Depresyon tanısı konulan şizofreni hastalarında eklenen antidepresan ilaç tedavisinin depresif belirtiler ve bilişsel işlevler üzerine etkisinin karşılaştırılması
Comparison of the effects of antidepressant treatment on depressive symptoms and cognitive functions in schizophrenia patients diagnosed with depression
Yazar: EMİNE ÖNAL
Danışman: DR. ÖĞR. ÜYESİ BİLGE ÇETİN İLHAN
Sağlık Bilimleri Üniversitesi / Konya Beyhekim Eğitim ve Araştırma Hastanesi / Psikiyatri Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2024
Konu: Psikiyatri = Psychiatry
Dizin: Şizofreni = Schizophrenia

Özet:
AMAÇ: Şizofreni hastalığı algılamada bozulma, düşüncede bozulma, afektif ifadelerde azalma, sosyal iletişimde azalma, davranışlarda bozulma ve nörobilişsel bozulma ile seyreden, aslında pek çok bozukluğun içinde olduğu bir hastalık kümesidir. Hastalığın başlangıcı ve ilerleyişinde hastalar pek çok zorlanma ve bunun getirdiği sıkıntılarla mücadele etmek durumunda kalırlar. Bilişsel fonksiyonlarda bozulma ve işlevsellikte azalma klinisyenlerin pek etkin olamadığı ve hemen tüm hastalarda farklı derecelerde de olsa gözlenen bir durumdur. İlk semptomların ortaya çıkmasından sonra hayatlarının herhangi bir döneminde, şizofreni hastalarının kliniğine depresyonun eklenmesi sık rastlanan bir komorbiditedir. Gerek şizofreninin doğası gereği gerek depresyonun eklenmesi ile artabilen bilişsel bozulma hastaların hayat kalitesi üzerinde ciddi etkisi olan bir durumdur. Çalışmamızda klinik görüşme esnasında depresyon ek tanısı alan hastaların değerlendirilmesi ve tedavi düzenlenmesi sonrası durumlarında değişmeyi incelemeyi amaçladık.
YÖNTEM: Çalışmamıza, şizofreni tanısı ile takip edilen, klinik değerlendirme sırasında depresyon tanısı alan ve Calgary Şizofrenide Depresyon Ölçeği'nden (CŞDÖ) 11 ve üzeri puan alan 53 hasta dahil edildi. Hastalara Pozitif ve Negatif Sendrom Ölçeği (PANSS), Klinik Global İzlem Ölçeği (CGI), Global Değerlendirme Ölçeği (GAS), İntihar Olasılığı Ölçeği (İOÖ), İşitsel-Sözel Öğrenme Testi (İSÖT) ve İz Sürme Testi A/B (İST A/B) uygulanmıştır. Hastalar 6 hafta (42 gün) takip edildi ve 42. günde PANSS, CŞDÖ, CGI, GAS, İOÖ, İSÖT ve İST A/B ölçekleri çalışma kriterlerine uyum sağlayabilen 40 hastaya tekrar uygulandı. Başlangıç ve sondaki veriler değerlendirildi.
BULGULAR: Çalışmaya dahil edilen 53 hastanın ve çalışmayı tamamlayan 40 hastanın verileri incelendiğinde, klinik ölçek puanları depresyon tanısı aldıkları anda ve antidepresan tedavi aldıktan sonrası karşılaştırıldığında; ilk görüşmede PANSS toplam puanı 82,63±17,26, PANSS pozitif puanı 18,3±4,6, PANSS negatif puanı 20,9±5,1ve PANSS genel psikopatoloji puanı ise 43,3±8,8 olarak bulunmuştur. Antidepresan tedavi sonrası PANSS toplam puanı 62,3±14,8, PANSS pozitif puanı 12,9±4,1, PANSS negatif puanı 17,1±4,4 ve PANSS genel psikopatoloji puanı ise 32,3±7,7 olarak bulunmuştur. (p<0,05) Depresyon tanısı aldıkları zamanda Calgary Şizofrenide Depresyonu Değerlendirme Ölçeği (CŞDÖ) puanı 13,4±2,4, antidepresan tedavi sonrasında ise 4,0±2,2 olarak saptandı. (p<0,05) Depresyon tanısı aldıkları zamanda İntihar Olasılığı Ölçeği (İOÖ) toplam puan 77,05±15,28, alt ölçeklerden umutsuzluk 27,73±6,57, intihar düşüncesi 13,45±4,76, kendini olumsuz değerlendirme 23,05±5,55, düşmanlık 12,70±3,72 olarak bulundu. Antidepresan tedavi kullanımı sonrası İOÖ toplam puan 61,20±11,67, alt ölçeklerden umutsuzluk 20,83±5,49, intihar düşüncesi 10,48±2,93, kendini olumsuz değerlendirme 19,23±4,70, düşmanlık 10,68±2,80 olarak saptandı. (p<0,05)  (p<0,05) Bilişsel fonksiyonları değerlendiren İSÖT ve İST A-B testlerinde depresyon tanısı aldıkları anda hastaların İSÖT A1 skoru ortalama 4,0 (2,0), A1-A5 ortalama toplam puanı 32,0 (10,7), İSÖT B1 ortalama puanı 3,0 (1,7), İSÖT A6 ortalama puanı 7,0 (3,0), İSÖT A7 ortalama puanı ise 7,0 (2,7), İSÖT toplam doğru ortalama değeri 49,5 (19,5), toplam yanlış ortalama değeri 1,5 (5,5) olarak saptandı. Antidepresan kullanımları sonrasındaki İSÖT A1 skoru ortalama 6,0 (2,0), hastaların A1-A5 toplam puanı ortalama 39,0 (16,5), İSÖT B1 ortalama puanı 4,0 (2,0), İSÖT A6 ortalama puanı 8,0 (3,0), İSÖT A7 ortalama puanı ise 8,0 (3,0), İSÖT toplam doğru ortalama değeri 58,0 (20,0), toplam yanlış ortalama değeri 1,0 (2,5) olarak saptandı. (p<0,005)  Depresyon tanısı aldıkları anda İST-A testi ortalama saniye 84,0 (54,2), İST-B testi ortalama saniye 226,5 (207,2), İST-B-A ortalama değeri ise 131,00 (168,25) olarak saptandı. Hastaların antidepresan tedavi kullandıktan sonra İST-A testi ortalama saniye 62,0 (56,5), İST-B testi ortalama saniye 169,5 (115,2), İST-B-A ortalama değeri ise 97,00 (78,75) olarak saptandı. (p<0,005)
SONUÇ: Çalışmamızda klinik görüşme esnasında depresyon ek tanısı alan hastalar değerlendirilmiş olup, tedavilerine antidepresan ilaç eklenerek kullanımlarından sonra bilişsel fonksiyonlarının birçok ölçek ve alt ölçekle değerlendirilen bellek, dikkat ve yürütücü işlevler gibi kısımlarında iyileşme olduğu saptandı. Hastaların şizofreni semptomlarında, genel klinik görünümlerinde ve depresif semptomlarında iyileşme ve depresyonun en önemli risklerinden birisi olan intihar olasılığının da antidepresan tedavi sonrası azaldığı saptandı. Antidepresan tedavi eklenmesinin, şizofreni hastaları açısından bilişsel fonksiyonlarda iyileşmeye yardımcı olması umut vadetmektedir. Daha kapsamlı verilere ulaşmak için geniş örneklemli ve daha uzunlamasına çalışmalara ihtiyaç vardır.
Anahtar sözcükler: Şizofreni, depresyon, bilişsel fonksiyonlar, intihar

Abstract:
OBJECTIVE: Schizophrenia is a cluster of disorders characterized by impaired perception, thought disorder, decreased affective expression, decreased social communication, behavioral disturbances, and neurocognitive impairment. Patients with schizophrenia often face many challenges and struggles in coping with the onset and progression of the illness. Impairment in cognitive functions and decreased functionality are commonly observed in varying degrees in almost all patients, making it difficult for clinicians to effectively intervene. The addition of depression to the clinic of schizophrenia patients at any stage of their lives after the onset of initial symptoms is a common comorbidity. Cognitive impairment, which can increase due to both the nature of schizophrenia and the addition of depression, is a condition that significantly affects the quality of life of patients. In our study, we aimed to examine the changes in patients' conditions after the evaluation and treatment adjustment of those diagnosed with depression during clinical interviews.
METHOD: In our study, 53 patients diagnosed with schizophrenia, who were also diagnosed with depression during clinical assessment and scored 11 or higher on the Calgary Depression Scale for Schizophrenia (CDSS), were included. Patients were assessed using the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale (CGI), Global Assessment Scale (GAS), Scale for Suicide Probability (SSP), Auditory-Verbal Learning Test (AVLT), and Trail Making Test A/B (TMT A/B). Patients were followed for 6 weeks (42 days), and on the 42nd day, PANSS, CDSS, CGI, GAS, SSP, AVLT, and TMT A/B scales were re-administered to 40 patients who met the study criteria. Data from the baseline and final assessments were evaluated.
RESULTS: When the data of 53 patients included in the study and 40 patients who completed the study were examined, it was found that; the PANSS total score at the initial assessment was 82.63±17.26, PANSS positive score was 18.3±4.6, PANSS negative score was 20.9±5.1, and PANSS general psychopathology score was 43.3±8.8. After antidepressant treatment, the PANSS total score was found to be 62.3±14.8, PANSS positive score was 12.9±4.1, PANSS negative score was 17.1±4.4, and PANSS general psychopathology score was 32.3±7.7 (p<0.05). The Calgary Depression Scale for Schizophrenia (CDSS) score at the time of depression diagnosis was 13.4±2.4, and after antidepressant treatment it was found to be 4.0±2.2 (p<0.05). At the time of diagnosis of depression, The Suicide Probability Scale (SPS) total score was found to be 77.05±15.28, with subscale scores of hopelessness at 27.73±6.57, suicidal ideation at 13.45±4.76, negative self-evaluation at 23.05±5.55, and hostility at 12.70±3.72. After antidepressant treatment, the SPS total score was determined to be 61.20±11.67, with subscale scores of hopelessness at 20.83±5.49, suicidal ideation at 10.48±2.93, negative self-evaluation at 19.23±4.70, and hostility at 10.68±2.80 (p<0.05).In the cognitive function assessments of AVLT and TMT A-B tests, patients' AVLT A1 score at the time of diagnosis of depression had an average of 4.0 (2.0), A1-A5 average total score of 32.0 (10.7), AVLT B1 average score of 3.0 (1.7), AVLT A6 average score of 7.0 (3.0), AVLT A7 average score of 7.0 (2.7), AVLT total correct average value of 49.5 (19.5), and total incorrect average value of 1.5 (5.5). After antidepressant use, the average AVLT A1 score was found to be 6.0 (2.0), the patients' A1-A5 total score averaged 39.0 (16.5), AVLT B1 averaged 4.0 (2.0), AVLT A6 averaged 8.0 (3.0), AVLT A7 averaged 8.0 (3.0), AVLT total correct average value was 58.0 (20.0), and total incorrect average value was 1.0 (2.5) (p <0.005). When diagnosed with depression, the TMT-A test had an average of 84.0 seconds (54.2), TMT-B test had an average of 226.5 seconds (207.2), and TMT-B-A average value was 131.00 (168.25). After patients used antidepressant treatment, the TMT-A test had an average of 62.0 seconds (56.5), TMT-B test had an average of 169.5 seconds (115.2), and TMT-B-A average value was 97.00 (78.75) (p <0.005).

CONCLUSION: In our study, patients who received an additional diagnosis of depression during clinical interviews were evaluated, and it was found that after adding antidepressant medication to their treatment regimen, there was improvement in various aspects of cognitive function, including memory, attention, and executive functions, assessed with multiple scales and subscales. Improvement was observed in patients' schizophrenia symptoms, overall clinical presentations, and depressive symptoms, and it was found that the likelihood of suicide, one of the most significant risks of depression, decreased after antidepressant treatment. The addition of antidepressant treatment holds promise for improving cognitive function in schizophrenia patients. However, more extensive and longitudinal studies are needed to obtain more comprehensive data.

Key words: Schizophrenia, depression, cognitive functions, suicide 
OBJECTIVE: Schizophrenia is a cluster of disorders characterized by impaired perception, thought disorder, decreased affective expression, decreased social communication, behavioral disturbances, and neurocognitive impairment. Patients with schizophrenia often face many challenges and struggles in coping with the onset and progression of the illness. Impairment in cognitive functions and decreased functionality are commonly observed in varying degrees in almost all patients, making it difficult for clinicians to effectively intervene. The addition of depression to the clinic of schizophrenia patients at any stage of their lives after the onset of initial symptoms is a common comorbidity. Cognitive impairment, which can increase due to both the nature of schizophrenia and the addition of depression, is a condition that significantly affects the quality of life of patients. In our study, we aimed to examine the changes in patients' conditions after the evaluation and treatment adjustment of those diagnosed with depression during clinical interviews.
METHOD: In our study, 53 patients diagnosed with schizophrenia, who were also diagnosed with depression during clinical assessment and scored 11 or higher on the Calgary Depression Scale for Schizophrenia (CDSS), were included. Patients were assessed using the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale (CGI), Global Assessment Scale (GAS), Scale for Suicide Probability (SSP), Auditory-Verbal Learning Test (AVLT), and Trail Making Test A/B (TMT A/B). Patients were followed for 6 weeks (42 days), and on the 42nd day, PANSS, CDSS, CGI, GAS, SSP, AVLT, and TMT A/B scales were re-administered to 40 patients who met the study criteria. Data from the baseline and final assessments were evaluated.
RESULTS: When the data of 53 patients included in the study and 40 patients who completed the study were examined, it was found that; the PANSS total score at the initial assessment was 82.63±17.26, PANSS positive score was 18.3±4.6, PANSS negative score was 20.9±5.1, and PANSS general psychopathology score was 43.3±8.8. After antidepressant treatment, the PANSS total score was found to be 62.3±14.8, PANSS positive score was 12.9±4.1, PANSS negative score was 17.1±4.4, and PANSS general psychopathology score was 32.3±7.7 (p<0.05). The Calgary Depression Scale for Schizophrenia (CDSS) score at the time of depression diagnosis was 13.4±2.4, and after antidepressant treatment it was found to be 4.0±2.2 (p<0.05). At the time of diagnosis of depression, The Suicide Probability Scale (SPS) total score was found to be 77.05±15.28, with subscale scores of hopelessness at 27.73±6.57, suicidal ideation at 13.45±4.76, negative self-evaluation at 23.05±5.55, and hostility at 12.70±3.72. After antidepressant treatment, the SPS total score was determined to be 61.20±11.67, with subscale scores of hopelessness at 20.83±5.49, suicidal ideation at 10.48±2.93, negative self-evaluation at 19.23±4.70, and hostility at 10.68±2.80 (p<0.05).In the cognitive function assessments of AVLT and TMT A-B tests, patients' AVLT A1 score at the time of diagnosis of depression had an average of 4.0 (2.0), A1-A5 average total score of 32.0 (10.7), AVLT B1 average score of 3.0 (1.7), AVLT A6 average score of 7.0 (3.0), AVLT A7 average score of 7.0 (2.7), AVLT total correct average value of 49.5 (19.5), and total incorrect average value of 1.5 (5.5). After antidepressant use, the average AVLT A1 score was found to be 6.0 (2.0), the patients' A1-A5 total score averaged 39.0 (16.5), AVLT B1 averaged 4.0 (2.0), AVLT A6 averaged 8.0 (3.0), AVLT A7 averaged 8.0 (3.0), AVLT total correct average value was 58.0 (20.0), and total incorrect average value was 1.0 (2.5) (p <0.005). When diagnosed with depression, the TMT-A test had an average of 84.0 seconds (54.2), TMT-B test had an average of 226.5 seconds (207.2), and TMT-B-A average value was 131.00 (168.25). After patients used antidepressant treatment, the TMT-A test had an average of 62.0 seconds (56.5), TMT-B test had an average of 169.5 seconds (115.2), and TMT-B-A average value was 97.00 (78.75) (p <0.005).

CONCLUSION: In our study, patients who received an additional diagnosis of depression during clinical interviews were evaluated, and it was found that after adding antidepressant medication to their treatment regimen, there was improvement in various aspects of cognitive function, including memory, attention, and executive functions, assessed with multiple scales and subscales. Improvement was observed in patients' schizophrenia symptoms, overall clinical presentations, and depressive symptoms, and it was found that the likelihood of suicide, one of the most significant risks of depression, decreased after antidepressant treatment. The addition of antidepressant treatment holds promise for improving cognitive function in schizophrenia patients. However, more extensive and longitudinal studies are needed to obtain more comprehensive data.

Key words: Schizophrenia, depression, cognitive functions, suicide