中国的老年抑郁症

老年抑郁症指老年人表现出长时间情绪低落或丧失兴趣的一种精神障碍。利物浦大学进行的一项荟萃分析显示，与西欧12%的患病率相比，中华人民共和国的老年抑郁症占比为 3.86%，这可能受到中国传统文化、社会期望和生活条件等因素的影响。其中，研究中所报告的较低患病率是否因文化和传统差异导致仍存在争议。 Yesavage和Brink编制的老年抑郁量表(Geriatric Depression Scale; GDS) 是在众多关于中国老年抑郁症研究中最常见的方法。而后,来自香港中文大学的Chu Lee Hing将其翻译成了中文版本。在香港的一项研究表明，其“简洁的回答形式尤其适用于老年人”，并且提供了“令人满意”的抑郁症筛选结果。 GDS分析了有关哭泣、食欲不振、睡眠、体重、记忆力、注意力、活力和愉悦等一系列简单的行为症状，然而仅针对情感的分析可能会根据文化环境产生不同的含义。 一般健康问卷(The General Health Questionnaire; GHQ)在某项研究中也被认为是可靠的，但不如GDS敏感。本研究也以香港老年人为样本。而另一种适用于中国老年人的评估方法是老年精神状态量表(GMS)。这是一种评估65岁及以上老年患者精神病理的访谈法，根据症状类型和该类型随时间发生的变化进行分类。在GMS中的分数可以使用计算机辅助诊断系统(Automated Geriatric Examination for Computer Assisted Taxonomy, AGECAT)进行进一步的详细诊断。 长期以来，学者们一直在研究中西方对抑郁症定义的差异。Science Magazine 杂志的心理健康记者Greg Miller写道:“在传统中医中，精神疾病通常被归因于心脏类疾病。” Harvard Review of Psychiatry 发现，传统中医中没有情绪障碍的概念；相反，它强调一种身体上的不平衡。据报道，抑郁症患者将自己描述为“情绪上…...加身体上的干扰，尤其是对心脏的影响…...这种身体上的不适并非仅仅是比喻；在哈佛大学的一项有关中国人抑郁经历的民族学的研究中，一些患者表示他们的抑郁症表现为心脏不舒服”。像“心慌”、“心烦”、“心痛”等短语是抑郁症患者用来形容身体不适的词语。在这项研究中，患者很少将他们的感受描述为悲伤，因为它通常被视为是“可耻的”，是“性格软弱”的表现。因此，在宣扬坚忍的这种文化下长大的中国人更愿意接受抑郁症是身体上的疾病，比如心脏疼痛或失眠，而非情绪上的问题。 神经衰弱，即“神经缺乏力量”，在20世纪初被引入中国大陆后就成为精神疾病的首选诊断结果。在汉语中，神经衰弱指整个身体的生命能量(气)流动的虚弱。这似乎更像是一种躯体疾病，包括疲劳、身体非特异性疼痛、头晕、胃部不适、食欲不振、记忆力衰退和失眠等症状。直到邓小平提出改革开放，政治上才允许“公共与私人空间界限的重新出现”，从而提升了社会对这种疾病的接受度，承认了其本质上是情绪的问题，并开始针对情绪障碍进行研究和治疗。 到了20世纪80年代，“神经衰弱”的标签被去掉，改用西方的“抑郁症”一词。 在中国文化中，“养老”是很重要的概念。在儒家思想中，子女们为长辈提供身体上、经济上和情感上的照顾是一种表示尊敬的方式。与此同时，老年人很期望能通过他们的建议和服务为社区做出贡献，而不是自己接受这些建议和服务——这是一种“人情”。对于坚持传统的老年人来说，老年生活的目的和自我价值是通过对家庭的积极影响来衡量的。 《中国医学杂志》(Chinese Medical Journal)的一项关于中国的孝道文化以及对老年人经济照顾的研究显示，在某个从中国大陆移民到加拿大的华人样本中，23.2%的人被评估有抑郁症状。而在抑郁组中，17.3%的人被认为处于“经济状况不稳定”的状态。 总体而言，在许多研究中，女性抽样调查中抑郁的人数比男性更多。这可能是由中国社会长久以来认为男性应该压抑情感导致的，因为任何情感问题上的求助都被视为软弱的表现。此外，也有研究发现，城市社区中受教育程度低的寡妇患抑郁症的风险更高。 Chong 等人的一项研究还发现，健康问题是老年人产生心理压力的一大因素。另一项研究发现，与没有接受任何治疗的老人相比，参加太极拳运动的中国老年人的抑郁症状有所减轻，这与《国际老年精神病学杂志》（International Journal for Geriatric Psychiatry）的发现相符。而香港中文大学的一项研究表明，体能和健康问题会影响病人的生活质量，而生活质量会影响抑郁程度。发表在《Stroke》杂志上的一项研究数据证实，中风后的抑郁症状很常见。中风导致日常生活活动减少，对中国农村老年人抑郁的严重程度有很大影响。另一项在中国农村进行的研究发现，“未被发现的”高血压与抑郁症有显著关系，这表明 "在老年群体中进行高血压筛查可能对预防抑郁症和心血管疾病有必要"。 据一项针对香港华人老年人的研究发现，“吸烟者（当下/曾经）比不吸烟者更容易出现抑郁症状” 。 据调查，在1987 年， 65%的中国老人与两代（有时是三代）家人同住，18%与一代同住，11%的老年夫妇没有与子女同住，只有 4%的老人独居（尽管他们有子女），2%单身。研究发现，在香港，孤独感对老年女性抑郁症患病率的影响比老年男性更大。最后得出结论，这是因为大龄男性（因在香港找不到妻子）与内地女子跨境结婚，从而适应了两地分居的生活方式。 Li Hong和Martin Tracy的研究表明，1999年，48%的中国老年人依赖配偶，40%依赖子女。克里夫兰州立大学的Rongjun Sun说：“担心没有足够的钱支付医疗费用是城市居民新的压力来源。”Sun的研究结果表明，“医疗覆盖的充足性对提升老年人的幸福感有实质性影响”，“在所有家庭支持措施中，子女的情感支持被发现对老年人的抑郁有显著的缓冲作用。” 与收入不同，经济压力，也就是支付日常开支的能力和“出现意外支出需求”时感到的担忧都会影响抑郁症。这项针对香港老年人的研究进一步发现，身体健康有问题的女性更容易因经济压力而加重抑郁。此外，研究还认为，社会支持增强并不一定会减轻经济压力对抑郁的影响，这与上文提及的Sun的“缓冲效应”的发现相矛盾。1998年对武汉市老年人的一项研究发现，“对经济支持的期望”（anticipated support）是减少经济压力对抑郁症影响的来源。预期支持带来安全感，而“获得经济支持” （received support）通常会引发老年人的内疚感。 一些人认为，由于文化差异，报道中的低患病率是有误的，而另一些人则认为，文化差异是低患病率的原因。Gordon Parker等人认为，大多数中国人否认抑郁症。“抑郁症在中国人中似乎不太明显，并且更有可能通过躯体表达，这是一系列因素相互关联的结果”，而Mjelde-Mossey等人则认为，“坚持传统与抑郁症呈负相关，因此这是一种对抗抑郁症的方法”。R. Chen等人基于对中国农村老年人的研究，给出了抑郁症患病率较低的三个原因: 第一，中国老年人的社会支持和积极的生活价值观水平较高。第二，农村地区的工作和生活环境更轻松(例如，工作压力更小，体力劳动更多)。第三，群体内部疾病的原因可能不同于解释群体之间差异的因素。 Parker研究中造成低患病率的因素： 抑郁症报告率低 神经衰弱的“惯用报道” “缺乏基于标准的分类”导致抑郁症筛查出现问题 斯多葛主义、文化支持和较低城市化水平的应对机制 Mjolde-Mossey 研究中使用的中国传统量表中项目的频率分布： 据预测，到22世纪中叶，中国老年人将占世界老年人口的25%。基于这样的数据，了解如何预防中国老年人的抑郁症，将有助于改善关于照顾老年人及其家人福祉上可能出现的一些问题。 Sun的研究发现，相较于与子女相隔远的老年人，与子女同住的老人的幸福感更高。由于人际关系的复杂性和不同测量方法带来等变量带来的影响，家庭支持对老年人的幸福感并没有持续产生积极影响，然而，孙的研究证实，家庭关系在缓冲不良社会事件的影响方面发挥了关键作用。考虑到中国未来的家庭状况，独生子女政策将会对独生子女赡养父母带来不少问题。 Mjelde-Mossey等人的研究还得出了一个结论：由于恪守传统可以减少抑郁的产生，老年人可以通过将他们的传统信仰应用到生活中的任何非传统情况和关系中，以此在一定程度上达到稳定的精神状态。在这样的背景下，中国老年人可能会被其他社会变化而影响，如独生子女，家庭成员间接触的缺乏以及对于青年自我中心化等西方传统观念的支持。 Chen, R., J. R. M. Copeland, and L. Wei. "A Meta-Analysis of Epidemiological Studies in Depression of Older People in the People's Republic of China." Copeland, J. R. M., et al (1999). "Depression in Europe". "Depression in China: Lost in Translation?" Harvard Mental Health Letter. Yesavage JA, Brink TL, Rose TL, et al. 1983. 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