Transcript Presentation Thomas Kjellström.pdf

Thomas Kjellström
F. d. överläkare,
Docent internmedicin och
endokrinologi
Helsingborgs lasarett
10 oktober 2014
1
F
Folksjukdom
Prevalens över 2 %
2
VÄRLDENS VANLIGASTE SJUKDOMAR ÅR
2020 (enligt WHO)
• 1. KARDIOVASKULÄRA SJUKDOMAR
• 2. DEPRESSION
• 3. ÖVRIGA
3
Depression – en folksjukdom
Prevalens
Livstidsrisk
100%
Befolkning >65 år
Totalbefolkning
90
80
30
20
10
Ref. WHO 1974, Sartorius 1974
Hagnell et al. Psychol Med.1982;12(2):279-289
4
Diabetes och depression
Typ 1 diabetes har cirka
DIABETES
OCH DEPRESSION
16 % depression.
Typ 2 diabetes har cirka
17 % depression.
Icke-diabetiker hälften.
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Depression – god prognos vid rätt hjälp
Förekomst av
depression i
befolkningen (3-5%)
Exempel: 100 individer
70% söker inte hjälp
30% söker hjälp i
primärvården eller
psykiatrin
Ex: 30 individer
60% får:
- fel diagnos
- rätt diagnos, men fel behandling
- rätt behandling, men farmaka i för låg dos
eller under för kort period
40% får rätt
behandling
Ex: 12 individer
20%
oförbättrade
80% blir
bra
Ex: 10
Ref Bodlund O. Läkartidningen, vol 97, nr 11 2000
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Diagnos klassifikationssystem
•
DSM-IV
-
•
Diagnostic and Statistical Manual of mental disorder-4th edition
Utarbetad av APA (American Psychiatric Association)
ICD-10
International Classification of Diseases and Related Health Problems
Utarbetad av WHO (World Health Organisation)
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PATIENT HEALTH QUESTIONNAIRE
(PHQ 2 ELLER 9)
1. Little interest or pleasure in doing
things?
2. Feeling down, depressed, or hopeless?
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Diagnoskriterier för egentlig depression DSM-IV
A Minst fem av följande symtom
under minst två veckor – minst ett av
symtomen (1) eller (2) måste
föreligga:
(1) nedstämdhet
(2) minskat intresse, minskad glädje
(3) viktnedgång alt viktuppgång minskad alt ökad
aptit
(4) sömnstörning
(5) psykomotorisk hämning alt agitation
(6) svaghetskänsla alt brist på energi
(7) känslor av värdelöshet, skuldkänslor
(8) minskad tanke – eller koncentrations-förmåga
(9) tankar på döden, självmordstankar
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Remission är viktigt
Att inte uppnå remission kan innebära:
•
•
•
•
Minskad livskvalitet
Minskad arbetsförmåga
Ökad risk för återfall
- remission (återfallsfrekvens 24%)
- respons (återfallsfrekvens 74%)
Ökad risk för suicid
Ref. Keller MB et al 2002;17:265-271
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Prevalence of major depression in
chronic medical illness
Alzheimer's disease
HIV
CAD
Stroke
MI
Diabetes
Cancer
Parkinson's disease
11%
12%
17%
23%
25%
27%
42%
51%
NHDS, NAMCS, NHAMCS. Sutor et al. Mayo Clin Proc 1998; 73 (4): 329–337; Jiang et al. CNS Drugs 2002; 16 (2):111–127
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VID KLINISK DEPRESSION FÖRÄNDRAS
FYSIOLOGIN PÅ MÅNGA SÄTT (ex.)
• Aktivering av nervsystemet (sympatikus + ,
parasympatikus -)
• Immunologiska förändringar
• Rytmrubbningar i hjärtat
• Trombocytfunktionen
• Endotelfunktionen
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Behaviour (1)
Depression decreases adherence to medical regimens
• Adversely influences expectations and benefits of
treatment efficacy
• Increases withdrawal and social isolation
• Reduces cognitive (executive) functioning and memory
• Influences dietary choices and reduces motivation to
exercise and follow self-management regimens
•
e.g. checking blood glucose
DiMatteo et al. Arch Intern Med 2000; 160 (14): 2101–2107
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Behaviour (2)
Depression decreases medication adherence in diabetes
Non-adherent days (%)
40
Non-depressed
Depressed
30
20
10
0
Oral
hypoglycaemic
Lipid lowering
meds
ACE inhibitors
Lin et al. Diabetes Care 2004; 27 (9): 2154–2160
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Risk factors (2)
Depression and increased BMI (>30 kg/m2)
80
p<0.001 vs none
Percent with
BMI >30 kg/m2 (%)
70
p<0.01 vs none
60
50
40
30
20
10
0
None
Minor
Depression group
n=4,225; Adjusted for demographics, medical comorbidity, diabetes severity,
diabetes type and duration, treatment type, HbA1c and clinic
Major
Katon et al. Diabetes Care 2004; 27 (4): 914–920
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Depression increases mortality rate in diabetes by
two-fold
Kaplan-Meier survival estimate
Kaplan-Meier estimate
1.0
Non-depressed patients
Depressed patients
0.9
0.8
0
24
48
72
96
Survival time (weeks)
120
144
Katon et al. Diabetes Care 2005; 28 (11): 2668–2672
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Depression associated with increased mortality
post MI
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Cox model hazard ratio for 6-month mortality associated
with depression: 5.74 (95% CI: 4.61–6.87) p=0.0006
Percent
mortality (%)
20
Depressed (n=35)
15
10
Non-depressed (n=187)
5
0
0
1
2
3
4
Time after MI (months)
5
6
Frasure-Smith et al. JAMA 1993; 270: 1819–1825
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SSRIs heal a SADHART
Patients treated with sertraline had 22% fewer adverse cardiac
events, 60% fewer deaths
Sertraline
Placebo
Heart rate
65/64
65/66
PR (ms)
167/167
172/173
VT
20/14
21/23
SDNN (ms)
100/104
109/103
Deaths
2
5
JAMA 2002
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Depression after coronary artery disease is
associated with heart failure
1.0
Event-free survival
No depression diagnosis
0.9
0.8
Depression diagnosis
0.7
0.6
0.5
0
1,000
2,000
3,000
4,000
5,000
Days to heart failure admission
May et al. J Am Coll Cardiol 2009; 53 (16): 1440–1447
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Post-stroke depression (PSD)
• Depression is one of the most frequent co-morbid
psychiatric disorders in stroke patients
• About 40% of patients with stroke will develop depression
during the first 2 years after the acute event
• PSD peaks within 3–6 months after the stroke
Starkstein et al. Expert Opinion 2008; 9: 1291–1298
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M-PRO-05-LIP-046-CSB
The Cytokine Theory of
Depression
Depression – en
inflammatorisk
sjukdom som
svar på kronisk psykisk
stress
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Development of atherosclerotic plaques
Fatty streak
Lipid rich plaque
Normal
Foam cells
Fibrous cap
Complex plaque
Lipid core
Thrombus
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Preventing atherosclerotic progression
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Atherosclerosis Involves More Than Just Lipids
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Plaque Disruption Leading to Atherothrombosis
Formation
Aggregated platelets
BLOOD
FLOW
Fibrin
Macrophage
Tissue factor
Adapted from: Falk E et al. Circulation 1995; 92: 657–71.
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Most MIs Arise From Smaller Stenosis
% Stenosis
Falk et al: Circulation 1995; 92:657-671
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Manifestations of Atherothrombosis are Commonly Found in More
than One Arterial Bed in an Individual Patient*1
Cerebrovascular
disease
Coronary
disease
7.4%
24.7%
29.9%
3.3%
11.8%
3.8%
19.2%
Peripheral arterial disease
*Data from CAPRIE study (n=19,185)
1. Coccheri S. Eur Heart J 1998; 19(suppl): P1268.
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Peripheral Arterial Disease (PAD) and AllCause Mortality*1
1.00
Normal Subjects
Survival
0.75
Asymptomatic LV-PAD†
0.50
Symptomatic LV-PAD†
Severe Symptomatic LV-PAD†
0.25
0.00
0
2
4
6
8
10
12
Year
*Kaplan-Meier survival curves based on mortality from all-causes
†Large-vessel PAD
1. Criqui MH. Vasc Med 2001; 6(suppl 1): 3–7.
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Statins and Stroke
•No clear relationship between cholesterol
and the incidence of total stroke
•An unexpected finding: some statin trials
showed reductions in the risk for stroke
even in patients taking aspirin
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© G.Walldius, I. Jungner
Hjärtinfarktrisk i relation till LDL-C och apo B
LDL-C
3.6
mmol/L
C
C
C
3.6
mmol/L
C
C C
C
C C
apo B
apo B
Large buoyant
apo B
CHD risk
0.8
g/L
†
Small dense
1.5
g/L
††
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AMORIS: fatal myocardial infarction
6,0
5,0
Adjusted for age, gender
TC and TG
O d d s -R
r a t io ( 9 5 % C I)
4,0
3,0
2,0
1,5
1,0
0,9
0,8
1
2
3
4
5
6
7
8
9
10
a p o B / a p o A - 1 ( d e c ile )
M e a n:
0.48
0 .6 1
0.70
0.77
0 .8 4
0 .9 1
1 .0 0
1.10
1 .2 3
1 .5 6
Cases:
61
78
123
146
155
236
265
298
372
479
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Look AHEAD trial
• Long-term effects of a lifestyle intervention on weight and
cardiovascular risk factors in individuals with type 2
diabetes.
•
Arch Intern Med 2010; 170; 1566-75.
• 5145 individer. 4 år. Intervention och kontrollgrupp.
• -6.15% i vikt, HbA1c -0.36%, systoliskt bltr – 5.33, diast
bltr – 2.92 och lipider bättre.
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