精神医学51巻7号

2009年07月発行

特集 精神疾患と睡眠マネージメント―最新の知見

うつ病における併存不眠の治療管理

著者： 三島和夫¹

所属機関： ¹国立精神・神経センター 精神保健研究所・精神生理部

ページ範囲：P.635 - P.647

はじめに

　DSMやICDではうつ病(気分障害，大うつ病)の診断項目の1つに不眠が挙げられている。不眠がうつ症状の1つに過ぎないとすれば，うつ病の発症とともに出現し，寛解や治癒とともに消失するはずである。しかし，現実は異なる。うつ病でみられる不眠の多くは難治性であり，うつ病の寛解後も高率に残遺する。うつ病の臨床経過の中で寛解と再燃に伴う抗うつ薬の増減はあれども，睡眠薬は寛解時にも減量できずに年余にわたり服用を続けるケースは稀ではない。これを睡眠薬の常用量依存と片付けるのはきわめて早計であり，うつ病における睡眠問題の本質を見誤っている。うつ病患者でしばしばみられる慢性不眠は単なるうつ症状の1つではなく，うつ病の臨床経過と乖離して持続する実にやっかいな併存症であるため，睡眠薬が中止できないケースがきわめて多いのである。また，うつ病患者の不眠の原因は，うつ病に起因するもの，併存症としての不眠症のみならず，睡眠時呼吸障害，薬剤起因性によるものなど多岐にわたり治療法も異なるが，実地臨床で適切な診断と対処がなされているとは言い難い(図1)。本項では，うつ病の病態生理，診断や治療を考えるうえで不眠症をどのようにとらえるべきか，最近の考え方を紹介する。

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