埋藏式心律转复除颤器患者心理障碍及其处理对策研究

Research and therapeutic strategy on the psychological disturbances of patients with implantable cardioverter defibrillator

目的了解埋藏式心律转复除颤器(ICD)患者心理障碍的发病率,探讨心理障碍的病因与发病学机制,评价综合治疗即"拼盘治疗"的疗效。方法选取1998年5月～2009年5月在昆明医学院第一附属医院初次行ICD/CRT-D植入术并能完成随访的患者138例(男108例,女30例,平均年龄65.7岁),所有患者均接受中国生活事件量表(LES)、适应不良自评量表、防御方式问卷(DSQ)、症状自评量表(SCL-90)、社会支持评定量表(SSRS)、ICD与回避行为问卷、汉密尔顿抑郁量表(HRSD)和汉密尔顿焦虑量表(HAMA)进行心理状态评估,并选取昆明医学院部分在校研究生130例作为正常对照组,采用相同量表进行心理状态评估,与ICD患者进行对比分析。所有患者于术前1周和术后1周、1月、3月、6月及9月分别采用上述量表进行心理状态评估。随访病例中存在心理障碍的患者予以综合治疗即"拼盘治疗"并在治疗后1周、2周、4周、6周和10周再次进行心理状态评估,与此同时采用病情严重程度(SI)与疗效总评(GI)两项指标进行疾病严重程度和疗效评价。随访采用门诊复查、住院观察、电话随访及上门随访等方式进行,患者心理评估采用观察法、问卷法及半结构式晤谈法进行。结果 138例患者共完成随访834例次,ICD患者的心理健康状况较差存在心理障碍58例(42.03%),明显高于正常对照组差异具有显著统计学意义,其中以焦虑、惊恐发作、睡眠障碍、适应不良、幻影放电和抑郁为主要表现。本研究表明以SCL-90作为ICD患者是否出现心理障碍的衡量指标,其中以躯体化、焦虑与恐怖是最有意义的预测因子;应用HRSD作为抑郁的评判指标,ICD患者抑郁状态以焦虑/躯体化、绝望感、睡眠障碍、迟缓和认知障碍作为预测指标;应用HAMA作为焦虑的评判指标,ICD患者焦虑状态中精神性与躯体性症状具有同等重要的意义,均是其发生的有力预测因素。在综合治疗疗法治疗ICD患者心理障碍的研究中,治疗前后以适应不良自评量表,SCL-90,HAMA,HRSD,SI和GI作为评价指标,结果证明该疗法能够明显改善患者心理障碍的严重程度,并在患者接受治疗的第二周开始显现疗效。本研究发现ICD放电与心理防御方式是ICD患者心理障碍的强烈预测因素。由本研究揭示的心理障碍病因及其他研究的成果推论ICD患者心理障碍发病的可能潜在机制为经典条件反射理论、学习无助理论和认知评价理论所解释。结论 1.ICD患者心理障碍的发病率显著高于健康人群,长期未受到应有重视。2.本研究发现ICD患者心理障碍发病高危预测因素为:ICD放电、心理防御方式。3.ICD患者心理障碍发病的潜在机制可能为经典条件反射理论、学习无助理论和认知评价理论所解释。4.综合治疗即"拼盘治疗"对存在心理障碍的ICD患者能够发挥上佳的治疗效果,并在治疗第二周开始发挥疗效。5.ICD患者的常规随访中应定期进行心理状态评估和心理咨询,及时对ICD患者的心理障碍发挥早发现、早治疗的一、二级预防作用。

Objective The study was designed to understand the rate of psychological disturbances in patients with implantable cardioverter defibrillator（ICD）retrospectively,to explore the etiological factors and psychopathogenesis and to evaluate the therapeutic effect of standard educational interventions program and comprehensive therapy likewise called＂combination therapy＂.Methods The study enrolled 138 patients（108 male,30 female,mean age of 65.7 years）,who accepted and received a medical or physical examination after the implantation of ICD CRT-D in The First Affiliated Hospital of Kunming Medical College during May 1998～May 2009.All patients were assessed by life event scale of China（LES）,maladaptation self-rating scale,defense style questionnaire（DSQ）,symptom checklist 90（SCL-90）,social support rating scale（SSRS）,avoidance behaviors of ICD,Hamilton depression rating scale for depression（HRSD） and Hamilton anxiety scale（HAMA）.A part of post-graduates（130persons） in the Kunming Medical College selected as the control group（heath persons） were appraised in the same ways.Both of results were compared after data were collected.ICD recipients were randomly divided into two groups.The one received a set of experimental educational interventions about health and the other one received a series of comprehensive educational interventions related to ICD.Psychological assessment of all operation-patients were executed 1 week before and 1 week,1 month,3 months,6 months and 9months after implantation.Among all patients except operation-patients without shock in the former study,patients who suffered with psychological disturbances accepted a comprehensive therapy likewise called＂combination therapy＂and psychological assessment of such patients were carried out 1 week,2weeks,4weeks,6weeks and 10weeks after treatment.Severity of illness（SI） and global improvement（GI） were thought as index suggesting severity of diseases and therapeutic effect at the same time.Out-patient clinical examination,in-patient observation,care by telephone and drop-in investigation were adopted in the follow-up period.Observation,questionnaire and semi-structured interview were employed in the progress of psychological assessment.Results 138 patients were enrolled and 834 case-trials eligible in the study.The research indicated that the mental health was poor in ICD patients and 42.03% of patients suffered psychological disturbances.The most frequent problems of which included anxiety（containing panic attack and generalized anxiety）,sleep disorder,adjustment disorder and depression.It was obviously statistically significant compared with the heath controls（P0.01）.The study found that somatization,anxiety and photic anxiety could reasonably predict the psychological status when SCL-90 was considered as a predictor stating whether the mental heath was well or not.Anxiety somatization,hopelessness,sleep disturbances,retardation and congnitive disturbance were believed as predictors for depression when the depression standard was HARD,and somatic anxiety and psychic anxiety were equally meaningful predictors when HAMA was adopted to demonstrate existence of anxiety.SCL-90,HAMA and HRSD were applied for appraisal indexes in the control research about operation-patients.The severity of mental disorder in patients receiving the experimental educational intervention was far more than that in patients receiving the comprehensive educational intervention,and rehabilitation time of the former was apparently longer than that of the latter statistically.The mental disorder attacked ahead of time and the severity of illness reduced in the standard intervention group,compared to the results of the simple intervention group.The psychological disturbances of ICD patients might gradually vanished with time in both groups.In the therapeutic effect concerning the comprehensive therapy pilot study,SCL-90,maladaptation self-rating scale,HAMA,HRSD,SI and GI were deemed indexes of therapeutic effect,which were measured before and 1 week,2 weeks,4 weeks,6 weeks and 10 weeks after treatment.The study concluded that the treatment strategies could substantially improve the severity of psychological disturbances,which was statistical significance,and discovered that the therapeutic effect emerged after the second week.The psychopathogenesis of psychological disturbances might be explained altogether by the classical conditioning theory,the learned helplessness theory and the cognitive appraisal theory.Conclusion 1.The attack rate of psychological disturbances of the patients exceeds that of the health people.2.The symptoms of psychological disturbances may gradually vanish with time.3.This study finds that the high-risk predictors for psychological disturbances in ICD recipients are ICD shock and mental defense mechanism.4.The classical conditioning theory,the learned helplessness theory and the cognitive appraisal theory have been altogether invoked to conceptualize these psychological disturbances in ICD patients.5.The standard educational intervention may utmost reduce the incidence of psychological disturbances,relieve the severity of psychological disturbances in ICD recipients and quickly regain the normal life after implantation.6.The comprehensive therapy also called＂combination therapy＂may significantly relieve the symptoms of psychological disturbances in patients with ICD,which achieves the optimal therapeutic effect and produces a marked effect in the second week.7.The study implies that it is vital that patients attend the routine psychological assessment and psychological consultation,in order to detect and treat psychological disturbances of ICD patients in the early stage,which refers to the primary or secondary prevention.