rTMS治疗食管癌患者抑郁疗效的功能磁共振评估
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摘要
目的探讨重复经颅磁刺激(rTMS)对食管癌患者抑郁的临床疗效及对大脑神经活动的影响。方法选取南充市中心医院2015年11月～2016年12月住院的22例食管癌抑郁患者,按入院顺序分为单次rTMS治疗组(s-rTMS组,12例)和多次rTMS治疗组(m-rTMS组,10例)。s-rTMS组只接受1次rTMS治疗(10Hz,110%静息运动阈值强度,左侧背外侧前额叶皮层);m-rTMS组接受连续5d rTMS治疗(两组参数完全相同)。比较两组治疗前后及组间汉密尔顿抑郁量表(HAMD)、抑郁自评量表(SDS)评分及低频振幅(ALFF)的变化和差异,并计算HAMD、SDS评分改变量与ALFF改变量的相关性。结果 rTMS治疗后,s-rTMS组和m-rTMS组两组HAMD及SDS评分均有明显改善(P<0.05),且m-rTMS组比s-rTMS组改善更明显(P<0.05);治疗后s-rTMS组ALFF明显增高的脑区包括双侧前额叶(PFC)、双侧前扣带回(ACC)、右侧丘脑(THA)、右侧海马HIP(HIP);m-rTMS组ALFF明显增高的脑区包括在双侧PFC、双侧ACC、右侧苍白球、右侧HIP;与s-rTMS组比较,m-rTMS组治疗后双侧PFC、双侧ACC、右侧尾状核头的ALFF增加更明显(P<0.05)。两组治疗前后ACC的ALFF改变量与HAMD评分改变量均呈显著负相关;m-rTMS组治疗前后右侧HIP的ALFF改变量与HAMD评分改变量呈显著负相关(P<0.05)。结论高频rTMS治疗为食管癌抑郁提供了一种安全、有效的治疗方法,且多次rTMS刺激比单次rTMS刺激具有更好的疗效,其抗抑郁疗效可能与rTMS对大脑神经活动的调节尤其是对ACC及右侧HIP神经活动的调节有关。
Objective To investigate the clinical therapeutic effects and the influence on the neural activity of esophageal cancer patients with depression after repetitive transcranial magnetic stimulation(rTMS). Methods Twenty-two identified esophageal cancer patients with depression were recruited in this study and divided into single rTMS(s-rTMS) group(12 patients), and multiple rTMS(m-rTMS) group(10 patients). Patients in the s-rTMS group received one session of high-frequency rTMS(10.0 Hz, 110 % of resting motor threshold) treatment over the left dorsolateral prefrontal cortex. The m-rTMS group received rTMS in five consecutive days, with the same parameters. Comparisons of the HAMD, SDS and amplitude of low frequency fluctuation(ALFF) were carried out before and after the treatment in each group as well as between s-rTMS and m-rTMS groups after the treatment. Furthermore, correlation between the change of behavioral scores(HAMD and SDS) and the change of ALFF were also calculated. Results HAMD and SDS scores were significantly increased both in s-rTMS and m-rTMS groups after treatment(P< 0.05) and the m-rTMS group improved more than s-rTMS group. Comparison of the ALFF between baseline and after treatment, ALFF was significantly increased in the bilateral prefrontal cortices(PFC), bilateral anterior cingulate cortex(ACC), right thalamus(THA), and the right hippocampus(HIP) in s-rTMS group. The ALFF was significantly increased in the bilateral PFC, bilateral ACC, right pallidum, and the right HIP in m-rTMS group after the rTMS treatment. The m-rTMS group also achieved more significant improved ALFF in the bilateral PFC, bilateral ACC, and the head of the right caudate nucleus compared to the s-rTMS group(P< 0.05). The significantly negative correlation between the ALFF changes in the ACC and the HAMD score changes were observed in both groups. In addition, the significant negative correlation was found between the ALFF changes in the right HIP and the HAMD score changes in m-rTMS group(P< 0.05).Conclusion High frequency rTMS which is a safe method might have a positive antidepressant effect on esophageal cancer patients with depression, and the treatment using m-rTMS is more effective than s-rTMS. This may be associated with the regulation of rTMS on neural physiological activities in the related brain areas, especially on the ACC and the right HIP.
Objective To investigate the clinical therapeutic effects and the influence on the neural activity of esophageal cancer patients with depression after repetitive transcranial magnetic stimulation(rTMS). Methods Twenty-two identified esophageal cancer patients with depression were recruited in this study and divided into single rTMS(s-rTMS) group(12 patients), and multiple rTMS(m-rTMS) group(10 patients). Patients in the s-rTMS group received one session of high-frequency rTMS(10.0 Hz, 110 % of resting motor threshold) treatment over the left dorsolateral prefrontal cortex. The m-rTMS group received rTMS in five consecutive days, with the same parameters. Comparisons of the HAMD, SDS and amplitude of low frequency fluctuation(ALFF) were carried out before and after the treatment in each group as well as between s-rTMS and m-rTMS groups after the treatment. Furthermore, correlation between the change of behavioral scores(HAMD and SDS) and the change of ALFF were also calculated. Results HAMD and SDS scores were significantly increased both in s-rTMS and m-rTMS groups after treatment(P< 0.05) and the m-rTMS group improved more than s-rTMS group. Comparison of the ALFF between baseline and after treatment, ALFF was significantly increased in the bilateral prefrontal cortices(PFC), bilateral anterior cingulate cortex(ACC), right thalamus(THA), and the right hippocampus(HIP) in s-rTMS group. The ALFF was significantly increased in the bilateral PFC, bilateral ACC, right pallidum, and the right HIP in m-rTMS group after the rTMS treatment. The m-rTMS group also achieved more significant improved ALFF in the bilateral PFC, bilateral ACC, and the head of the right caudate nucleus compared to the s-rTMS group(P< 0.05). The significantly negative correlation between the ALFF changes in the ACC and the HAMD score changes were observed in both groups. In addition, the significant negative correlation was found between the ALFF changes in the right HIP and the HAMD score changes in m-rTMS group(P< 0.05).Conclusion High frequency rTMS which is a safe method might have a positive antidepressant effect on esophageal cancer patients with depression, and the treatment using m-rTMS is more effective than s-rTMS. This may be associated with the regulation of rTMS on neural physiological activities in the related brain areas, especially on the ACC and the right HIP.
引文
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[21] Bennett M R.The Prefrontal-limbic Network in depression:Modulation by hypothalamus,basal ganglia and midbrain [J].Prog Neurobiol,2011,93(4):468-487.
[22] Anand A,Li Y,Wang Y,et al.Reciprocal effects of antidepressant treatment on activity and connectivity of the mood regulating circuit:an fMRI study [J].J Neuropsychiatry Clin Neurosci,2007,19(3):274-282.doi:10.1176/jnp.2007.19.3.274
[23] 冯晓荣,梁立华,吴明祥,等.抑郁症患者治疗前后的静息态fMRI比较探究[J].中国医疗前沿,2013,8(10):93.doi:10.3969/j.issn.1673-5552.2013.10.0068
[24] Samson AC,Meisenzahl E,Scheuerecker J,et al.Brain activation predicts treatment improvement in patients with major depressive disorder [J].J Psychiatr Res,2011,45(9):1214-1222.
[25] Marie J,Nic J,Odile A,et al.Regional brain volume in depression and anxiety disorders[J].Arch Gen Psychiatry,2010,67:1002-101 1.
[26] Rajkowska G,Miguel-Hidalgo JJ,Wet JR,et al.Morphometric evidence for neuronal and glial prefrontal cell pathology in major depression [J].Biol Psychiatry,1999,45:1085-1098.
[27] 李丽,董奇.抑郁症的脑神经结构和功能改变研究[J].中国临床心理学杂志,2006,(14):106-108.
[28] Pizzagalli D,Pascual-Marqui RD,Nitschke JB,et al.Anterior cingulate activity as a predictor of degree of treatment response in major depression:evidence from brain electrical tomography analysis [J].Am J Psychiatry,2001,158(3):405-415.
[29] Anand A,Li Y,Wang Y,et al.Antidepressant effect on connectivity of the mood-regulating circuit:an FMRI study [J].Neuropsychopharamcology,2005,30(7):1334-1344.
[30] Amico F,Meisenzahl E,Koutsouleris N,et al.Structural MRI correlates for vulnerability and resilience to major depressive disorder[J].J Psychiatry Neurosci,2011,36:15-22.
[31] 邱美慧,吴彦,彭代辉.抑郁症海马的结构及功能磁共振成像的研究进展[J].上海交通大学学报,2015,(6):901-910.
[32] Jiao Q,Ding J,Lu G,et al.Increased activity imbalance in fronto-subcortical circuits in adolescents with major depression [J].PLoS One,2011;6(9):e25159.
[33] Fu CH,Williams SC,Cleare AJ,et al.Neural responses to sad facial expressions in major depression following cognitive behavioral therapy [J].Biol Psychiatry,2008,64(6):505-512.
[2] Hamilton M.A rating scale for depression [J].J Neurol Neurosurg Psychiatry,1960,23:56-62.
[3] Zung WW.A self-rating depression scale [J].Arch Gen Psychiatry,1965,12:63-70.
[4] Teng S,Guo Z,Peng H,et al.High-frequency repetitive transcranial magnetic stimulation over the left DLPFC for major depression:Session-dependent efficacy:A meta-analysis [J].Eur Psychiatry,2017,41:75-84.
[5] 赫捷,陈万青.2012年中国肿瘤登记年报[M].北京:军事医学科学出版社,2012:54.
[6] 夏宏伟,方秦模,刘丽丽,等.食管癌根治术后化疗患者症状困扰与生活质量的关系[J].中华现代护理杂志,2016,22(17):2415-2418.
[7] Bodurka-Bevers D,Basen-Engquist K,Carmaek CL,et al.Depression anxiety,and quality of life in patients with epithelial ovarian cancer [J].Gynecol Oncol,2000,78 (3 Pt 1):302-308.
[8] Lloyd-Williams M,Friedman T.Depression in palliative care patients-a prospective study [J].Eur J Cancer Care (Engl),2001,10 (4):270-274.
[9] 吴怜媛.癌症患者伴发抑郁之发病调查及中医诊治(肝郁气滞型)研究[D].长沙:湖南中医学院,2005.
[10] 吴晓丹,郑美春,辛明珠,等.Ⅱ期、Ⅲ期食管癌辅助化疗病人生活质量与焦虑、抑郁、应对方式的相关性研究[J].护理研究,2015,29(7):813-816.
[11] Luborzewski A,Schubert F,Seifert F,et al.Metabolic alterations in the dorsolateral prefrontal cortex after treatment with high-frequency repetitive transcranial magnetic stimulation in patients with unipolar major depression[J].J Psychiatr Res,2007,41(7):606-615.
[12] Baeken C,De Raedt R,Leyman L,et al.The impact of one HF-rTMS session on mood and salivary cortisol in treatment resistant unipolar melancholic depressed patients [J].J Affect Disord,2009,113(1-2):100-108.
[13] Yukimasa T,Yoshimura R,Tamagawa A,et al.High-frequency repetitive transcranial magnetic stimulation improves refractory depression by influencing catecholamine and brain-derived neurotrophic factors [J].Pharmacol Psychiatry,2006,39(2):52-59.
[14] Zanardini R,Gazzoli A,Ventriglia M,et al.Effect of repetitive transcranial magnetic stimulation on serum brain derived neurotrophic factor in drug resistant depressed patients [J].J Affect Disord,2006,91(1):83-86.
[15] Pogarell O,Koch W,Popperl G,et al.Striatal dopamine release after prefrontal repetitive transcranial magnetic stimulation in major depression:preliminary results of a dynamic [123I] IBZM SPECT study [J].J Psychiatry Res,2006,40 (4):307-314.
[16] Sibon I,Strafella AP,Gravel P,et al.Acute prefrontal cortex TMS in healthy volunteers:effects on brain 11C-alpha Mtrp trapping [J].Neuroimage,2007,34(4):1658-1664.
[17] Fitzgerald PB,Hoy K,Daskalakis ZJ,et al.A randomized trial of the anti-depressant effects of low-and high-frequency transcranial magnetic stimulation in treatment-resistant depression [J].Depress Anxiety,2009,26(3):229-234.
[18] Speer AM,Kimbrell TA,Wassermann EM,et al.Opposite effects of high and low frequency rTMS on regional brain activity in depressed patients [J].Biol Psychiatry,2000,48:1133.
[19] Hernández-Ribas R,Deus J,Pujol J,et al.Identifying brain imaging correlates of clinical response to repetitive transcranial magnetic stimulation (rTMS) in major depression [J].Brain Stimul,2013,6(1):54-61.
[20] Zang YF,He Y,Zhu CZ,et al.Altered baseline brain activity in children with ADHD revealed by resting-state functional MRI [J].Brain Dev,2007,29 (2):83-91.
[21] Bennett M R.The Prefrontal-limbic Network in depression:Modulation by hypothalamus,basal ganglia and midbrain [J].Prog Neurobiol,2011,93(4):468-487.
[22] Anand A,Li Y,Wang Y,et al.Reciprocal effects of antidepressant treatment on activity and connectivity of the mood regulating circuit:an fMRI study [J].J Neuropsychiatry Clin Neurosci,2007,19(3):274-282.doi:10.1176/jnp.2007.19.3.274
[23] 冯晓荣,梁立华,吴明祥,等.抑郁症患者治疗前后的静息态fMRI比较探究[J].中国医疗前沿,2013,8(10):93.doi:10.3969/j.issn.1673-5552.2013.10.0068
[24] Samson AC,Meisenzahl E,Scheuerecker J,et al.Brain activation predicts treatment improvement in patients with major depressive disorder [J].J Psychiatr Res,2011,45(9):1214-1222.
[25] Marie J,Nic J,Odile A,et al.Regional brain volume in depression and anxiety disorders[J].Arch Gen Psychiatry,2010,67:1002-101 1.
[26] Rajkowska G,Miguel-Hidalgo JJ,Wet JR,et al.Morphometric evidence for neuronal and glial prefrontal cell pathology in major depression [J].Biol Psychiatry,1999,45:1085-1098.
[27] 李丽,董奇.抑郁症的脑神经结构和功能改变研究[J].中国临床心理学杂志,2006,(14):106-108.
[28] Pizzagalli D,Pascual-Marqui RD,Nitschke JB,et al.Anterior cingulate activity as a predictor of degree of treatment response in major depression:evidence from brain electrical tomography analysis [J].Am J Psychiatry,2001,158(3):405-415.
[29] Anand A,Li Y,Wang Y,et al.Antidepressant effect on connectivity of the mood-regulating circuit:an FMRI study [J].Neuropsychopharamcology,2005,30(7):1334-1344.
[30] Amico F,Meisenzahl E,Koutsouleris N,et al.Structural MRI correlates for vulnerability and resilience to major depressive disorder[J].J Psychiatry Neurosci,2011,36:15-22.
[31] 邱美慧,吴彦,彭代辉.抑郁症海马的结构及功能磁共振成像的研究进展[J].上海交通大学学报,2015,(6):901-910.
[32] Jiao Q,Ding J,Lu G,et al.Increased activity imbalance in fronto-subcortical circuits in adolescents with major depression [J].PLoS One,2011;6(9):e25159.
[33] Fu CH,Williams SC,Cleare AJ,et al.Neural responses to sad facial expressions in major depression following cognitive behavioral therapy [J].Biol Psychiatry,2008,64(6):505-512.