Depresijos po gimdymo diagnostika ir gydymas

Depresijos po gimdymo diagnostika ir gydymas

 Įvadas

Depresija po gimdymo yra viena labiausiai paplitusių nėštumo komplikacijų. Tai sukeliantis sunkumų, bet pagydomas psichikos sutrikimas (1). Depresija po gimdymo yra įtraukta į Amerikos psichiatrų asociacijos Psichikos sutrikimų diagnostikos ir statistikos vadovo penktąjį leidimą (DSM-5) kaip didžiosios depresijos epizodas, susijęs su nėštumu ir gimdymu, kai nuotaikos sutrikimų atsiranda nėštumo metu ar per 4 savaites po gimdymo (1 lentelė) (2). Tačiau depresija, kuri prasideda praėjus 4 savaitėms po gimdymo arba neatitinka visų didžiosios depresijos kriterijų, taip pat turi būti gydoma (3). Klinikinėje praktikoje ir klinikiniuose tyrimuose depresija po gimdymo (depresija po gimdymo be psichozės) yra apibrėžiama kaip depresija, kuri išsivysto per 4 savaites arba per 3 mėnesius po gimdymo, o kitais atvejais – per 6 mėnesius arba net per 12 mėnesių po gimdymo.

Depresijos po gimdymo paplitimas siekia 6,5–12,9 proc. (1, 4, 5). Dažniausi šios patologijos simptomai yra miego sutrikimai (išskyrus atvejus, kai jie yra susiję su kūdikio priežiūra), nerimas, dirglumas, greitas nuovargis, perdėtas rūpinimasis kūdikio sveikata, jo maitinimu. Tyrimų duomenimis, motinos depresija, mintys apie savižudybę, nerimas neigiamai veikia kūdikį (6). Tiksli depresijos po gimdymo patofiziologija iki šiol nėra žinoma. Pats didžiausias šios patologijos rizikos veiksnys yra anksčiau buvę nuotaikos sutrikimai, nerimo epizodai, ypač negydyta depresija ir nerimas nėštumo metu (6). Po gimdymo sparčiai sumažėjęs lytinių hormonų kiekis taip pat gali skatinti depresijos vystymąsi, ypač jautresnėms moterims (7). Depresija dažniau išsivysto genetinę predispoziciją turinčioms moterims bei toms, kurios negauna pakankamai socialinės paramos, patiria ar yra patyrusios sunkumų šeimoje, partnerio smurtą, lytinę prievartą (10). Nepaisant skirto gydymo, pati depresijos po gimdymo eiga savaime gali būti labai įvairi. Kai kurioms moterims depresijos simptomai išnyksta per kelias savaites net ir neskiriant jokio gydymo, tačiau apie 20 proc. depresijos simptomai vargina praėjus 1 metams, o 13 proc. – praėjus 2 metams po gimdymo. Apytiksliai 40 proc. moterų diagnozuojamas depresijos po gimdymo atkrytis pakartotinių nėštumų metu (11). Problema ta, kad dažna moteris, net ir suvokdama, kad jos savijauta nėra normali, nesikreipia į gydytojus pagalbos. Dėl tos priežasties daugeliu atvejų depresija po gimdymo nėra diagnozuojama, moterys negauna tinkamos medicininės pagalbos.

Šiame straipsnyje pateikiama apibendrinta informacija, kaip įtarti ir diagnozuoti depresiją po gimdymo, kokie rekomenduojami ir plačiausiai taikomi šios patologijos gydymo būdai.

 

Atrankinė pacienčių patikra ir depresijos po gimdymo diagnostika

Šiuo metu nėra sutarta, koks yra geriausias būdas diagnozuoti depresiją po gimdymo. Daugeliu atvejų gydytojai tiesiog pasiteirauja, kaip jaučiasi moteris po gimdymo, jei reikia, pabendrauja su jos artimaisiais. Amerikos akušerių ir ginekologų kolegija (16) ir Amerikos pediatrų akademija rekomenduoja dešimties klausimų Edinburgo depresijos po gimdymo skalę (15) kaip metodą nustatyti tikėtinai depresijai pagimdžius. Jungrinių Amerikos Valstijų sveikatos kokybės tyrimų agentūros duomenimis, įvairūs testai gali padėti sumažinti klaidingai neigiamų ir teigiamų rezultatų skaičių tuomet, kai pirmiausia naudojami jautrūs 2 klausimai pirminei atrankai: ar pacientė yra prislėgtos nuotaikos, jaučiasi beviltiškai ir skundžiasi interesų bei pasitenkinimo įvairiomis veiklomis sumažėjimu (20).

Jungtinės Karalystės nacionalinis sveikatos priežiūros institutas rekomenduoja visų pagimdžiusių moterų paprašyti atsakyti į tuos pačius 2 klausimus (1 pav.), pasižyminčius dideliu suminiu jautrumu ir mažu suminiu specifiškumu (20). Jei teigiamai atsakoma į bent 1 iš 2 klausimų, vėliau taikomas Edinburgo depresijos po gimdymo skalės tyrimas (15) arba Paciento sveikatos klausimynas 9 (22). Jei pagal išsamaus klausimyno duomenis kyla didelis depresijos po gimdymo įtarimas, būtina surinkti išsamią klinikinę anamnezę ir patikslinti diagnozę (18).

Patvirtinant diagnozę moterims, kurioms tikėtina ši depresija, svarbu kruopščiai surinkti tikslią anamnezę, nustatyti kartu esančius psichikos sutrikimus, kitas ligas, atkreipti dėmesį į psichosocialines pacientės problemas. Maždaug 70 proc. jaunų motinų patiria lengvus depresijos simptomus 2–5 dieną po gimdymo. Dažniausia tai yra ašarojimas, liūdesys, nuotaikos labilumas, irzlumas, nerimas. Paprastai šie simptomai nesutrikdo kasdienės veiklos ir išnyksta savaime per 2 savaites. Vis dėlto retais atvejais šie lengvi depresijos simptomai gali progresuoti į kliniškai ryškią depresiją po gimdymo (24). Atskirti šias patologijas padeda nuolatinis pacientės būklės įvertinimas ir simptomų dinamikos stebėjimas.

Renkant anamnezę, reikėtų išsiaiškinti, ar pacientė anksčiau yra patyrusi depresijos, psichozės po gimdymo, bipolinio sutrikimo simptomų. Ar šios patologijos buvo diagnozuotos kokiam nors pacientės giminaičiui. Kadangi bipolinis sutrikimas gali manifestuoti depresijos epizodu, visų moterų, kurios yra prislėgtos nuotaikos, reikėtų paklausti, ar per pastarąsias 4 ir daugiau dienų jos nebuvo neįprastai pakylėtos ar dirglios nuotaikos, nejautė padidėjusio aktyvumo ir energijos antplūdžio, ar artimieji nepastebėjo moters charakterio pokyčių (21). Jei į šiuos klausimus atsakoma teigiamai (1 pav.), reikalingas papildomas pacientės įvertinimas, nes gydymas vien antidepresantais gali pabloginti bipolinio sutrikimo eigą.

Jei simptomai leidžia įtarti organinę ligos priežastį, turi būti įvertinta psichinė ir fizinė pacientės būklė. Laboratoriniai tyrimai skiriami pagal indikacijas, tačiau daugeliu atvejų vertėtų įvertinti hemoglobino ir skydliaukę stimuliuojančio hormono kiekį. Visų moterų reikėtų paklausti, ar jos vartoja psichoaktyviąsias, priklausomybę sukeliančias medžiagas, ar patiria smurtą artimoje aplinkoje, ar turėjo minčių apie savęs, kito žmogaus ar naujagimio žalojimą. Jei pacientė atsako teigiamai nors į vieną klausimą, reikėtų įvertinti jos psichikos būseną ir, esant reikalui, suteikti skubiąją pagalbą. Neatidėliotina pagalba būtina ir toms moterims, kurios negali pasirūpinti savimi arba kūdikiu (1, 18).

Svarbu atpažinti ir identifikuoti psichozes po gimdymo, kurios gali būti susijusios su pirminėmis psichozėmis, manijos epizodais ar depresijos epizodais su psichozės požymiais. Psichozė po gimdymo, kaip ir depresija pagimdžius, prasideda per pirmąsias kelias dienas ar savaites po gimdymo, tačiau pasireiškia kliedesiais, haliucinacijomis, keistu elgesiu, sumišimu ar padrikomis mintimis, kurias lydi prislėgta ar pakylėta nuotaika (21).

Psichozės po gimdymo paplitimas – 1–2 atvejai 1 tūkst. gimdyvių. Dažniausiai psichozė po gimdymo manifestuoja bipoliniu sutrikimu. Įtariant šią patologiją, rekomenduojama skubi psichiatro konsultacija. Suteikus pirmąją pagalbą, pacientę gali tekti hospitalizuoti dėl greitai pasikeitusios būsenos, padidėjusios savižudybės rizikos ar pavojaus kūdikiui.

 

Prevencija

Tyrimų duomenimis, moterys, kurioms depresija buvo negydyta nėštumo metu, turi 7 kartus didesnę riziką susirgti depresija po gimdymo, palyginti su moterimis, kurios susirgo depresija ir buvo gydytos nėštumo metu. Todėl depresijos gydymas iki nėštumo ar jo metu yra viena depresijos po gimdymo prevencijos priemonių (22). Viename apžvalginiame tyrime nustatyta, kad 78 proc. moterų, kurioms pirmuoju nėštumo trimestru buvo diagnozuota depresija ir taikomas gydymas psichoterapija ar vaistais, depresija po gimdymo nepasikartojo. Tuo tarpu 92 proc. moterų, kurioms pirmuoju nėštumo trimestru diagnozuota depresija buvo negydyta, vėliau diagnozuota depresija po gimdymo (17). Keliuose atsitiktinių imčių tyrimuose nustatyta, kad moterys, kurios turėjo bent 1 iš depresijos simptomų ir kurioms buvo suteikta sveikatos priežiūros darbuotojų ir artimųjų pagalba, turėjo mažesnę depresijos po gimdymo išsivystymo riziką, palyginti su moterimis, kurios turėjo depresijos simptomų, tačiau aiškios pagalbos nesulaukė (13,6 proc. vs. 16,6 proc., PI 0,66–0,93) (23).

Kaip prevencija depresijai po gimdymo rekomenduojama ir sveika mityba, reguliari mankšta, pakankamas miegas.

 

Gydymas psichoterapija

Tinkamiausi depresijos po gimdymo gydymo būdai skiriasi priklausomai nuo moters simptomų sunkumo laipsnio ir jos būklės, įskaitant gebėjimą rūpintis ir rasti ryšį su naujagimiu. Lengvus ar vidutinio sunkumo simptomus gali koreguoti pirminės sveikatos priežiūros grandies gydytojas. Psichiatrui pacientę reikėtų nukreipti tuomet, kai nepadeda pradinis gydymas ir reikalinga skubi pagalba sunkios ligos atveju, pasireiškia manija, psichozė, mintys apie savęs ar kitų žalojimą (18).

Moterims, kurioms pasireiškia vidutinio sunkumo simptomai, padeda artimųjų parama, netiesioginis sveikatos priežiūros specialistų konsultavimas grupėse ar vizituojant slaugytojams (18). 5 tyrimų duomenimis, moterys, kurioms buvo taikomos psichosocialinės intervencijos, pirmaisiais metais po gimdymo buvo mažiau prislėgtos nuotaikos, palyginti su moterimis, kurioms buvo taikoma standartinė sveikatos priežiūra po gimdymo, kurią vykdė bendrosios praktikos slaugytojos, pirminės sveikatos priežiūros grandies gydytojas, visuomenės sveikatos ar bendruomenės slaugytojos (depresijos dažnis atitinkamai 32 proc. ir 46 proc., 95 proc. PI 0,39–0,94) (24).

Moterims, kurioms diagnozuota vidutinio sunkumo depresija po gimdymo ir kurioms taikytos psichosocialinės intervencijos nebuvo veiksmingos, rekomenduojama psichoterapija. Daugelio tyrimų duomenimis, gerų rezultatų pasiekiama taikant grupinę ar individualią ribotos trukmės (12–14 savaičių) struktūrizuotą kognityvinę elgesio ar tarpasmeninę psichoterapiją. Kognityvinė elgesio terapija, orientuota į minčių schemų ir elgesio keitimą, padeda pagerinti emocinę būseną. Tarpasmeninė terapija, orientuota į nuotaikos ir tarpasmeninių santykių korekciją, padeda pagerinti tarpasmeninius santykius, pereiti į tėvystę. 5 klinikinių tyrimų sisteminėje apžvalgoje nustatyta, kad kognityvinė elgesio psichoterapija buvo 60,3 proc. efektyvesnė nei įprasta priežiūra, o tarpasmeninė psichoterapija 48,1 proc. efektyvesnė nei įprasta priežiūra.

 

Farmakoterapija

Gydymas antidepresantais rekomenduojamas tais atvejais, kai depresijos po gimdymo simptomai neišnyksta taikant psichosocialines intervencijas ir psichoterapiją, taip pat tuomet, kai simptomai yra sunkūs ir reikia greito poveikio (18). Cohrane centro mokslininkų komanda atliko 6 klinikinių tyrimų sisteminę apžvalgą ir įvertino antidepresantų efektyvumą gydant depresiją po gimdymo. 3 atsitiktinių imčių tyrimuose analizuotas depresijos simptomų kitimas ir remisijos dažniai moterų, gydytų selektyviais serotonino reabsorbcijos inhibitoriais (SSRI) arba placebu, grupėse. Pacienčių, vartojusių SSRI, atsakas į gydymą buvo geresnis, palyginti su placebu (52,2 proc. vs. 36,4 proc., PI 1,03–2,03), o remisijos dažnis didesnis (46 proc. vs. 25,7 proc., PI 1,08–2,98) (25).

Dauguma SSRI patenka į motinos pieną. Jame SSRI koncentracija yra 10 proc. mažesnė nei motinos kraujyje. Nors trūksta duomenų apie vaistų poveikį ilgalaikiam vaiko vystymuisi, daugeliu atvejų antidepresantus vartojančios pacientės neturėtų nutraukti žindymo. Tais atvejais, kai moteriai iškyla žindymo sunkumų arba miego stoka pagilina depresijos simptomus, gydytojai ir artimieji turėtų palaikyti jos pasirinkimą nežindyti. Nepaisant to, kad skirtingi antidepresantai skirtingais kiekiais patenka į motinos pieną, sutrikus žindymui, vieno antidepresanto keisti kitu nerekomenduojama, ypač pacientėms, kurioms stebimas geras terapinis poveikis. Naujai pirmą kartą išsivysčiusiais depresijai po gimdymo gydyti kaip pirmo pasirinkimo vaistas rekomenduojamas sertralinas, nes jo mažiausiai patenka į motinos pieną (26). Išnagrinėjus daugiau nei 50 atvejų, kai žindančios moterys vartojo fluoksetiną arba citalopramą, nenustatyta jokių naujagimiams išsivysčiusių nepageidaujamo poveikio reiškinių. Todėl šie preparatai taip pat priskiriami pirmo pasirinkimo vaistams. Serotonino norepinefrino reabsorbcijos inhibitoriai (SNRI) ar mirtazapinas dažniausia skiriami tais atvejais, kai SSRI yra neveiksmingi arba kai moteris anksčiau buvo gydyta SNRI ir poveikis buvo geras. Nors SNRI nedaug patenka į motinos pieną, duomenų apie šių vaistų saugumą žindymo metu nėra daug (27). Naujausi antidepresantai turėtų būti skiriami tik tada, kai kitų grupių vaistų neįmanoma gauti arba jie yra neefektyvūs. Monoamino oksidazės inhibitoriai taip pat retai skiriami žindyvėms dėl nepakankamų duomenų apie jų poveikį naujagimiams (29). Keliose publikacijose pristatyti atvejai, kad bupropioną vartojusių ir žindžiusių moterų kūdikiams išsivystė traukuliai (29). Žindančioms moterims vengiama skirti triciklių antidepresantų, nes jų gausiai patenka į pieną bei turi neigiamą poveikį širdžiai. Yra žinomi atvejai, kai doksepiną vartojus žindyvei, naujagimiui išsivystė kvėpavimo sistemos slopinimas, sutriko čiulpimas, išsivystė hipotomija ir vėmimas (30).

Nors ir trūksta duomenų apie depresijos po gimdymo gydymo trukmę, antidepresantus rekomenduojama vartoti 6–12 mėnesių, o nutraukti palaipsniui mažinant dozę tuomet, kai pirmojo depresijos epizodo simptomai ilgą laiką liks sumažėję (31). Moterims, kurioms būdingi pasikartojantys depresijos epizodai, reikalingas ilgesnis gydymas vaistais.

Sunkią depresiją gali prireikti gydyti ir kitų grupių vaistais. Benzodiazepinai gali būti laikinai vartojami esant stipriam nerimui ir nemigai arba esant abiem minėtiems simptomams. Dažniausia benzodiazepinus galima nutraukti tuomet, kai antidepresantai pasiekia veikimo piką. Moterims, kurioms diagnozuota depresija su psichozės požymiais, papildomai gali būti skiriami antipsichoziniai vaistai. Sunkiais atvejais, kai nėra atsako į gydymą medikamentais, nustatoma didelė savižudybės rizika arba psichozė, gali prireikti hospitalizuoti pacientę ir skirti elektroimpulsinę terapiją (1, 18).

 

Kiti gydymo būdai

Manoma, kad kai kurioms moterims depresiją po gimdymo sukelia hormoniniai svyravimai. Tokiais atvejais gali padėti įvairios hormoninių preparatų formos. Vieno tyrimo duomenimis, perodiniai estrogenų preparatai gali sumažinti depresijos po gimdymo simptomus, tačiau išsamesnių tyrimų kol kas nėra atlikta (32). Kitame tyrime nustatyta, kad sintetinis progestinas buvo susijęs su padidėjusia depresijos po gimdymo rizika (32). Dar viename atsitiktinių imčių tyrime, kuriame dalyvavo 14 depresija po gimdymo sergančių pacienčių, nustatyta, kad transkranijinė magnetinė stimuliacija efektyviau nei placebas numalšino depresijos simptomus (36). Kaip papildomi ir alternatyvūs preparatai depresijai po gimdymo gydyti gali būti skiriami omega-3 riebalų rūgščių, folio rūgšties, S-adenozilmetionino, jonažolių papildai, šviesos terapija, mankšta, masažas, akupunktūra. Vis dėlto duomenų apie šių priemonių efektyvumą esama mažai (34).

 

Apibendrinimas

  • Depresija po gimdymo yra dažna patologija, sukelianti sunkumų tiek pačiai gimdyvei, tiek jos artimiesiems.
  • Po gimdymo svarbu surinkti išsamią moters psichikos būsenos anamnezę, atkreipti dėmesį į tai, ar pacientė skundžiasi prislėgta nuotaika, interesų praradimu.
  • Svarbu įvertinti, ar su depresijos simptomais nėra bipolinio sutrikimo ar psichozės po gimdymo požymių. Tokiais atvejais gydymo taktika skiriasi.
  • Depresijos po gimdymo gydymas priklauso nuo simptomų sunkumo ir moters gebėjimų su jais susidoroti. Lengvai depresijai gydyti gali būti taikomos psichosocialinės intervencijos, vidutinio sunkumo depresijai gydyti rekomenduojama psichoterapija.
  • Sunki depresija gydoma vaistais. Pirmo pasirinkimo preparatai – SSRI grupės antidepresantai, kurie laikomi suderinamais su sveikų naujagimių žindymu.

 

Kristina Lašaitė

Vilniaus universiteto Medicinos fakultetas

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  13. Dennis CL, Dowswell T. Psychosocial and psychological interventions for pre- venting postpartum depression. Cochrane Database Syst Rev 2013;2:CD001134.
  14. Dennis CL, Hodnett E. Psychosocial and psychological interventions for treat- ing postpartum depression. Cochrane Database Syst Rev 2007;4:CD006116.
  15. Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K. Antidepres- sant treatment for postnatal depression. Cochrane Database Syst Rev 2014;9: CD002018.
  16. Orsolini L, Bellantuono C. Serotonin reuptake inhibitors and breastfeeding: a systematic review. Hum Psychopharma- col 2015;30:4-20.
  17. Gentile S. Use of contemporary anti- depressants during breastfeeding: a pro- posal for a specific safety index. Drug Saf 2007;30:107-21.
  18. Smit M, Dolman KM, Honig A. Mir- tazapine in pregnancy and lactation – a systematic review. Eur Neuropsycho- pharmacol 2016;26:126-35.
  19. Sriraman NK, Melvin K, Meltzer-Brody S. ABM clinical protocol #18: use of anti- depressants in breastfeeding mothers. Breastfeed Med 2015;10:290-9.
  20. Gentile S. Tricyclic antidepressants in pregnancy and puerperium. Expert Opin Drug Saf 2014;13:207-25.
  21. Lam RW, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guide- lines for the management of adults with major depressive disorder: introduction and methods. Can J Psychiatry 2016;61: 506-9.
  22. Dennis CL, Ross LE, Herxheimer A. Oestrogens and progestins for prevent- ing and treating postpartum depression. Cochrane Database Syst Rev 2008;4: CD001690.

   33.Myczkowski ML, Dias AM, Luvisotto T, et al. Effects of repetitive transcranial magneticstimulationonclinical,social, and cognitive performance in postpartum depression. Neuropsychiatr Dis  Treat 2012; 8:491-500.

  1. Deligiannidis KM, Freeman MP. Com- plementary and alternative medicine ther- apies for perinatal depression. Best Pract Res Clin Obstet Gynaecol 2014;28:85-95.
  2. Postpartum Depression: Action To- wards Causes and Treatment (PACT) Consortium. Heterogeneity of postpartum depression: a latent class analysis. Lancet Psychiatry 2015;2:59-67.

362 mintys apie “Depresijos po gimdymo diagnostika ir gydymas

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