抑郁症：修订间差异

对抑郁症的诊断一般由医生遵照DSM或ICD标准（两者基本一致）进行，一般症状较重的患者考虑诊断为重性抑郁障碍，症状较轻但是病程较长的患者则有可能是心境恶劣障碍，有明显季节性特征的患者可能诊断为季节性情绪失调。另外，在按此标准诊断前一般须排除其他有相似症状的生理疾病<ref name="NIMHPub">{{cite web|title=Depression|url=http://www.nimh.nih.gov/health/publications/depression/nimhdepression.pdf|accessdate=2008-09-07|format=PDF|publisher=National Institute of Mental Health (NIMH)|archiveurl=https://web.archive.org/web/20071025164433/http://www.nimh.nih.gov/health/publications/depression/nimhdepression.pdf|archivedate=2007-10-25|deadurl=yes}}</ref>。

抑郁症属于常见的心理疾病的一种，目前全球有超过2.64亿名患者<ref>{{Cite journal|title=Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017|url=https://linkinghub.elsevier.com/retrieve/pii/S0140673618322797|last=James|first=Spencer L|last2=Abate|first2=Degu|date=2018-11|journal=The Lancet|issue=10159|doi=10.1016/S0140-6736(18)32279-7|volume=392|pages=1789–1858|language=en|pmc=PMC6227754|pmid=30496104|last3=Abate|first3=Kalkidan Hassen|last4=Abay|first4=Solomon M|last5=Abbafati|first5=Cristiana|last6=Abbasi|first6=Nooshin|last7=Abbastabar|first7=Hedayat|last8=Abd-Allah|first8=Foad|last9=Abdela|first9=Jemal|access-date=2021-01-31|archive-date=2021-03-08|archive-url=https://web.archive.org/web/20210308005458/https://linkinghub.elsevier.com/retrieve/pii/S0140673618322797|dead-url=no}}</ref>。近年来抑郁症的发病年龄有提早，且发病率提高的趋势。终身患病率在不同国家中不尽相同，有调查显示中国的患病率约为6%<ref>{{cite journal|title=浙江省15岁及以上人群精神疾病流行病学调查|author=石其昌，章健民，徐方忠，费立鹏，许毅，傅永利，顾卫，周夏江，王淑敏，张滢，俞敏|url=http://d.wanfangdata.com.cn/Periodical_zhyfyx200504003.aspx|journal=中华预防医学杂志|issue=4|year=2005|volume=39|access-date=2009-10-09|archive-date=2015-06-18|archive-url=https://web.archive.org/web/20150618210236/http://d.wanfangdata.com.cn/Periodical_zhyfyx200504003.aspx|dead-url=no}}</ref>，而日本的患病率则高达20%<ref name="NIMHPub" /><ref name="pmid9895168">{{Cite journal|title=Psychiatric epidemiology in Japan: towards psychological understanding of the etiology of minor psychiatric disorders|url=https://pubmed.ncbi.nlm.nih.gov/9895168|last=Kitamura|first=T.|date=1998-12|journal=Psychiatry and Clinical Neurosciences|doi=10.1111/j.1440-1819.1998.tb03243.x|volume=52 Suppl|pages=S275–277|issn=1323-1316|pmid=9895168|access-date=2021-01-31|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133453/https://pubmed.ncbi.nlm.nih.gov/9895168/|dead-url=no}}</ref>。Covid-19致使全球青少年抑郁概率翻倍增加。<ref>{{Cite journal|title=Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19|url=https://jamanetwork.com/journals/jamapediatrics/fullarticle/2782796|last=Racine|first=Nicole|last2=McArthur|first2=Brae Anne|date=2021-08-09|journal=JAMA Pediatrics|doi=10.1001/jamapediatrics.2021.2482|language=en|issn=2168-6203|last3=Cooke|first3=Jessica E.|last4=Eirich|first4=Rachel|last5=Zhu|first5=Jenney|last6=Madigan|first6=Sheri|access-date=2021-09-01|archive-date=2021-10-02|archive-url=https://web.archive.org/web/20211002134115/https://jamanetwork.com/journals/jamapediatrics/fullarticle/2782796|dead-url=no}}</ref>

在积极治疗的情况下抑郁症的癒后良好，但考虑到患者须承受极大痛苦并有自杀的可能，因此应尽早进行积极治疗。患者在症状缓解后仍有复发的可能，世界卫生组织建议对抑郁症的药物治疗至少持续到症状缓解后的六个月。<ref name="pmid184582032">{{Cite journal|title=Population-Based Study of First Onset and Chronicity in Major Depressive Disorder|url=http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archpsyc.65.5.513|last=Eaton|first=William W.|last2=Shao|first2=Huibo|date=2008-05-01|journal=Archives of General Psychiatry|issue=5|doi=10.1001/archpsyc.65.5.513|volume=65|pages=513|language=en|issn=0003-990X|pmc=PMC2761826|pmid=18458203|last3=Nestadt|first3=Gerald|last4=Lee|first4=Ben Hochang|last5=Bienvenu|first5=O. Joseph|last6=Zandi|first6=Peter}}</ref>对于发病较早、有精神病症状或对药物反应不良的患者则很有可能反复发作造成不良后果<ref name="pmid18251627">{{Cite journal|title=Long-term outcome of major depressive disorder in psychiatric patients is variable|url=https://pubmed.ncbi.nlm.nih.gov/18251627|last=Holma|first=K. Mikael|last2=Holma|first2=Irina A. K.|date=2008-02|journal=The Journal of Clinical Psychiatry|issue=2|doi=10.4088/jcp.v69n0205|volume=69|pages=196–205|issn=1555-2101|pmid=18251627|last3=Melartin|first3=Tarja K.|last4=Rytsälä|first4=Heikki J.|last5=Isometsä|first5=Erkki T.|access-date=2021-01-31|archive-date=2021-03-18|archive-url=https://web.archive.org/web/20210318061409/https://pubmed.ncbi.nlm.nih.gov/18251627/|dead-url=no}}</ref><ref name="pmid12877398">{{Cite journal|title=Time to recurrence after recovery from major depressive episodes and its predictors|url=https://pubmed.ncbi.nlm.nih.gov/12877398|last=Kanai|first=T.|last2=Takeuchi|first2=H.|date=2003-07|journal=Psychological Medicine|issue=5|doi=10.1017/s0033291703007827|volume=33|pages=839–845|issn=0033-2917|pmid=12877398|last3=Furukawa|first3=T. A.|last4=Yoshimura|first4=R.|last5=Imaizumi|first5=T.|last6=Kitamura|first6=T.|last7=Takahashi|first7=K.|access-date=2021-01-31|archive-date=2021-03-18|archive-url=https://web.archive.org/web/20210318053729/https://pubmed.ncbi.nlm.nih.gov/12877398/|dead-url=no}}</ref>。

去甲肾上腺素、多巴胺让人感觉精力旺盛、情绪饱满、感觉振奋，如果缺乏则表现为快感缺失，情绪低落，没有精神与动力，思考迟缓，学习能力变低。该学说由Schildkraut等于1965年首先提出，认为抑郁症的发生是由于大脑中枢神经系统中[[去甲肾上腺素]]含量不足所致<ref>{{Cite journal|title=Catecholamine metabolism in affective disorders: I.|url=https://linkinghub.elsevier.com/retrieve/pii/0022395665900038|last=Schildkraut|first=Joseph J.|last2=Gordon|first2=Edna K.|date=1965-12|journal=Journal of Psychiatric Research|issue=4|doi=10.1016/0022-3956(65)90003-8|volume=3|pages=213–228|language=en|last3=Durell|first3=Jack|access-date=2021-01-31|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133512/https://linkinghub.elsevier.com/retrieve/pii/0022395665900038|dead-url=no}}</ref>。去甲肾上腺素受体主要有α、β受体，其中去甲肾上腺素β、α₂受体敏感导致抑郁症的发生。有研究者认为抑郁症患者去甲肾上腺素生成释放减少是由于突触前膜α₂受体过于敏感所致<ref>{{Cite journal|title=Receptor targets for antidepressant therapy in bipolar disorder: An overview|url=https://linkinghub.elsevier.com/retrieve/pii/S0165032711002102|last=Fountoulakis|first=Konstantinos N.|last2=Kelsoe|first2=John R.|date=2012-05|journal=Journal of Affective Disorders|issue=3|doi=10.1016/j.jad.2011.04.043|volume=138|pages=222–238|language=en|last3=Akiskal|first3=Hagop|access-date=2021-01-31|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133523/https://linkinghub.elsevier.com/retrieve/pii/S0165032711002102|dead-url=no}}</ref>；关于受体敏感性提高的原因，有研究者认为是因脑内去甲肾上腺素功能长期降低而使β受体产生代偿性敏感性增高所致<ref>{{Cite journal|title=Dexamethasone enhances the norepinephrine-induced ERK/MAPK intracellular pathway possibly via dysregulation of the alpha2-adrenergic receptor: implications for antidepressant drug mechanism of action|url=https://pubmed.ncbi.nlm.nih.gov/20605057|last=Yaniv|first=Shiri P.|last2=Lucki|first2=Anat|date=2010-09|journal=European Journal of Cell Biology|issue=9|doi=10.1016/j.ejcb.2010.05.002|volume=89|pages=712–722|issn=1618-1298|pmid=20605057|last3=Klein|first3=Ehud|last4=Ben-Shachar|first4=Dorit|access-date=2021-01-31|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133551/https://pubmed.ncbi.nlm.nih.gov/20605057/|dead-url=no}}</ref>。

5-羟色胺又名[[血清素]]，它被普遍认为是幸福和快乐感觉的贡献者。该学说由Coppen等人于1965年提出，认为抑郁症的发生是中枢神经系统中5-羟色胺功能下降，释放5-羟色胺减少，突触间隙含量下降所致<ref>{{Cite journal|title=CHANGES IN 5-HYDROXYTRYPTOPHAN METABOLISM IN DEPRESSION|url=https://pubmed.ncbi.nlm.nih.gov/14261721|last=Coppen|first=A.|last2=Shaw|first2=D. M.|date=1965-01|journal=The British Journal of Psychiatry: The Journal of Mental Science|doi=10.1192/bjp.111.470.105|volume=111|pages=105–107|issn=0007-1250|pmid=14261721|last3=Malleson|first3=A.|access-date=2021-01-31|archive-date=2021-02-27|archive-url=https://web.archive.org/web/20210227080305/https://pubmed.ncbi.nlm.nih.gov/14261721/|dead-url=no}}</ref>。

行为主义主张应研究可被观察和直接测量的行为，反对研究没有科学根据的意识。所以行为学派不去追溯抑郁在意识中的根源，而是集中探讨一个人得到的肯定和否定产生的结果<ref>{{Cite book|chapter=The Behavioral Study and Treatment of Depression|title=Progress in Behavior Modification|url=https://linkinghub.elsevier.com/retrieve/pii/B9780125356015500093|publisher=Elsevier|date=1975|isbn=978-0-12-535601-5|pages=19–64|volume=1|doi=10.1016/b978-0-12-535601-5.50009-3|language=en|first=Peter M.|last=Lewinsohn|access-date=2021-01-31|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133555/https://linkinghub.elsevier.com/retrieve/pii/B9780125356015500093|dead-url=no}}</ref><ref>{{cite book|author1=Lewinsohn P. M.|author2=Hoberman H. M.|author3=Teri L.|author4=Hautzinger M.|title=Theoretical issues in behavior therapy|url=https://archive.org/details/theoreticalissue0000unse_y8i4|date=1985|publisher=Academic Press|location=Orlando|isbn=9780125863605|pages=[https://archive.org/details/theoreticalissue0000unse_y8i4/page/331 331]-359}}</ref>。从这点来看，当一个人生命经历重大变更时，若总是被否定，就会导致抑郁，而且会因他人的关注和同情强化此情绪。

在所有抑郁症中，重度抑郁障碍的症狀最严重，其主要影响心境、认知和軀体功能。心境方面，患者长期（两周以上）处于在抑郁的情感狀态中；认知方面，患者往往看到事物的消极方面，被空虚感和无价值感包覆；軀体功能方面主要有进食和睡眠障碍和无力感，头痛等<ref name="abnormals" />。患者可能反覆想到自殘以及想死或者有自杀企图，最终约有3.4%的患者自杀<ref name="pmid11437805">{{Cite journal|title=Major depression: does a gender-based down-rating of suicide risk challenge its diagnostic validity?|url=https://pubmed.ncbi.nlm.nih.gov/11437805|last=Blair-West|first=G. W.|last2=Mellsop|first2=G. W.|date=2001-06|journal=The Australian and New Zealand Journal of Psychiatry|issue=3|doi=10.1046/j.1440-1614.2001.00895.x|volume=35|pages=322–328|issn=0004-8674|pmid=11437805|access-date=2021-01-31|archive-date=2021-03-18|archive-url=https://web.archive.org/web/20210318060320/https://pubmed.ncbi.nlm.nih.gov/11437805/|dead-url=no}}</ref>。

对重性抑郁障碍的诊断主要依据的是[[精神疾病诊断与统计手册]]（DSM）中的相关标準。医师需要先排除生理因素、药物濫用<ref>{{Cite journal|title=Do psychiatrists perform appropriate physical investigations for their patients? A review of current practices in a general psychiatric inpatient and outpatient setting|url=http://www.tandfonline.com/doi/full/10.1080/09638230701498325|last=Dale|first=Jenny|last2=Sorour|first2=Eman|date=2008-01|journal=Journal of Mental Health|issue=3|doi=10.1080/09638230701498325|volume=17|pages=293–298|language=en|issn=0963-8237|last3=Milner|first3=Gabrielle|access-date=2021-01-31|archive-date=2019-05-26|archive-url=https://web.archive.org/web/20190526164742/https://www.tandfonline.com/doi/full/10.1080/09638230701498325|dead-url=no}}</ref>，然后进行有关抑鬱程度的测试以确诊判断<ref name="NIMHPub" />。

对于确诊患者，医师往往会建议抗憂鬱药物治疗，即[[选择性5-羟色胺再吸收抑制剂]]（{{lang|en|SSRIs}}），单胺氧化酶抑制剂（MAOI）和三环类抗抑郁药，有时会建议患者参加心理治疗而学校校方方面会由相对应辅导<ref name="NIMHPub" />。对于年轻患者，例如儿童则应先考慮心理自疗辅导<ref name="NICEkids5">{{cite book|author=National Institute for Health and Clinical Excellence（NICE）|title=NICE guidelines: Depression in children and adolescents|publisher=NICE|location=London|year=2005|pages=5|isbn=1-84629-074-0|url=http://www.nice.org.uk/Guidance/CG28/QuickRefGuide/pdf/English|accessdate=2008-08-16|archive-date=2008-09-24|archive-url=https://web.archive.org/web/20080924152314/http://www.nice.org.uk/Guidance/CG28/QuickRefGuide/pdf/English|dead-url=no}}</ref>，而对于症状特别严重（如自杀企图或者緊张性患者）的患者则可能进行[[电痙攣疗法]]（ECT）<ref name="APAguidelines">{{Cite journal|title=Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association|url=https://pubmed.ncbi.nlm.nih.gov/10767867|date=2000-04|journal=The American Journal of Psychiatry|issue=4 Suppl|volume=157|pages=1–45|issn=0002-953X|pmid=10767867|access-date=2021-01-31|archive-date=2021-03-16|archive-url=https://web.archive.org/web/20210316193008/https://pubmed.ncbi.nlm.nih.gov/10767867/|dead-url=no}}</ref>。大多数重度抑鬱障碍患者愈后仍能正常生活。多数患者在未治疗下能康复<ref name="apaguidelines">{{Cite book|edition=1|chapter=Practice Guideline for the Treatment of Patients With Major Depressive Disorder Second Edition|title=APA Practice Guidelines for the Treatment of Psychiatric Disorders: Comprehensive Guidelines and Guideline Watches|url=http://www.psychiatryonline.com/content.aspx?aID=48690|publisher=American Psychiatric Association|date=2006|location=Arlington, VA|isbn=978-0-89042-336-3|volume=1|doi=10.1176/appi.books.9780890423363.48690|language=en|access-date=2021-01-31|archive-date=2011-10-01|archive-url=https://web.archive.org/web/20111001002329/http://www.psychiatryonline.com/content.aspx?aid=48690|dead-url=no}}</ref>或緩解<ref>{{Cite journal|title=Untreated short-term course of major depression: a meta-analysis of outcomes from studies using wait-list control groups|url=https://pubmed.ncbi.nlm.nih.gov/11578666|last=Posternak|first=M. A.|last2=Miller|first2=I.|date=2001-10|journal=Journal of Affective Disorders|issue=2-3|doi=10.1016/s0165-0327(00)00304-9|volume=66|pages=139–146|issn=0165-0327|pmid=11578666|access-date=2021-01-31|archive-date=2021-02-25|archive-url=https://web.archive.org/web/20210225015029/https://pubmed.ncbi.nlm.nih.gov/11578666/|dead-url=no}}</ref>。超过35%的患者依会复发<ref name="pmid18458203">{{Cite journal|title=Population-based study of first onset and chronicity in major depressive disorder|url=https://pubmed.ncbi.nlm.nih.gov/18458203|last=Eaton|first=William W.|last2=Shao|first2=Huibo|date=2008-05|journal=Archives of General Psychiatry|issue=5|doi=10.1001/archpsyc.65.5.513|volume=65|pages=513–520|issn=1538-3636|pmc=2761826|pmid=18458203|last3=Nestadt|first3=Gerald|last4=Lee|first4=Hochang Benjamin|last5=Lee|first5=Ben Hochang|last6=Bienvenu|first6=O. Joseph|last7=Zandi|first7=Peter|access-date=2021-01-31|archive-date=2021-03-18|archive-url=https://web.archive.org/web/20210318060227/https://pubmed.ncbi.nlm.nih.gov/18458203/|dead-url=no}}</ref>，事后而心理治疗较能有效預防复发<ref>{{Cite journal|title=Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials|url=https://pubmed.ncbi.nlm.nih.gov/16955421|last=Cuijpers|first=Pim|last2=van Straten|first2=Annemieke|date=2006-12|journal=International Journal of Geriatric Psychiatry|issue=12|doi=10.1002/gps.1620|volume=21|pages=1139–1149|issn=0885-6230|pmid=16955421|last3=Smit|first3=Filip|access-date=2021-01-31|archive-date=2021-03-18|archive-url=https://web.archive.org/web/20210318055753/https://pubmed.ncbi.nlm.nih.gov/16955421/|dead-url=no}}</ref>。对于发病早、有精神症狀或者同时患有人格障碍的患者则预后不良，他们可能会反覆发作，自杀率也较高<ref name="pmid18251627"/><ref name="pmid12877398"/>。

季节性抑郁症的症状与重度抑郁症相似，有时归类为重度抑郁症的一个亚型<ref>{{Cite journal|title=Seasonal affective disorder|url=https://pubmed.ncbi.nlm.nih.gov/17111890|last=Lurie|first=Stephen J.|last2=Gawinski|first2=Barbara|date=2006-11-01|journal=American Family Physician|issue=9|volume=74|pages=1521–1524|issn=0002-838X|pmid=17111890|last3=Pierce|first3=Deborah|last4=Rousseau|first4=Sally J.|access-date=2021-01-31|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133730/https://pubmed.ncbi.nlm.nih.gov/17111890/|dead-url=no}}</ref>。这种抑郁症的主要特点就是经常在寒冷季节发病并在其他季节完全缓解。季节性抑郁症随纬度的增高而越发流行, 意即日照时间越少，发病率越高。多曬太阳可減轻病情，对这种疾病的诊断需要确认患者只在特定时节发病而在其他季节从未发病。对患者的治疗与重性抑郁障碍的治疗相似，对于季节性情绪障碍，[[光照治疗|光照疗法]]似乎特别有效。澳洲[[昆士兰大学]]的学者于2013年绘制的“抑郁症世界地图”显示，日本与阳光充足、气候温暖的[[东南亚]]、[[南欧]]、[[澳大利亚]]同属抑郁症发病率较低的地区，而气候寒冷、缺少阳光的[[北欧]]、[[俄罗斯]]等地区则属抑郁症高发区<ref name="abnormals" /><ref>{{Cite web|title=科学家绘制抑郁症世界地图 日本成最快乐国度|url=https://health.qq.com/a/20131114/006154.htm|accessdate=2021-01-31|date=2013-11-14|publisher=腾讯网|archive-date=2021-02-12|archive-url=https://web.archive.org/web/20210212133640/https://health.qq.com/a/20131114/006154.htm|dead-url=no}}</ref>。

在一些特殊情况下，患者可能表现出明显的抑郁症状，但是不符合DSM任何一种具体病症的诊断标准，这时可以作出[[非典型抑郁症]]的诊断<ref>{{cite web|title=Depressive Disorder Not Otherwise Specified (NOS)|url=http://behavenet.com/capsules/disorders/nos.htm|accessdate=2009-10-09|author=American Psychiatric Association|year=1994|work=DSM-IV|archiveurl=https://web.archive.org/web/20090806074448/http://www.behavenet.com/capsules/disorders/nos.htm|archivedate=2009-08-06|deadurl=yes}}</ref>。