躁郁症与代谢症候群 (Bipolar Disorder & Metabolic Syndrome) 图文并茂网志版：http://pharmawind.pixnet.net/blog/post/36129627 代谢症候群 (metabolic syndrome, MeS) 是一种涵盖了许多临床与生化风险因子的疾病 ，这些病人可能正被心血管疾病、糖尿病与过早死亡等问题侵蚀着。 The metabolic syndrome (MeS) is a collection of clinical and biochemical risk factors that predispose affected individuals to cardiovascular disease (CVD), diabetes mellitus, and premature mortality (Med Clin North Am. 2006;90 (4): 573-591). 代谢症候群最主要的潜在风险因子是腹部肥胖 (abdominal obesity) 与胰岛素阻抗性 (insulin resistance)。此外，不好活动者、年长者与荷尔蒙失衡也被认为是代谢症候 群的病理性因子。其他被认为与代谢症候群相关的状况包括非酒精性脂肪肝、多发性卵巢 症候群、睡眠呼吸中止症，以及脂肪萎缩症。 The major underlying risk factors for MeS are abdominal obesity and insulin resistance. Habitual inactivity, aging, and hormonal imbalances are also considered to be pathogenic factors for MeS (J Am Coll Cardiol. 2005;44 (3): 720-732). Other conditions associated with MeS are non-alcoholic fatty liver disease, polycystic ovarian syndrome, sleep apnea, and lipodystrophies (Bipolar Disord. 2005;7 (3): 246-259). 虽然有几个协会皆有对代谢症候群进行定义，但目前最广为被引用的，系属美国国家胆固 醇教育计画 (NCEP) 检测、评估与治疗成人高血脂症之专家会议的第三次报告中所发表之 定义。 Although several definitional schemas have been proposed for MeS, the Third Report of the US National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) is the most often cited detion. 其中各个协会制定的定义中皆强调，肥胖与胰岛素阻抗性是代谢症候群典型的生理进程。 The commonalities across the various schemas for difining MeS emphasize obesity and insulin resistance as paradigmatic physiological processes. 近来有许多流病学与临床研究指出，在某些精神官能症，如重度忧郁症 (major depressive disorder, MDD) 患者，其罹患代谢症候群的风险会较一般人高。 The increased risk for MeS in individuals with psychotic as well as major depressive disorders has been well documented in both epidemiological and clinical studies (McEvoy et al., 2005). 此外，也有文献指出，罹患精神分裂症合并代谢症候群的高风险群为较年长者、白种人、 女性，以及具有较高的 Short Form (SF) 12量表分数者。 Individuals with comorbid schizophrenia and MeS were more likely to be older, white and female and to have higher scores on the Short Form (SF)12 (Physical score). (Meyer et al., 2005). 　　　 实验方法 (Methods) 简略来说，作者去 Pubmed 用 metabolic syndrome, bipolar disorder, mania, manic-depression 等关键字，捞了从 2005 年 1 月到 2009年 7 月的英文论文，以期探 讨代谢症候群与躁郁症病患族群的相关性。 We conducted a PubMed search of all English-language articles published between January 2005 and July 2009 with the following search terms: metabolic syndrome and bipolar disorder, mania and manic-depression. 统合与概述 (Synthesis and synopsis) 作者将这些从12个国家来的研究进行整合： 首先，各个研究中对躁郁症病患是否有符合代谢症候群的标准，会依照其所参照的各个协 会有不同的定义。 Taken together, there are several themes that emanate from the extant data reviewed herein from twelve countries. Firstly, it is well established that individuals with BD are differentially affected by NCEP-III- and IDF-defined MeS. 其次，代谢症候群患者在患病定义中的各项标准於各个研究中几乎都是增加的，其中所有 研究皆一致地显现腰围异常的状况。 Secondly, each component of the MeS is abnormal in most studies with increased waist circumference as the most consistently reported abnormality. 三者，发生代谢症候群与躁郁症的病患，与较复杂的病况表现 (自杀行为)，对治疗反应 较差，以及不良的疾病进程与治疗成效有较高度的相关性。 Thirdly, the co-occurrence of MeS and BD is associated with a more complex illness presentation, less favorable response to treatment, and adverse course and outcome. 第四，这些合并产生代谢症候群与躁郁症的患者，几乎都有使用会引起体重增加之抗精神 分裂症药物。 虽然以现有的文献并无法去确切的评估这些精神科药物对於引起代谢症候群的伤害揪竟有 多大，但可以确信的是，其影响是显着的。 Fourthly, the co-occurence of MeS and BD is very often associated with exposure to weight-gain promoting psychotropic agents. As such, the precise extent to which psychotropic agents account for the hazard for MeS in this population cannot be precisely estimated but appears to be significant. 作者也提到，在整合这些研究中，因为研究方法的缺陷等问题因此让研究结果有所缺陷。 1) 各个研究的病患组成、内容，以及对躁郁症与代谢症候群诊断标准或定义不一所造成 的异质性 2) 几乎都来自於回溯型横断性研究 3) 在收纳的病患中并没有提到对於代谢症候群患者在发病前的治疗资料 There are several methodological deficiencies that limit inferences and interpretations of the data. They include, but are not limited to: 1) heterogeneity in sample size, diagnostic criteria for BD and MeS, sample composition 2) a reliance on largely cross-sectional retrospective studies 3) insufficient pre-treatment information on MeS in enrolled subjects. 临床建议 (Clinical Recommendations) 临床医师应仔细的评估每一位躁郁症患者，并适切的回顾病史、用药史和家族史，注意其 是否具有可能与代谢症候群相关的风险因子。 Clinicians should carefully screen all BD patients for risk factors related to MeS as well as comprehensively review medical and family history. 腰围已被证实是用来观测腹部肥胖良好的参数，此外我们也可以藉由观测腰围的变化，来 探知病患在基础值 (baseline) 乃至治疗期间的趋势曲线。 Waist circumference has been demonstrated to be a surrogate for abdominal obesity and can easily be measured at baseline and during ongoing surveillance of a patient (Bosello and Zamboni, 2000; Yusuf et al., 2005). 美国糖尿病／美国精神病／协会与国际躁郁症安全性评估准则指引一致建议： ※ 接受第二代抗精神分裂症药物 (second-generation antipsychotic agents, SGAs) 治疗之躁郁症患者，应在 baseline 与开始服药或换药後之第 4, 8, 12 周测量其体重与 BMI值，并於每季进行例行性追踪。 Extrapolating from the American Diabetes/American Psychiatric/Association Consensus recommendations as well as the International Society for Bipolar Disorder Guidelines on the safety monitoring of the bipolar patient, BD patients receiving SGAs should have their weight and BMI evaluated at baseline and assessed at 4, 8, and 12 weeks after initiating or changing SGA and quarterly thereafter at the time of routine visits (American Diabetes Association, 2004; Ng et al., 2009). ※ 在开始服用抗精神分裂症药物三个月後，应追踪其空腹血糖值、血脂浓度与血压值。 Fasting plasma glucose, lipid levels, and blood pressure should also be assessed 3 months after initiation of antipsychotic medications. ※ 之後应每年定期检查血压和血糖值，而在某些 baseline 就显示为糖尿病或高血压 高风险群的病人，应更频繁的进行监测。 Thereafter, blood pressure and plasma glucose values should be obtained annually or more frequently in those who have a higher baseline risk for the development of diabetes or hypertension. ※ 在接受治疗後三个月内血脂数据呈现正常的病患，应每三年接受血脂检验，如临床上 　 有需要，可更频繁的追踪。 In patients with a normal lipid profile at 3 months, repeat testing should be performed at 3-year intervals or more frequently if clinically indicated. 　 治疗 (Treatment) 非典型抗精神分裂症药物 (SGAs) 目前已知会显着的造成体重增加与肥胖，并可能加速糖 尿病的进程。对於躁郁症病患而言，合并使用 SGAs 与 mood stabilizers 可能会造成更 大的肥胖风险。此外，与使用 SGAs 单一治疗相较，病患使用抗精神病药的多重治疗会有 较高的比率罹患代谢症候群与胰岛素阻抗性。 Treatment with atypical antipsychotics is well known to be associated with significant weight gain and obesity, as well as with hyperglycemia, exacerbation of pre-existing diabetes, or development of type 2 diabetes (Henderson, 2008). The combination of atypical antipsychotics and mood stabilizers may result in additional risk for obesity in patients with BD (Kim et al., 2008). Compared with antipsychotic monotherapy, patients receiving antipsychotic polytherapy were shown to have higher rates of MeS and insulin resistance (Correll et al., 2007) 　　 SGAs: clozapine, olanzapine, risperidone and quetiapine et al. Mood stabilizers: lithium, valproate et al. Adapted from Journal of Affective Disorder 2010; 126: 366-367 Link: http://www.ncbi.nlm.nih.gov/pubmed/20541810 　 Wind 11 Nov. 2011 -- 女友铭 发不在长、马尾就行，爱不在浓、温柔则灵； 斯是小鸟，惟吾是依。 点心做得精、情话说得勤，能舞会调情、体贴且窝心； 可以腰纤细、掌中轻，无唠叨之乱耳、无打扫之劳形； 情似深海隽，貌略天仙逊；永不云：今晚不行。 --

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