孕期心理干预对产后抑郁影响、相关危险因素和雌激素受体的关联研究

发布时间：2018-06-17 04:06

本文选题：抑郁 + 焦虑　；参考：《复旦大学》2007年博士论文

【摘要】： [目的]探讨孕期心理干预能否降低产后抑郁的发生，并探讨产后抑郁的相关危险因素和可能存在的ERβ遗传易感性。 [方法](1)采用RCT设计。于2005.3—2006.2部分连续整群抽样800例孕16-20周的孕妇，随机分配至干预组(n=386)和对照组(n=414)。干预组在常规孕妇保健的基础上给予以“正确看待产后抑郁”为主题的集体心理干预(5次孕妇+1次丈夫)课程，对照组予常规孕妇保健。所有对象每月跟踪随访至产后3天、42天和3月(包括婴儿气质)。孕妇的情绪采用HAD自评，产后采用HAD和EPDS双重自评。产后在自评的基础上采用SCID分层临床会晤。婴儿气质采用EITQ评估。采用ITT原则分析资料。(2)所有对象每次随访时评估自编相关危险因素表、LES以及产科检查表，并评估EPQ1次，采用纬度法和类别法多元回归序惯结合分析产后抑郁的相关危险因素。(3)对于产后抑郁者和非抑郁者分别随机抽取静脉血70例和110例，采用聚合酶链反应—限制性酶切多态性(PCR-RFLP)的方法进行ERβ的2个SNPs(rs1256030和rs3020444)基因分型。分别采用改良式关联分析、病例-对照关联分析以及两点单体型关联分析获得产后抑郁的遗传易感性。 [结果] 第一部分：(1)在PP数据集中，当采用HAD评估时，孕妇心理干预可以减轻孕期和产后的焦虑情绪；当采用EPDS评估时，未能发现干预效果。在FAS数据集中，无论采用HAD还是EPDS评估，都未能发现干预效果。孕妇在接受心理干预课较好的基础上其丈夫接受心理干预对产妇的产后焦虑存在干预作用。孕妇受干预次数以及与丈夫受干预次数之和与孕32-36周(干预正好结束)和孕38-40周的焦虑分值(A项分)呈直线负相关。(2)根据HAD或EPDS划分界值，未能发现心理干预对产后三个时点的焦虑或抑郁症状具有影响作用。(3)采用SCID诊断，未能发现心理干预对产后三个时点或整个三个月中的重性抑郁障碍、未特定的抑郁障碍或任何抑郁障碍具有干预作用。在产后三个时点重性抑郁障碍的发生率(调整发生率)干预组分别为4.04％、14.92％、7.85％，对照组分别为3.61、18.12％、5.39％。产后三个月中总的重性抑郁障碍的发生率，干预组为11.79％，对照组为12.68％。产后三个月中总样本重性抑郁障碍的发生率为12.24％，未特定的抑郁障碍为12.98％，任何抑郁障碍为27.82％。(4)孕期心理干预明显提高小婴儿“易带”的(易养型和中间偏易养型)的比例，明显降低小婴儿气质维度上的趋避性和反应阈。第二部分：用纬度法分析，在产后三个时点产后抑郁共同的危险因素为：婴儿看护应激、神经质人格(EPQ的高N分)、既往抑郁发作史和对父母不满意。在产后3天还存在的危险因素有：担心产后无人照料自己、新生儿感染、产后休息和产后普通休养室；在产后42天还存在的危险因素有：孕期焦虑、不良生活事件、对丈夫不满意、产后同事探望不满意、坐月子不满意、居住环境差和产后出血；在产后3月还存在的危险因素有：孕期抑郁、不良生活事件、对以后工作的担忧、产后睡眠不满意和居住环境差。用类别法考察部分危险因素时，，再次发现：既往抑郁发作史、神经质人格、婴儿看护应激(担忧带孩子问题)以及孕期抑郁、产后出血成为产后抑郁的危险因素。第三部分：ERβ基因rs3020444(T／C)多态“T／T”基因型与产后抑郁关联，导致产妇患产后抑郁的风险是对照组的2.91倍(P＜0.05)；病例组“T”等位基因导致产妇患产后抑郁的风险是对照组的2.72倍(P＜0.05)。未发现rs1256030(C／T)的等位基因或基因型与产后抑郁存在关联。基于rs1256030(C／T)和rs3020444(T／C)的单体型“C-C”对产后抑郁具有保护作用，OR=0.312[0.104-0.942]，P=0.039。 [结论] 1．孕期心理干预对预防孕期和产后的焦虑情绪具有作用。丈夫接受心理干预可以帮助干预依从性好的孕妇预防产后的焦虑情绪。孕妇和其丈夫接受心理干预的次数越多，对于预防孕中-晚期的焦虑情绪就越有作用。 2．孕期心理干预对预防产后抑郁的效果不明显。 3．孕期心理干预对小婴儿的心理发育有着积极意义。 4．产后42天是重性抑郁障碍的高发时点。其次为产后3月，产后3天最低。 5．相对于SCID诊断来说，用HAD来筛查产后抑郁，8／9划分界值出现了较低的筛查率；用EPDS来筛查产后抑郁，12／13划分界值也出现了较低的筛查率，假阴性较高。 6．用纬度法分析产后抑郁的危险因素，不但可以全面的占有资料，具有较高的统计效能，而且推导出的危险因素与类别法推导出的危险因素并无大的差别。 7．婴儿看护应激、既往抑郁发作史、神经质人格以及对父母的不满意是上海部分女性产后抑郁的重要的危险因素。 8．ERβ基因有可能参与了产后抑郁的发病。具有rs3020444(T／C)“T／T”基因型的女性在产后随着雌激素的剧烈撤退，触发转录异常，引发抑郁，但具体途径尚不清楚。基于rs1256030(C／T)和rs3020444(T／C)的单体型“C-C”对产后抑郁却具有保护作用。
[Abstract]:[Objective] to explore whether postpartum depression can be reduced by psychological intervention during pregnancy, and to explore the related risk factors of postpartum depression and possible ER beta genetic susceptibility.
[method] (1) RCT design. 800 pregnant women with 16-20 weeks of pregnancy in 2005.3 to 2006.2 parts were randomly assigned to the intervention group (n=386) and the control group (n=414). On the basis of the routine maternal health care, the intervention group was given a group psychological intervention (5 pregnant women with pregnant women) on the theme of "the correct treatment of postpartum depression" (5 pregnant women), and the control group. Routine maternal health care. All subjects were followed up to 3 days, 42 days and March (including baby temperament). HAD self evaluation was adopted for pregnant women, HAD and EPDS were adopted after postpartum. After postpartum, the SCID stratified clinical meeting was adopted. The infant temperament was evaluated by EITQ. The ITT principle was used to analyze the data. (2) every object every time. At the time of follow-up, the related risk factors, LES and obstetric checklist were evaluated, and EPQ1 times were evaluated. Latitudes and classification methods were used to analyze the related risk factors of postpartum depression. (3) 70 cases of venous blood and 110 cases were randomly selected for postpartum depression and non depressive, and polymerase chain reaction restrictive enzyme digestion was used. Polymorphism (PCR-RFLP) method was used to classify 2 SNPs (rs1256030 and rs3020444) genotyping of ER beta. The genetic susceptibility of postnatal depression was obtained by modified association analysis, case control correlation analysis and two point haplotype association analysis.
[results]
The first part: (1) in the PP data set, the psychological intervention of pregnant women can reduce the anxiety of pregnancy and postpartum when using the HAD assessment. When the EPDS assessment is used, the intervention effect can not be found. In the FAS data set, the intervention effect is not found by the use of HAD or EPDS assessment. Pregnant women are better on the basis of accepting psychological intervention classes. The intervention of the husband's psychological intervention on puerperal postpartum anxiety had a negative correlation with the number of intervention of the pregnant women and the number of intervention of the husband and the 32-36 weeks of pregnancy (the intervention just ended) and the 38-40 weeks of pregnancy (A score). (2) according to the boundary value of HAD or EPDS, no psychological intervention was found on the three point postpartum focal points. (3) the SCID diagnosis failed to detect the intervention of the psychological intervention on the three time points of postpartum or the whole three months of depressive disorder, no particular depressive disorder or any depressive disorder. At the three time postpartum, the incidence of depressive disorder was 4.04, respectively, in the intervention group. %, 14.92%, 7.85%, the control group was 3.61,18.12%, 5.39%., the incidence of total heavy depressive disorder in three months postpartum, the intervention group was 11.79%, the control group was three months postpartum, the incidence of total depressive disorder was 12.24%, no specific depressive disorder was 12.98%, any depressive disorder was 27.82%. (4) pregnancy. Psychological intervention significantly increased the proportion of "easy to take" (easy to foster and intermediate prone type) in the small infants, and obviously reduced the taxis and reaction threshold in the dimension of the baby's temperament.
The second part: the latitudinal analysis showed that the common risk factors for postpartum depression at three postpartum periods were baby care stress, neuroticism (EPQ N), history of previous depression and dissatisfaction with parents. The risk factors for the 3 day postpartum were: fear of postpartum no one, neonatal infection, postpartum rest and postpartum. The risk factors of 42 days postpartum were: pregnancy anxiety, bad life events, dissatisfaction with the husband, dissatisfaction of postpartum visit, dissatisfaction of the month, poor living environment and postpartum hemorrhage; the risk factors for postpartum March were depression in pregnancy, bad life events, worry about future work and postpartum. Sleep dissatisfaction and poor living conditions. When examining some of the risk factors with the category method, the history of previous depression, neuroticism, baby care (worrying about children) and depression in pregnancy, and postpartum hemorrhage are the risk factors for postpartum depression.
The third part: the ER beta gene rs3020444 (T / C) polymorphism "T / T" genotype was associated with postpartum depression. The risk of postpartum depression was 2.91 times as high as that of the control group (P < 0.05). The risk of postpartum depression in the case group was 2.72 times as high as the control group (P < 0.05). The allele of rs1256030 (C / T) was not found. Or genotypes associated with postpartum depression. Rs1256030 (C / T) and rs3020444 (T / C) haplotype "C-C" has a protective effect on postpartum depression, OR=0.312[0.104-0.942], P=0.039.
[Conclusion]
1. pregnancy psychological intervention has a role in preventing pregnancy and postpartum anxiety. The husband's psychological intervention can help the intervention of pregnant women with good compliance to prevent postpartum anxiety. The more times the pregnant women and their husbands receive psychological intervention, the more effective it is to prevent the middle and late pregnancy anxiety.
2. the effect of psychological intervention during pregnancy is not obvious in preventing postpartum depression.
3. psychological intervention during pregnancy has positive significance for psychological development of infants.
4. postpartum 42 days is the high incidence point of major depressive disorder, followed by postpartum March, the lowest 3 days after delivery.
5. compared with the SCID diagnosis, HAD was used to screen postpartum depression, and the 8 / 9 boundary values had a lower screening rate; EPDS was used to screen postpartum depression, and the 12 / 13 boundary values also had a lower screening rate, and the false negative was higher.
6. the latitudinal analysis of the risk factors of postpartum depression can not only take full possession of the data, but also have high statistical efficiency, and there is no significant difference between the risk factors and the risk factors derived from the category method.
7. baby care stress, past history of depression, neuroticism and dissatisfaction with parents are important risk factors for postpartum depression in some women in Shanghai.
The 8.ER beta gene may be involved in the onset of postpartum depression. Women with rs3020444 (T / C) "T / T" genotype have a severe withdrawal of estrogen after postpartum, triggering transcriptional abnormalities and causing depression, but the specific way is not clear. The monosomatograph based on rs1256030 (C / T) and rs3020444 (T / C) is protected by postpartum depression. Effect.
【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R395.5

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