LJILJANA RADANOVIĆ-GRGURIĆ

Doktorska disertacija: "Veliki depresivni poremećaj u prognanika".
Obrana 16. prosinca 2005.g. u Zagrebu.

SAŽETAK

Istraživanjem smo pokušali procijeniti pojavnost i obilježja kliničke slike velikog depresivnog poremećaja i socijalnu prilagodbu u osoba koje su tijekom ratnih zbivanja u razdoblju 1991.-1995. god. proživjele iskustvo progonstva. Ponavljanjem istraživačkih postupaka dvije godine poslije htjeli smo utvrditi što se s bolesnicima dešavalo tijekom vremena. Pokušali smo utvrditi uzajamni odnos velikog depresivnog poremećaja i progonstva te utjecaj tog odnosa na ishod depresije, kako bismo što primjerenije provodili terapijske postupke i time izbjegavali moguće komplikacije.
Istraživanjem smo obuhvatili 58 žena, dobi od 35 do 55 godina, novooboljelih od velikog depresivnog poremećaja, koje su se tijekom razdoblja istraživanja od godinu dana obratile za pomoć na Psihijatrijsku kliniku u Osijeku. Istraživačke postupke ponovili smo dvije godine poslije, s 45 odazvanih bolesnica.
Dijagnozu velikog depresivnog poremećaja postavili smo prema DSM-IV dijagnostičkim kriterijima, s definiranih najmanje 17 bodova na Hamiltonovoj ocjenskoj Ljestvici za depresiju. U istraživanju smo rabili i Zungovu Ljestvicu za samoocjenjivanje depresivnih, Ljestvicu ukupnih kliničkih dojmova, Strukturirani dijagnostički intervju (prema DSM-III-R) za posttraumatski stresni poremećaj te Samoocjensku ljestvicu socijalne prilagodbe. Bolesnicama smo određivali serumske koncentracije hormona štitnjače, ACTH, kortizola, glukoze, kolesterola i triglicerida.
Iskustvo progonstva proživjelo je 20 bolesnica. Ratom traumatiziranih bolesnica bilo je 27, dok je samo 11 depresivnih bolesnica, sve s područja koje gravitira Klinici, bilo bez proživljenog traumatskog iskustva. Dvije godine poslije, 56% prognanica i 56% bolesnica s proživljenom ratnom traumom te 33% bolesnica bez traumatskog iskustva bolovale su od velikog depresivnog poremećaja.
Dvije trećine prognanica proživjelo je višestruko traumatsko iskustvo. Bile su slabijeg općeg zdravlja neovisno o prisutnosti depresivnog poremećaja.
S vremenom je jačina depresije u prognanica značajno opala. Sve bolesnice su subjektivno iskazivale umanjeni doživljaj depresije. Neki depresivni simptomi su se održavali i nakon što je depresivni poremećaj prestao biti klinički manifestan.
Nešto niže vrijednosti fT3 u osoba s iskustvom progonstva i ratne traume u odnosu na netraumatizirane te nešto više koncentracije kortizola u prognanica u odnosu na ratom traumatizirane upućuju na iscrpljenost uslijed dugotrajne izloženosti nepovoljnim životnim okolnostima i traumatizaciji.
Sve prognanice i ratom traumatizirane bolesnice istovremeno su pokazivale i simptome posttraumatskog stresnog poremećaja.
Sve depresivne bolesnice su pokazivale slabiju socijalnu prilagodbu. Mnoga obilježja socijalne prilagodbe održavala su se slabim i po povlačenju depresivnog poremećaja.
Obilježja progonstva značajno su utjecala na ekspresiju velikog depresivnog poremećaja te socijalnu prilagodbu. S dužinom progonstva slabila je sveukupna težina depresije, ali je istovremeno uvjetovala apatiju, samoprebacivanje i pesimizam te vegetativnu pobuđenost. Boravak kod poznatih uslovljavao je nezadovoljstvo, neurastenične smetnje te neodlučnost. Teži depresivni poremećaj s izrazitijim depresivnim promišljanjima pokazivale su prognanice koje su u progonstvu bile s cijelom obitelji. One koje su u progonstvu bile samo s djecom, bile su manje inhibirane. Socijalna prilagođenost u prognanica je bila to bolja, što je progonstvo trajalo kraće, kada je bilo provedeno u poznatoj sredini ili se mjesto boravka više puta mijenjalo te kad je prognanica u progonstvu bila samo s dijelom obitelji, preuzevši ulogu vođe.
Najznačajnim prediktorima velikog depresivnog poremećaja u prognanica pokazali su se udruženost nižih serumskih vrijednosti ACTH i kortizola; udruženost simptoma pobudljivosti, izbjegavanja i repeticije s dominantnom ulogom simptoma repeticije te niže serumske razine kortizola. Mlađa dob i tjelesni poremećaj bili su nešto slabijeg učešća u predikciji depresije.
Prognanici i ratom traumatizirane osobe u širem smislu, rizična su skupina za razvoj depresivnog poremećaja. Prepoznavanjem svih rizičnih čimbenika te ranim dijagnosticiranjem depresivnog poremećaja i najčešćeg popratnog posttraumatskog stresnog poremećaja, uz primjereno liječenje, moguće bi bilo smanjiti rizik kronifikacije i komplikacije depresije te slabe socijalne prilagodbe.

SUMMARY

The research objective was to estimate the frequency and the symptoms of major depressive disorder and the social adaptation of the persons that were displaced during the war period - from 1991 until 1995. By repeating the research procedure two years later, we wanted to see what had happened with the patients during two years period. We tried to define relation between major depressive disorder and displacement and the relation impact to the outcome of depression in order to improve the treatment and avoid possible complications.
The research included 58 female, aged 35 to 55 years, treated for major depressive disorder for the first time, who asked for help at the University Clinic for Psychiatry in Osijek during one year period. The research procedure was repeated after two years in the group of 45 patients who responded to our invitation.
Diagnosis of major depressive disorder was based upon DSM-IV diagnostic criteria with defined score of at least 17 at Hamilton Rating Scale for Depression. Zung Self Rating Depression Scale, Clinical Global Impressions, Structured Clinical Interview for Posttraumatic Stress Disorder (according DSM-III-R) and Social Adaptation Self-evaluation Scale were applied in this research as well. Serum concentrations of thyroide hormones, ACTH, cortisole, glucose, cholesterol and tryglycerides were defined for each patient.
Twenty patients had the experience of displacement, 27 were traumatized by the war while just 11 of depressed patients, from the region that gravitate to the University Clinic for Psychiatry in Osijek, did not experienced any trauma. Two years later, 56 % of displaced, 56% of patients with war trauma and 33% of the patients with no trauma suffered from major depressive disorder.
Almost 75% of displaced experienced multiple trauma. They all had poor general health status regardless to the presence of major depressive disorder.
The intensity of depression of displaced significantly decreased during the time. Some depressive symptoms were present even after the depressive disorder stop to be clinically significant.
A little bit lower fT3 concentration values of displaced and traumatized by war and a little bit higher concentration values of cortisole of displaced in relation to traumatized by war, indicated the exhaustion caused by long- term exposure to bad life conditions and trauma.
All displaced and patients traumatized by war manifested the symptoms of posttraumatic stress disorder at the same time.
All depressed patients manifested poor social adaptation. Many characteristics of social adaptation remain poor even after the withdrawal of depressive disorder.
The characteristics of displacement influenced significantly the expression of major depressive disorder as well as social adaptation. The length of displacement weakened general severity of depression but at the same time caused apathy, self-reproaching, pessimism, and vegetative arousal. Living with relatives, friends or known people while being displaced caused dissatisfaction, neurasthenic symptoms and indeciseveness. Severe depressive disorder with intensive depressive ideas was manifested by displaced who were displaced with complete family. Those that were displaced and alone with children were less inhibited. Social adaptation of displaced was better if displacement was shorter, when they were in known /familiar surrounding, if they had change surrounding several times or if displaced were displaced with incomplete family taking the role of the leader.
Most significant predictors of the major depressive disorder for displaced were: combinations of lower serum concentration of ACTH and cortisole , combinations of symptoms of arousal, avoidance and repetition (with dominant role of the symptoms of repetition) and lower serum concentration of cortisole. The age, especially younger age, and somatic disorders were less successful in prediction of depression.
Displaced and persons traumatized by war, generally speaking, are risk groups for development of depressive disorder. Recognition of all risk factors, early diagnosis of depressive disorder and most frequent comorbid posttraumatic stress disorder, followed by appropriate treatment could decrease the risk of chronicle and complicated depression as well as the risk of poor social adaptation.