急性期抑郁症患者外显攻击行为与主观认知下降相关性的前瞻性对照研究

Association between overt aggression and subjective cognitive decline in patients with depression during acute-phase:A prospective study

目的探讨急性期抑郁症患者外显攻击行为与主观认知下降的相关性。方法选取383例急性期抑郁症患者,予以艾司西酞普兰或文拉法辛治疗。采用17项汉密尔顿抑郁量表(HAMD-17)、修订版外显攻击量表(MOAS)和抑郁症认知功能缺陷自评量表(PDQ-D)分别于基线时及治疗后第4、8周末对其抑郁症状、外显攻击行为和主观认知功能进行评估。结果入组抑郁症患者中有攻击行为的抑郁发作次数更多,发病年龄更小,未治疗时间更长,认知功能更差。伴忧郁和非典型特征的患者,其计划/组织和回顾性记忆更差(P<0.05)。抑郁症状与主观认知功能的下降呈正相关(P<0.05)。自我攻击和对外攻击的患者在抑郁症急性期认知功能受损。治疗后第4周末,对外攻击患者的认知功能全面恢复。但在治疗后8周末,同时有自我和对外攻击患者的认知功能恶化(OR=76.77,P<0.001)。结论攻击行为与急性期抑郁症患者的主观认知功能下降有关。

Objective It remains unclear whether aggression affects subjective cognitive function during the acute phase of depression.This study aims to explore correlation between overt aggression and subjective cognitive decline among patients with acute depression,and to provide a basis for early intervention of cognitive impairment.Methods In this eight-week prospective study,a total of 383 depressive patients were recruited from the outpatients of Shanghai Mental Health Center from May 1,2017 to October 30,2018.These 383 cases were divided into non-aggression group,overt aggression group,self-aggression group,and self and overt aggression group according to their scores of Modified Overt Aggression Scale(MOAS).Participants were treated with escitalopram or venlafaxine at a dose titration range of escitalopram 10~20 mg/d and venlafaxine 75~225 mg/d as determined by the clinician based on the patients’conditions.After 4 weeks of treatment,if the treatment regimen was assessed to be effective(reduction in HAMD-17>30%),the regimen was continued until 8 weeks of treatment;if it was assessed to be ineffective,the treatment was switched to another antidepressant and continued for 8 weeks.Their depressive symptoms,overt aggressions,subjective cognitive decline were assessed using Hamilton Depression Scale 17-item(HAMD-17),Perceived Deficits Questionnaire for Depression(PDQ-D),and MOAS at baseline,and 4th,8th weekends after treatment.The PDQ-D scores for each subscale in patients with different types of overt aggression were compared by using the generalized estimating equation(GEE)modification of linear regression to account for intra-individual correlation over time.Results 259 participants(67.6%)completed the 8 weeks follow-up interviews and were included in final analysis.The mean age of the participants was(26.8±6.86)years old,and approximately 27.7%of the participants were male.There were 43.6%of patients reported with aggressive behavior at baseline,according to the MOAS score.Among them,19 cases(5%)had self-aggression,47 cases(12.3%)had overt-aggression,and 101 cases(26.4%)had self and overt aggression.Numbers of episodes were significantly more in patients with self-aggression than those in self and overt aggression group(95%CI:0.33~9.96,PBonferroni=0.029).Age of onset was younger in patients with self-aggression than that in overt aggression group(95%CI:-11.52~-0.80,PBonferroni=0.027).Patients with self and overt aggression had longer DUP compared to those without aggressive behaviors(95%CI:0.30~2.66,PBonferroni=0.006).HAMD cognitive impairment factor scores were higher in patients with self-aggression(95%CI:0.09~1.86,PLSD=0.031),self and overt aggression(95%CI:0.03~0.92,PLSD=0.037),compared with that in patients without aggressive behavior.Patient with melancholic features and atypical features had impairments in planning/organization(ORmelancholic features=0.20,Pmelancholic features=0.027;ORatypical features=0.24,Patypical features=0.009)and retrospective memory(ORatypical features=0.25,Patypical features=0.007).Depressive symptoms were significantly positively associated with subjective cognitive decline.In multi-adjusted GEE models,self-aggression and overt aggression were positively correlated with impairment of planning/organization,retrospective memory and attention/concentration(P<0.05).Furthermore,participants with self-aggressive behavior suffered from more severe impairment in cognition.The impairment in prospective memory was more pronounced in patients with overt aggression(P<0.05).At the end of 4 weeks follow-up,participants with overt aggression showed significant improvements in planning/organization(OR=4.8347E-18,P<0.001),prospective memory(OR=1.2818E-8,P=0.01),retrospective memory(OR=3.8042E-7,P=0.015)and attention/concentration(OR=2.384E-6,P<0.001).Attention/concentration in patients with combined self and overt aggression deteriorated at 8 weeks follow-up(OR=76.77,P<0.001).Conclusion Aggression impairs cognitive function in patients with acute depression.Cognitive functions are overall improved in patients with overt aggression after treatment.However,subjective cognitions are declined in patients with combined self and overt aggression after entering maintenance period.These findings suggest that aggression may be related to the subjective cognitive decline in depression,particular,the long-term effects on cognitive function.Therefore,further studies are needed to verify whether aggression has a long-term impact on cognitive function in patients with depression and examine if interventions may help to decrease aggressive behaviors in patients with depression,which may protect against future subjective cognitive declines.