generalmedical illnesses. Recent evidence from literature reviews inschizophrenia reveals similar results.
In the past, excess deathsassociated with bipolar illness were attributed to unnatural causes,such as suicide, homicide, and unintentional injuries. However, agrowing body of literature suggests this may account for only a portionof premature mortality in these individuals.
The investigatorsreviewed 17 studies involving more than 331,000 patients with bipolardisorder, affective psychosis, affective disorder requiring inpatientpsychiatric care or treatment with lithium, or schizoaffectivedisorder.
Compared with age- and sex-matched control sampleswithout mental illness from the general population, mortality ratiosfor death from natural causes and from specific general medicalconditions such as heart disease, stroke, diabetes, and chronicobstructive pulmonary disease were significantly higher.
Theinvestigators point out this finding was particularly striking inlarger studies of more than 2500 patients with bipolar disorder.
Vicious Cycle
Althoughthe mechanism is not entirely clear, Dr. Katon said research by hisgroup investigating the link between major depression and conditionssuch as heart disease, osteoarthritis, and diabetes suggests there maybe a bidirectional adverse interaction between chronic mental illnessand medical illness.
Having a major mental illness such as bipolardisorder increases the likelihood of developing physical illnessthrough a variety of factors, including poor diet, smoking, lack ofexercise, substance abuse, social deprivation, and a lack of medicalcare, among others.
In addition, he said, the chronic stressinherent in having a major medical illness can affect the hypothalamicpituitary adrenal axis, increasing cortisol levels and leading toheightened activity of the sympathetic nervous system, possibly leadingto earlier development of medical illness.
Once patients with amental illness contract a medical illness, it is often a greaterchallenge for them to manage their condition. With diseases likediabetes, which requires a lot of self-care, poor management can leadto more complications, which in turn can feed back and exacerbate themental-health condition.
"It really can turn into a vicious cycle," said Dr. Katon.
Role of Atypical Antipsychotics
Anotherpotential contributing factor to physical illness and prematuremortality in patients with bipolar disorder has been the introductionof second-generation, or atypical, antipsychotics and mood stabilizers,which are now in widespread use.
Although these agents have feweradverse effects, including extrapyramidal symptoms, than theirfirst-generation counterparts, they are associated with obesity andmetabolic abnormalities that may increase the risk for morbidity andmortality resulting from diabetes and cardiovascular disease, theresearchers note.
"So what we've seen in recent years is abeginning of the understanding in the field that mood stabilizers andatypical antipsychotics, although effective in treating mental illness,are bringing new problems to bear.
"This has really gottenpeople's attention and raised awareness in a way I've never seen before— that, as psychiatrists, we need to pay closer attention to ourpatients' physical health. There's not much point in effectivelytreating them for their mental-health problems only to watch them dieprematurely from their medical diseases," said Dr. Katon.
Attemptsto reduce rates of premature mortality in mentally ill patients areunder way and include increased training among psychiatry residentsabout common medical illnesses and the importance of addressing riskfactors.
New Models of Care Needed
In addition, he said, newmodels of care that marry primary-care health services with communitymental-health care are currently being developed and tested.
"Psychiatristsare now on the staff of a growing number of medical-specialty clinics,such as centers for diabetes, heart disease, and cancer, and atprimary-care centers such as family-medicine practices," Dr. Katon said.
"Mental-healthprofessionals are working side by side with providers who treat medicalillnesses. New approaches to healthcare and wellness programs are beingtested at a number of places to find effective models for preventingpremature deaths associated with bipolar disorder and other mentalillnesses," he added.
Dr. Katon discloses that he has receivedhonoraria from Eli Lilly, Pfizer, Forest Laboratories, and Wyeth. He isalso on an advisory board for Eli Lilly. Dr. Roshanei-Moghaddam reportsno competing interests.