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糖尿病合并神经精神疾病（抑郁与焦虑）的文献学研究 作为一种代谢内分泌疾病，糖尿病也是一种常见的心身疾病，国内外已有大量的研究证明心理社会因素在糖尿病的发生、发展和转归中起着重要的作用。尤其是不良情绪如焦虑、抑郁对糖尿病患者的代谢控制及病情转归有消极的影响，而糖尿病罹患后并发精神神经疾病的几率也大大增加。 为此，卫咨康讯公司对此领域进行文献学专项研究，对科学引文数据库SCI（1995至今）和PsycINFO数据库（2000年至今）发表文文献进行统计，同广大神经精神科科医师和内分泌科医师共同分享此领域的研究进展，帮助医师更多得把握研究趋势。 一、研究的年度发表与引用趋势
从SCI的发表数量和引用频次均可以看出对于此领域的研究呈逐年上升趋势，但引用频次的上升率要大于发表文献的次数，显示出了近年来此领域研究的整体集中度在逐渐增加。2001年是此领域研究的一个分界线，此后无论发表数量还是引用率都大幅增加。 表1：PsycINFO糖尿病研究年度发表文献趋势
二、研究的领先国家与期刊分布 对SCI发表文献的国家分布统计，美国是此领域研究绝对领先的国家，发表文献居全球首位（49.33%）。 表2：前20位研究国家分布
从文章的期刊分布上可以看出，糖尿病期刊DIABETES
CARE是在此领域收录相关文章最多的期刊，但数据也显示相关文章分布较为分散。 表3：前20位发表糖尿病心理精神研究文献期刊
三、产生较大影响的研究 季建林教授述评: 上世纪90年代初曾有学者预测，21世纪的精神医学是回归医学的时代，强调与临床其他各学科的融合。过去近10年来在有关“糖尿病与抑郁症”等方面的文献回顾至少证实了这一点，不仅反映在研究文献的逐年增加，更重要的是被引用次数的显著增加。这里选摘了引用频率最多的7篇文献，不难看出只有1篇是发表在精神科专业杂志（而该杂志是全球各种精神科杂志中SCI影响因子最高的，达12.64），其他均发表在非精神科专业杂志上，提示抑郁症不仅是精神科关注的重点，而且也已成为临床其他学科关注的热点之一。 这里选摘的影响力较大的7篇文献，既有对照、随访研究，又有荟萃分析和文献综述；内容涉及面广，既有抑郁症与其他内科疾病导致的社会功能损害比较、抑郁症与血糖控制、糖尿病治疗依从性、患糖尿病风险的关系，又有脂质代谢/脂肪组织分布等代谢异常与抑郁症、银屑病与生活质量等研究。如文献-1通过为期2年的随访比较研究发现，抑郁症所导致的社会功能损害及其对患者健康状况的影响与其他常见的内科疾病（如糖尿病、高血压、心肌梗死、心力衰竭等）所导致的健康后果相似，甚至更严重。文献-2与文献-5是荟萃分析，通过系统文献复习，糖尿病共病抑郁症的风险是非糖尿病患者的2倍，抑郁症与糖尿病患者的高血糖有关。值得提出的是，文献-7是社区样本人群的13年随访结果报道，提示重症抑郁障碍可能是糖尿病-II型患病的预测指征之一，相对风险系数估计值为 2.23。 （季建林,上海中山医院心理医学科）
1．Title: FUNCTIONING AND WELL-BEING OUTCOMES OF PATIENTS WITH DEPRESSION
COMPARED WITH CHRONIC GENERAL MEDICAL ILLNESSES Author(s):
HAYS RD，
WELLS KB， SHERBOURNE CD， ROGERS
W， SPRITZER K Source:
ARCHIVES OF GENERAL PSYCHIATRY 52 (1): 11-19 JAN 1995 Document
Type: Article Language:
English Cited
References: 39
Times Cited: 408 Abstract:
Background: Cross-sectional studies have
found that depression is uniquely associated with limitations in wellbeing and
functioning that were equal to or greater than those of chronic general medical
conditions such as diabetes and arthritis. However， whether these
relative limitations persist over time is not known. Methods: We conducted a 2-year
observational study of 1790 adult outpatients with depression， diabetes， hypertension， recent myocardial infarction， and/or congestive heart failure. Change in functional status and
wellbeing was compared for depressed patients vs patients with chronic general
medical illnesses， controlling statistically for
medical comorbidity， sociodemographics， system， and specialty of care. Results: Over 2 years of follow-up， limitations in
functioning and well-being improved somewhat for depressed patients; even so， at the end of 2 years， these limitations
were similar to or worse than those attributed to chronic medical illnesses.
Similar patterns were observed for depressed patients in the mental health
specialty sector and those in the general medical sector， but the patients in the mental health specialty sector improved
more. More severely depressed patients improved more in functioning， but even initially depressed patients without depressive disorder
had substantial persistent limitations. Conclusion: Depressed patients-have
substantial and long-lasting decrements in multiple domains of functioning and
well-being that equal or exceed those of patients with chronic medical
illnesses. 2．Title: The prevalence of comorbid depression in adults with diabetes - A
meta-analysis Author(s):
Anderson RJ， Freedland KE， Clouse RE， Lustman PJ Source: DIABETES CARE 24 (6): 1069-1078 JUN 2001 Document Type: Article Language:
English Cited
References: 94
Times Cited: 331 Abstract:
OBJECTIVE - To estimate the odds and
prevalence of clinically relevant depression in adults with type 1 or type 2
diabetes. Depression is associated with hyperglycemia and an increased risk for
diabetic complications; relief of depression is associated with improved
glycemic control. A more accurate estimate of depression prevalence than what
is currently available is needed to gauge the potential impact of depression
management in diabetes. RESEARCH DESIGN
AND METHODS - MEDLINE and PsycINFO databases and published references were used to
identify studies that reported the prevalence of depression in diabetes， Prevalence was
calculated as an aggregate mean weighted by the combined number of subjects in
the included studies. We used chi (2) statistics and odds ratios (ORs) to
assess the rate and likelihood of depression as a function of type of diabetes， sex， subject source， depression assessment method， and study
design. RESULTS - A total of 42 eligible
studies were identified; 20 (48%) included a nondiabetic comparison group. in
the controlled studies， the odds of depression in the diabetic group were twice that of the
nondiabetic comparison group (OR = 2.0， 95% CI 1.8-2.2)
and did not differ by sex， type of diabetes， subject source， or assessment method. The
prevalence of comorbid depression was significantly higher in diabetic women
(28%) than in diabetic men (18%)， in uncontrolled (30%)
than in controlled studies (21%)， in clinical (32%)
than in community (20%) samples， and when assessed by
self-report questionnaires (31%) than by standardized diagnostic interviews
(11%). CONCLUSIONS - The presence of diabetes
doubles the odds of comorbid depression. Prevalence estimates are affected by
several clinical and methodological variables that do nor affect the stability
of the ORs. 3．Title: The regulation of adipose tissue distribution in humans Author(s):
Bjorntorp P Source:
INTERNATIONAL JOURNAL OF OBESITY 20 (4): 291-302 APR 1996 Document
Type: Review Language:
English Cited
References: 117
Times Cited: 263 Abstract: The regulation of adipose
tissue distribution is an important problem in view of the close
epidemiological and metabolic associations between centralized fat accumulation
and disease. With visceral fat accumulation multiple endocrine perturbations
are found，
including elevated cortisol and androgens in women， as
well as low growth hormone (GH) and， in men， testosterone (T) secretion. These abnormalities probably derive
from a hypersensitive hypothalamo-pituitary-adrenal axis， with hyperinsulinemia related to a marked insulin resistance as a
consequence. These hormonal changes exert
profound effects on adipose tissue metabolism and distribution. At the
adipocyte level cortisol and insulin promote lipid accumulation by expressing
lipoprotein lipase activity， while T， GH and probably
estrogens exert opposite effects. The consequences will most likely be more
expressed in visceral than subcutaneous adipose tissues because of a higher
cellularity， innervation and blood flow. Furthermore， the density of cortisol and androgen receptors seems to be higher
in this than other adipose tissue regions. The endocrine perturbations found in
visceral obesity with an abundance of the lipid accumulating hormones cortisol
and insulin， and a relatively low secretion of the
lipid mobilizing sex steroid hormones and GH would therefore be expected to be
followed by visceral fat accumulation. The potential significance of local
synthesis of steroid hormones in adipose tissue requires more attention. Although studies in vitro are
informative when elucidating detailed mechanisms of hormonal interactions， they might not give a
true picture of the regional integrated regulation of adipose tissue lipid
storage and mobilization. Such information can be obtained by regional
measurements of lipid mobilization by free fatty acid turnover or by
microdialysis techniques， both showing lower rates of
mobilization in leg than in upper body adipose tissues. More detailed
information can be obtained by physiological oral administration of
triglycerides， labelled with a small amount of oleic
acid， followed by measurements of the regional uptake
and turn-over of adipose tissue triglycerides. Such studies show lipid uptake
in the order omental = retroperitoneal > subcutaneous abdominal >
subcutaneous femoral adipose tissues in men， with a
similar rank order for half-life of the triglyceride，
indicating also a turn-over of triglycerides in that order. T amplifies these
differences in men. In premenopausal women subcutaneous abdominal has a higher
turnover than femoral adipose tissue. Results of studies in vitro indicate that
this difference is diminished at the menopause， and
restored by estrogen substitution， suggesting that the
functional effects of estrogens in women are similar to those of T in men. The
mechanisms are， however，
probably indirect because of the apparent absence of specific estrogen and
progesterone receptors in human adipose tissue. This interpretation from the
studies referred to above fits well with physiological， and clinical
conditions with increased visceral fat mass， where the
balance between the lipid accumulating hormone couple (cortisol and insulin)
and the hormones which prevent lipid accumulation and instead activate lipid
mobilization pathways (sex steroid hormones and GH) is shifted to the advantage
of the former. Such conditions include Cushing's syndrome， the polycystic ovary syndrome， menopause， aging， GH-deficiency， depression， smoking and excess alcohol
intake. With appropriate interventions against hypercortisolemia and
substitution of deficient sex steroids and GH， visceral
fat mass is decreasing. Based on this evidence from
physiological， clinical， interventional observations and
detailed studies of mechanisms at cellular and molecular levels it is suggested
that the combined endocrine abnormalities in the syndrome of visceral obesity
direct storage fat to visceral adipose depots. Therefore， measurements of visceral fat accumulation may serve as an index of
such endocrine abnormalities. 4．Title: Depression and diabetes - Impact of depression symptoms on adherence， function， costs Author(s):
Ciechanowski PS， Katon WJ， Russo JE Source:
ARCHIVES OF INTERNAL MEDICINE 160 (21): 3278-3285 NOV 27 2000 Document
Type: Article Language:
English Cited
References: 50
Times Cited: 208 Abstract:
Background: Depression is common among
patients with chronic medical illness. We explored the impact of depressive
symptoms in primary care patients with diabetes on diabetes self-care， adherence to
medication regimens， functioning， and health care costs. Methods: We administered a
questionnaire to 367 patients with types 1 and 2 diabetes from 2 health
maintenance organization primary care clinics to obtain data on demographics， depressive symptoms， diabetes knowledge， functioning， and diabetes self-care. On the basis of automated data， we measured medical comorbidity， health
care costs， glycosylated hemoglobin (HbA( Results: Compared with patients in the
low-severity depression symptom tertile， those in the medium- and high-severity
tertiles were significantly less adherent to dietary recommendations. Patients
in the high-severity tertile were significantly distinct from those in the
low-severity tertile by having a higher percentage of days in nonadherence to
oral hypoglycemic regimens (15% vs 7%); poorer physical and mental
functioning;; seater probability of having any emergency department， primary care， specialty care， medical inpatient， and mental health costs;
and among users of health care within categories，
higher primary (51% higher)， ambulatory (75% higher)，and total health care costs (86% higher). Conclusions: Depressive symptom severity
is associated with poorer diet and medication regimen adherence， functional impairment， and higher health care costs in primary care diabetic patients.
Further studies testing the effectiveness and cost-effectiveness of enhanced
models of care of diabetic patients with depression are needed. 5．Title: Depression and poor glycemic control - A meta-analytic review of the
literature Author(s):
Lustman PJ， Anderson RJ， Freedland KE， de Groot M， Carney RM， Clouse RE Source: DIABETES CARE 23 (7): 934-942 JUL 2000 Document Type: Article Language:
English Cited
References: 74
Times Cited: 185 Abstract:
OBJECTIVE - Depression is common among
patients with diabetes， but its relationship to glycemic control has not been
systematically reviewed. Our objective was to determine whether depression is
associated with poor glycemic control. RESEARCH DESIGN
AND METHODS - Medline and PsycINFO databases and published reference lists were used to
identify studies that measured the association of depression with glycemic
control. Meta-analytic procedures were used to convert the findings to a common
metric，
calculate effect sizes (ESs)， and statistically analyze
the collective data. RESULTS - A total of 24 studies
satisfied the inclusion and exclusion criteria for the meta-analysis.
Depression was significantly associated with hyperglycemia (Z = 5.4， P < 0.0001). The
standardized ES was in the small-to-moderate range (0.17) and was consistent， as the 95% CI was narrow (0.13-0.21). The ES was similar in studies
of either type 1 or type 2 diabetes (ES 0.19 vs. 0.16) and larger when
standardized interviews and diagnostic criteria rather than self-report
questionnaires were used to assess depression (ES 0.28 vs. 0.15). CONCLUSIONS - Depression is associated
with hyperglycemia in patients with type 1 or type 2 diabetes. Additional
studies are needed to establish the directional nature of this relationship and
to determine the effects of depression treatment on glycemic control and the
long-term course of diabetes. 6．Title: Psoriasis causes
as much disability as other major medical diseases Author(s): Rapp SR， Feldman SR， Exum ML， Fleischer AB， Reboussin DM Source: JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY 41 (3): 401-407 Part 1， SEP 1999 Document Type: Article Language: English |
