精神科 實 證 期 刊 閱 讀 報 告 EBM-style Journal Reading 指導臨床教師： Dr. 鄭怡君 日期：2009/08/25 地點：十樓精神科會議室

Clinical Scenario （臨床情境） 40歲未婚林先生，七年前被診斷重鬱症與邊緣性人格 在規則服藥與接受心理治療的情況下，仍陸續住院19次，每次住院均因為生活事件 (失戀、被同事批評、與母親衝突、奶奶過世、家人生病等)、而出現酗酒、失眠、情緒低落、注意力不集中、食慾差、反應慢、體重變化大、甚至自殘 (潑汽油自焚、撞玻璃、撞牆、割腕、剁手指、跳樓、用香煙燙腳等)。

Clinical Scenario （臨床情境） 接受心理治療多年 曾使用過的抗憂鬱劑有以下幾種: Efexor (150 mg/day)、Seroxat (40 mg/day)、Remeron (120 mg/day)、Bupropion (300 mg/day) 目前使用的藥物 Lexapro 2＃hs Wellbutrin 2#qd Seroquel (200) 2#hs Lamictal (50) 1-0-2-0 Rivotril (2) 2# ON Propranolol (10) 1#bid Ritalin (10) 2# tida

Clinical Scenario （臨床情境） 入院後除原有的藥物與心理治療外，請病人每天騎固定式腳踏車運動30分鐘以上 病人描述每次騎腳踏車的半個小時一直到騎完的一兩個小時內心情都變好

Clinical Uncertainty → PICO 問題 Can a patient with depression benefits from exercise ?

Type of Question: Therapy 臨床個案的PICO Patient / Problem a patient with major depression Intervention Exercise+antidepressant+psychotherapy Comparison Antidepressant+psychotherapy Outcome Hospital stay Type of Question: Therapy

Search Terms & Strategy: （搜尋關鍵字與策略） 資料庫： pubmed 搜尋日期： 2009/08/16 搜尋關鍵字與策略： #2Search (depress* AND (exercise OR physical activit*)) AND systematic[sb] Limits: published in the last 1 year, only items with abstracts, Humans, Meta-Analysis, Review08:36:48　　　　　　　　　　　　　　　　　　19 #1Search (depress* AND (exercise OR physical activit*)) AND systematic[sb]08:36:05　　　　　　　　　　　　185  find the paper that I’m most interested in

Best available evidence: （挑選可獲得之最佳研究證據） Citation/s: Exercise for depression (Review) The Cochrane Library, 2009, Issue 3 Lead author's name : Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA

The Study: -1 Enrolled the articles published before May 2008 A total of 28 RCT trials were included Type of participants: 7 studies use clinical populations clinical interview in 9 studies The other 12 studies: Beck Depression Inventory、CES-D、Geriatric Depression Scale、Depression Adjective Checklist, Symptom Checklist Score、Minnesota Multiple Personality Inventory in selection

The Study: -2 Types of interventions: Types of outcomes 有氧運動 （跑步、在跑步機上行走、有氧訓練、跳舞、騎固定式腳踏車、氣功、太極….） 室內vs戶外運動 團體vs單獨運動 運動期間：10天～16週 Types of outcomes 住院長短、patient and clinical global impression、sickness impact profile、quality of life Level of Evidence: 1a

The Study:-3 本篇文獻的PICO (T) Patient / Problem Depressive patients (inpatient, outpatient) Intervention Exercise Comparison Social activities, CBT, bright-light therapy, antidepressants Outcome 住院長短、patient and clinical global impression、sickness impact profile、quality of life Time 10天～16週

The Evidence: Exercise >> Control Primary outcome measure Reduction in symptom severity at post-treatment (95% CI -1.12 to -0.51) →large clinical effect.

The Evidence: Exercise > Control（長期） Primary outcome measure Reduction in symptom severity at follow-up long-term follow-up data found only a moderate effect (SMD -0.44, 95% CI -0.71 to -0.18). no statistical heterogeneity

The Evidence: Exercise = CBT no significant difference between the two interventions (95% CI -0.51, 0.18) No statistical heterogeneity

The Evidence: Exercise > Bright light therapy exercise was superior to bright light therapy (95% CI -10.20, -2.60).

The Evidence: Exercise = Antidepressants no significant difference between the two interventions (SMD was -0.04 95% CI -0.31, 0.24)

Comment & Discussion: -1 限制： 本文所收錄的研究中，對於憂鬱症的定義範圍太廣，住院者、門診病人、甚至一般人有憂鬱症狀者均有。 若運動對於憂鬱症者有幫助，本文並沒有說明最適合的運動方式、運動的時間和持續多久、戶外或室內運動等的效果

Comment & Discussion: -2 運動之抗憂鬱效果可能的機轉（J Psychiatry Neurosci 2006;31(2):84-92.） 如同抗憂鬱劑，運動會增加大腦中新的神經元之合成，特別在hippocampus中神經元合成增加2～3倍 這點可以解釋為何憂鬱症病人運動後其食慾與體重會回復正常。

Comment & Discussion: -3 運動能否抗憂鬱，有不同的學者以不同的角度研究，其中心理學家以運動後對於壓力事件的忍受程度分析，結果與我們的假設相反--運動組在長達8個月的運動後，其壓力忍受程度並沒有比不運動組來得高（Psychosomatic Medicine 55: 347-363, 1993）。 由以上三篇文獻綜合來看，運動使得大腦的神經元增加、到形成抗憂鬱效果，中間的心理與行為歷程仍然有待探討。

Clinical bottom line 臨床決策底線 回到臨床個案情境 Clinical bottom line 臨床決策底線 To treatment depressive patients, exercise was effective compared with no treatment or control intervention. (95% CI -1.12, -0.51) 證據等級1a, 建議等級B

References: Exercise for depression (Review). The Cochrane Library 2009, Issue 3 Antidepressant effects of exercise: Evidence for an adult-neurogenesis hypothesis? J Psychiatry Neurosci 2006;31(2):84-92. Regular Exercise and Aerobic Fitness in Relation to Psychological Make-up and Physiological Stress Reactivity. Psychosomatic Medicine 55:347-363 (1993)

結 論 （標題 Title） To treat depressive patients, exercise did seem to be more effective than control intervention

Appraised by: Lee, Hsiu-chiung Date: 2009.8.25 E-mail: u9300010@cc.kmu.edu.tw Kill or Update By: