抗憂鬱藥物與中風患者痙攣之交互作用：病例報告

The Interaction between Antidepressants and Spasticity of Stroke: Case Report

林詩文(Shih-Wen Lin) ； 王榮俊(Zong-Jing Wang) ； 于瑛輝(Young-Hue Yu)

《中華民國復健醫學會雜誌》 29卷4期 (2001/12) Pp. 221-227

摘要

上運動神經元疾患(如腦血管病變，外傷性腦傷，脊髓損傷，多發性硬化症等)常造成患者肢體的痙攣(spasticity)。一般針對痙攣的治療藥物包括作用於中樞系統的baclofen、diazepam，α-2受器致效劑的clonidine與tizanidine，以及作用於周邊系統的dantrolene。這類患者發生憂鬱症狀的比例高於一般正常族群的9.2%，例如慢性脊髓損傷患者併有憂鬱的盛行率為9.7~45%，中風患者則有37%。此時醫師可能會為此類患者同時處方抗憂鬱劑，目前常用的抗憂鬱劑包括三環抗鬱劑(tricyclic anti-depressants)及選擇性血清張力素回收抑制劑(selective serotonin reuptake inhibitors)，它們皆會使突觸中血清張力素的量提高，而再度誘發運動神經元的興奮性，進而造成肢體的痙攣。其次上運動神經元患者會產生去神經化過敏感性(denervation supersensitivity)的生理現象，並且抗憂鬱劑對蛋白質的親和力大於baclofen。基於上述理由，不當的抗憂鬱劑使用將使得痙攣更加難以控制。
過去相關的研究與病例報告都集中在脊髓損傷患者部分，抗憂鬱劑的使用與其肢體痙攣的惡化已知有明確的關連性；而本病例提醒了腦中風(右側頂葉出血)患者也有類似的反應，在服用選擇性血清張力素回收抑制劑之後會導致肢體痙攣的惡化，但在停藥之後肢體痙攣即明顯改善。

關鍵字

痙攣 ； 抗憂鬱劑 ； 腦中風

並列摘要

The upper motor neuron diseases (such as cerebrovascular accidents, traumatic brain injury, spinal cord injury, and multiple sclerosis) frequently cause spasticity of extremities. The medications for treating spasticity include baclofen and diazepam, which take their effect in the central nervous system through their GABAergic action. The incidence of depression in patients with spasticity is much higher than that of the normal population. Many doctors prescribe antidepressants for these patients. Two common used antidepressants are tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRI). They could increase serotonin amount in synapses, and induce increased excitability of motor neurons, which in turn results in spasticity of extremities. Denervation supersensitivity in upper motor neuron diseases further enhances this phenomenon. The antidepressants are also much more readily bound to protein than baclofen. Thus improper usage of antidepressants can exacerbate spasticity in patients with upper motor neuron lesions. There have been reports on antidepressant-induced spasticity in spinal cord lesion. Our case indicates that use of SSRI can also worsen spasticity in stroke patients. The spasticity improved after discontinuation of SSRI.

並列關鍵字

spasticity ； antidepressants ； stroke