Wednesday, March 30, 2011

პლაცებო ეფექტი როგორც მნიშვნელოვანი ფაქტორი ფსიქოფარმაკოთერაპიაში (საქართველოს ფსიქიატრიის მოამბე #7)

“placebo” efeqti, rogorc mniSvnelovani faqtori fsiqofarmakoTerapiaSi
P SoTa gamyreliZe, fsiqiatriis s/k instituti,
irakli giorgobiani, elene kavsaZe, merab arvelaZe,
narkologiis s/k instituti, Tbilisi, saqarTvelo
   “placebo-efeqti” (placebo - uvnebeli wamali, romelic gamoiyeneba pacientis dasamSvideblad, an mis dasarwmuneblad iseT moqmedebaSi, romelsac wamali ver axdens) gulisxmobs araspecifikur fsiqologiur an fsiqofiziologiur reaqcias indiferentul Terapiul agentze, romelic amis miuxedavad axdens dadebiT zegavlenas daavadebis simptomze, sindromze an araiSviaTad mTlian daavadebaze da ganapirobebs paTologiur gamovlinebaTa mniSvnelovan reducirebas an mTlian likvidacias da morCenas maSin, rodesac sruliad cxadia, rom “placebo” agenti sruliad moklebulia specifikur sindromotropul an nozotropul aqtivobas.
   Tanamedrove medicinaSi arsebuli samkurnalo meTodebi an saSualebaTa didi umravlesoba saxelmoxveWili iyo ZiriTadad “placebo” moqmedebis xarjze. samkurnalwamlo Terapiis mTeli istoria, bolo 70-80 wlis gamoklebiT SeiZleba miviCnioT “placebo-Terapiis” istoriad. Cvens droSic eqimis mier gamowerili medikamentebis 20-40% warmoadgens “placebo” saSualebebs.
   “placebo-TerapiaSi” gamoyofen e.w. “aqtiur placebos”, rodesac samkurnalo preparats gaaCnia Tavisi farmakologiuri Tviseba, magram ara pirdapiri samkurnalo moqmedeba. “aqtiur placebos” miakuTvneben zogad gamamagrebel medikamentebs, mag.: vitaminebis “B” kompleqsis gamoyeneba  Zlieri gadaRlilobis dros, susti analgeziuri preparatebis daniSvna mcire dozebSi da sxva mravali simtomurad momqmedi medikamentebis daniSvna arapirdapiri daniSnulebiT (15).
   fsiqologiur eqsperimentebSi  monacemTa obieqtivizirebisaTvis,  jer kidevMme-20 saukunis dasawyisSi SemoRebuli iqna e.w. “ormagi kontrolirebuli brma” meTodi,  romelic amave saukunis 70-ian wlebSi gaxda maRal mecnierul doneze Sesrulebul fsiqofarmakologiur gamokvlevaTa erT-erTi umniSvnelovanesi nawili. aRniSnuli meTodi sxvadasxva SemTxvevebSi gamoiyeneba sxvadasxva saxiT:
1.       “brma meTodi” _ rodesac avadmyofma ar icis samkurnalo saSualebis moqmedebis raoba da xasiaTi;
2.      “ormagi brma meTodi” – arc avadmyofma da arc damkvirvebelma eqimma ar ician, Tu kerZod jgufSi vis eZleva aqtiurad momqmedi da vis “placebo” formis wamali;
3.       “sammagi brma meTodi” – gamokvlevis dawyebis win yvela avadmyofs jgufSi eZleva “placebo” preparati da mxolod gamokvlevis Semdgom stadiaSi CairTveba is avadmyofi, romelsac ar SeumuSavda placebo-efeqti;
4.      “ormagi jvaredina brma, kontrolirebuli meTodi” – sakvlevad SerCeuli kontingenti iyofa ramdenime jgufad da garkveuli drois ganmavlobaSi monacvleobiT eZlevaT xan aqtiurad momqmedi preparati da xan misi msgavsi “placebo” analogi.
   mkvlevarebi TiTqmis erTsulovanni arian SefasebaSi, rom ama Tu im medikamentis efeqturobis obieqtur SefasebaSi ormagi brma meTodi warmoadgens umniSvnelovanes meTods, romlis gamoyenebiT xdeba SesaZlebeli, mkurnalobis procesSi sakuTriv farmakologiuri aqtivoba gamoiyos da gaxdes TvalsaCino, sxva TandarTuli faqtorebisgan.
   FfsiqiatriaSi, fsiqikur daavadebaTa mkurnalobaSi, dRemde ar gagvaCnia paTognomuri (specifikuri) samkurnalo saSualebani, amitom fsiqofarmakologiur saSualebaTa masiuri gamoyenebis pirobebSic ki farTod gamoiyeneba iseTi meTodebi, rogoricaa: megavitaminoTerapia, insulinis subSokuri, eleqtrokonvulsiuri Terapiis submarginaluri gantvirTvebis meTodi, e.w. magnitoTerapia, “CJen ciu Terapia”, bioeleqtrovelis da e.w. “eqstrasensebis” manualuri Terapia, mcire dozebiT warmoebuli farmakoTerapia da a.S.
    klinikur praqtikaSi “placebo” saSualebebs iyeneben im SemTxvevebSi, rodesac eqims ar gaaCnia maRalefeqturi saSualeba, an rogorc damatebiT faqtors, aqtiuri Terapiuli saSualebebis moqmedebis gasaZliereblad. zogjer mkurnali eqimi “placebo” Terapias mimarTavs maSin, rodesac pacients aqtiurad momqmedi preparati aRar sWirdeba da mkurnalobis gagrZeleba mizanSeuwonelia, magram pacienti kategoriulad moiTxovs mis gagrZelebas.
    “placebo-faqtoris” moqmedeba SeiZleba iyos dadebiTi, rodesac igi aZlierebs Terapiul efeqts, an uaryofiTi, rodesac igi, piriqiT amcirebs an abaTilebs wamlis dadebiT efeqts. “placebo-faqtoris” uaryofiT moqmedebas uwodeben “nocebos”, rac miuTiTebs arsebuli simptomebis gauaresebaze an avadmyofis subieqtur uaryofiT damokidebulebaze wamlis araefeqturobis gamo. arsebobs moncemebi, rom uaryofiT “placebo” - efeqts xSirad iZlevian pirovnebani, romlebic xasiaTdebian agresiulobis maRali maCveneblebiT. avadmyofebi, romlebic iZlevian “nocebo-efeqts” naklebad reagireben farmakoTerapiaze (15). “nocebo” reaqciisaTvis damaxasiaTebelia: saerTo moduneba, Tvlema, Tavis tkivili, Tavbrusxveva, uZiloba da kuWnawlavis aSliloba. aRniSnuli simptomebi Tavisi gamovlinebiT naklebi intensivobisaa da advilad ganicdian ukuganviTarebas. literaturaSi aRwerilia iseTi SemTxvevebic, rodesac pacients gamoumuSavda “placebo”-faqtorze e.w. “daqvemdebarebis” reaqcia abstinenciiT da kritikuli mdgomareobiT, ris gamoc saWiro gaxda avadmyofis hospitalizacia (18), an rodesac “placebo” - faqtorma ganapiroba toqsikuri reaqciis ganviTareba (4). zog SemTxvevaSi avtorebi (8) miuTiTebdnen medikamentis paradoqsul moqmedebaze: agznebis momatebaze, RebinebiT reaqciebze, ara marto imave avadmyofebSi, aramed sxva avadmyofebSic, e.w. “Rebinebis epidemiaze”.
   Tanamedrove fsiqofarmakologiam SeimuSava ra ase Tu ise srulyofili  antifsiqozuri meTodebi da saSualebani, magram amis miuxedavad am medikamentebiT mkurnalobis procesSi mudam monawileoben fsiqologiuri da fsiqofiziologiuri faqtorebi, romlebic ayalibeben maTi moqmedebis gamaZlierebel “placebo-efeqts”, Tumca cxadia, rom igi daavadebis arsis mimarT indiferentulia. mkurnalobis procesSi avadmyofs uviTardeba pirobiTi refleqsi Terapiis mocemuli meTodis mimarT. warmoiqmneba gacnobierebuli, Tu aracnobieri survili mkurnalobam gaamarTlos eqimis imedi da mzrunveloba.
   “placebo-efeqti” arsSi garkvevis dros ismeba kiTxva, Tu ra faqtorebi gansazRvraven mis aRmocenebas. adre amis safuZvlad miiCnevdnen pirovnebis aweul STamgoneblobas, magram am problemis specialurma Seswavlam aCvena, rom “placebo” - efeqti yovelTvis ar korelirdeba im monacemebTan, romlebic miiReba  pirovnebis testobrivi gamokvlevebiT. saWiroa aRiniSnos, rom dRemde ar aris srulyofilad Seswavlili “placebo-efeqti” damokidebuleba iseT parametrebTan, rogorebicaa: pacientis asaki, sqesi, nozologiuri diagnozi, simptomatologia, proJeqtiuli testebis monacemebi, romelnic gamiznuli arian pirovnebis struqturis Taviseburebebis SeswavlisaTvis da a.S. aRmoCnda, rom pirovneba, romelic avlens fsiqoTerapiuli zemoqmedebisadmi midrekilebas, ara iSviaTad “placebo” - zemoqmedebaze iZleva uaryofiT, negatiur efeqts e.w. “nocebos”.
   udidesi mniSvneloba aqvs “placebo-efeqti” miRebaSi eqimis damokidebulebas samkurnalo meTodisadmi, avadmyofis pirovnebisa da mkurnalobis saboloo Sedegebisadmi, rasac zogierTi avtori uwodebs “pirdapir da arapirdapir iatro-placebo geneziss” (18, 19). mravali gamokvleva mieZRvna “placebo ” efeqti” ganviTarebaSi situaciuri faqtorebis rolis Seswavlas, rogoricaa: samkurnalo procesis organizacia, samedicino personalis ganwyobileba, avadmyofTa populaciis Taviseburebani da a.S. Seswavlilia placebo-genezisSi eqimsa da pacients Soris urTierTdamokidebulebis TaviseburebaTa roli, magram raime sarwmuno kanonzomiereba aRmoCenili ar yofila.
    rogorc irkveva, “placebo-efeqts” iZleva ara yvela pirovneba da saerTo populaciaSi maTi xvedriTi wili Seadgens 30%-s, rac gamovlindeba guneb-ganwyobis, inteleqtualur da fizikur SesaZleblobaTa SecvlaSi. “placebo” – efeqtze reagireba ufro xSiria avadmyofTa Soris da aRwevs 40%-s. mis mimarT ufro midrekilni arian fsiqonevrozuli aSlilobis mqone pacientebi, romelTaTvisac damaxasiaTebelia: saerTo mousvenroba, SfoTva, panikuri da depresiuli gamovlinebebi da a.S., e.w. “mcire” emociuri aSlilobani. aq “placebo-responderoba” aRwevs 50%-s. avtorTa azriT (18) kacobrioba unda daiyos 4 kategoriad: 1. romelic dadebiTad reagirebs “placeboze”; 2. romelic uaryofiTad reagirebs; 3. saerTod ar reagirebs da 4. aqvs mudmivad cvalebadi reagireba “placeboze”.
  “placebo-efeqtisaTvis” damaxasiaTebelia misi aRmocenebisa da gaqrobis siswrafe. “placebo-efeqti” Tavis TavSi Seicavs iseT moments, romelic iTvaliswinebs warsulSi masze Catarebuli mkurnalobis gamocdilebas, istorias, avadmyofTa fsiqopaTologiur struqturas, situacias, romelSic aris gaSlili avadmyofuri mdgomareoba, avadmyofis demografiul Tu pirovnul maxasiaTeblebs (11).
   narkologiur praqtikaSi “placebo-efeqti” warmatebiT gamoiyeneba rogorc fsiqoTerapiis meTodi, anu sxvagvarad rom vTqvaT, avadmyofze fsiqologiuri zemoqmedebis meTodi, ra drosac man ar icis, rom igi fsiqoTerapiuli zemoqmedebis qveSaa (21, 22). medikamentozuri saSualebebis zemoqmedebis fonze tardeba imperatiul – avtoritaruli sugestia, romelic mimarTulia fsiqoaqtiuri nivTierebis moxmarebis srul akrZalvaze (23, 24). yvelaze martivi meTodia garegnulad teturamis msgavsi, uvnebeli tabletebis gamoyeneba, rogoricaa mag.: fitini an kalciumis glicerofosfati, romlebic ideba teturamis an esperalis flakonSi. Azog SemTxvevaSi am preparatebs arqmeven specialur saxelebs, mag. “preparati #1, #2”, “torpedo” da sxva (22). ufro efeqturia teturam – alkoholis sinjis imitacia, risTvisac gamoiyeneba sxvadasxva medikamentebi intramuskularuli an intravenuri SeyvanisaTvis (mag. nikotinis mJava). “placebo” preparatebs, sugestiur TerapiasTan erTad unda SeeZloT gamoiwvion xanmokle, magram aqtiuri zemoqmedeba organizmze: hiperemia, taqikardia, gulisreva, temperaturis momateba da a.S.
   “placebo-Terapiis” dros mniSvnelovani roli eniWeba wamlis saxelwodebas, garegnul formas, gemos, suns da rac mTavaria, masze gansakuTrebul reaqcias. zogierTi avtoris azriT (23) “placebos” SeiZleba daematos iseTi nivTierebac, romelic iwvevs Sardis SeRebvas wiTlad, mag. fosfobionis 1%-iani xsnari, kokarboqsilaza da sxva. “placebo-Terapiis” dros mTavaria eqimis mier pacientis STagoneba misi miRebis aucileblobaSi. didi mniSvneloba eniWeba, aseve, eqimis avtoritets, raTa pacientma eWvi ar Seitanos tyuilSi da ar gamoaSkaravos igi. mniSvnelovania preparatis siaxle, rwmena mis efeqturobaSi da sxva pacientebis inducireba axali preparatis an mkurnalobis meTodis efeqturobis Sesaxeb.
    SemanarCunebeli (antirecidivuli) Terapiis dros karg Sedegs iZleva alkoholze damokidebuli pacientisaTvis “indiferentuli” abebis micema 1-2 Tvis xangrZlivobis antialkoholuri efeqtiT, raTa 1-2 Tvis Semdeg pacienti TviTon movides da miiRos eqimis xelidan aRniSnuli preparati. avtorTa azriT (22) aseTi preparatebis xangrZlivad miReba (6-12 Tve) ufro efeqturia, vidre teturamis. farTod gamoiyeneba. opioidebze damokidebulebis samkurnalod farTod gamoiyeneba opioidebis antagonisti naloqsoni (naltreqsoni, revia).
   erT-erTi meTodia, aseve “stress-fsiqoTerapia”, anu “kodireba” (21), ra drosac gamoiyeneba jgufuri, an individualuri sugestiuri Terapia, romlis Sedegadac xdeba pacientis “kodireba” garkveuli vadiT, romelic man TviTon SearCia (1, 2, 3 weli an mTeli sicocxlis ganmavlobaSi). aseve, pacients eZleva saSualeba ganTavisufldes “kodirebisgan” ra drosac moisurvebs. didi mniSvneloba eniWeba, aseve, SiSis STagonebas, risTvisac pacienti wers xelwerils, rom sxvadasxva garTulebebis, an sikvdilis SemTxvevaSi pasuxismgebeli TviTonaa.
   Cvens mier Seswavlili iqna sul 660 avadmyofi, maTgan 235 fsiqiatriuli profilis: 130 - SfoTvis nevroziT; 105 – depresiuli simptomebiT; xolo 325 narkologiuri profilis pacienti:  225 – alkoholis moxmarebiT gamowveuli fsiqikuri da qceviTi aSlilobebiT da 100 – opioidebis moxmarebiT gamowveuli fsiqikuri da qceviTi aSlilobebiT. Yyvela pacienti dayofili iyo or jgufad. I jgufSi Sediodnen pacientebi, romelTac utardebodaT mkurnaloba “placebo-meTodiT”, xolo II jgufSi – aqtiuri antisindromuli, antialkoholuri da antinarkotikuli saSualebebiT. fsiqiatriuli profilis pacientebSi, erT kviriani “placebo” – mkurnalobiT I jgufSi  da “placebo” an aqtiuri antisindromuli mkurnalobiT II jgufSi miRebuli iqna Sesabamisad pozitiuri efeqti 5,4 da 4,8%-Si da negatiuri efeqti Sesabamisad 7,7 da 1,9%-Si. negatiuri efeqti iyo gacilebiT naklebi iq, sadac gamoyenebuli iqna sindromotropuli farmakoTerapia, xolo placebo-Terapiaze amgvari sxvaoba ar gamovlinda.Nrac Seexeba narkologiuri profilis pacientebs, I jgufSi pozitiuri efeqti miRebuli iqna SemTxvevaTa 40,2 da 38,6%-Si, xolo II jgufSi – Sesabamisad – 30,1 da 29,9%-Si.
  Amsgavsi gamokvlevebi iZleva saSualebas “placebo-efeqtisadmi” reagirebis saxe gamoviyenoT prognozul testad mkurnalobis mosalodnel efeqtze da saerTod daavadebis Semdegi mdgomareobis Taviseburebaze. garda amisa, “placebo” – faqtors gansakuTrebuli Rirebuleba gaaCnia axali medikamentis farmakologiuri Sefasebisa da Terapiuli efeqturobis kvlevis procesSi.ьklinikur praqtikaSi “placebo-faqtoris” gamoyeneba yovelTvis ar SeiZleba, garda eTikuri normativebisa, “placebo” –mkurnaloba dauSvebelia mTel rig daavadebaTa dros, sadac arsebobs riski, rom gauaresdeba janmrTeloba, kerZod avTvisebiani simsivneebis, gulis organuli daavadebebis da zogierT sarisko mdgomareobaTa SemTxvevebSi, hipertonuli krizebis, mwvave gulsisxlZarRvTa ukmarisobis dros da a.S.
   amrigad, umravles daavadebaTa samkurnalod “placebo-Terapia” metad sasargeblo da aucileblad Casatarebeli meTodia: 1. Tu iswavleba axali klasis medikamenti, romelsac faqtiurad ar gaaCnia etaloni; 2. Tu samkurnalod gamoyenebul medikamentze ganviTarda raime garTuleba, mag.: aRkveTis sindromi, neirolefsiuri medikamentiT premedicirebis Sewyvetis Semdeg an xangrZlivi premedicirebis Semdeg mosalodnelia e.w. mogvianebuli diskineziis ganviTareba da a.S.; 3. Tu samkurnalod gamosayenebeli preparatis (mag. teturami, esperali da sxv.) gamoyeneba ukunaCvenebia sxvadasxva somaturi garTulebebis gamo.
   gansakuTrebiT karg Sedegs iZleva “placebo-Terapiis” Catareba mwvave nevrozuli aSlilobis SemTxvevebSi da Tu Terapiuli efeqti igvianebs, mxolod amis Semdeg unda iqnas gamoyenebuli farmakologiurad aqtiuri fsiqotropuli medikamentebi. gamokvlevebma gvaCvena, rom sxva fsiqikuri aSlilobebis dros msgavsi maRali “placebo-efeqti” ufro iSviaTia da igi upiratesad gvxvdeba emociuri xasiaTis fsiqonevrologiuri aSlilobis dros. gasaTvaliswinebelia agreTve isic, rom “placebo-efeqti”, rogorc wesi naklebad myaria da advilad ganlevadia.

Плацебо-эффект”,  как основной фактор в психофармфкотерапии.
Ш.Гамкрелидзе, И.Гиоргобиани, Е.Кавсадзе, М.Арвеладзе, Тбилиси, Грузия
Плацебо-эффект в лечении психических и наркологических заболеваний несомненно является значимым компонентом, повышающим эффективность терапии. Многочисленные двойные слепые плацебо-кониролируемые исследования показывают, что эффективность терапии антидепрессантами превосходит эффективность плацебо не более чем в два раза. Следовательно, суггестивный момент должен учитываться и активно применяться в наркологии и психиатрии.
Без преувеличения можно сказать, что плацебо-эффект является основным механизмом, используемым в лечении наркологических больных, особенно на этапе активного противоалкогольного лечения. При этом он представлен в виде «суггестивной надбавки» при применении известных фармакологических препаратов, а также в виде самостоятельного метода. Последнее относится в первую очередь к таким распространенным методам, как «Торпедо», «кодирование» и применение антагониста опиоидов налоксона.

“Placebo effect”, as basiс method in psychoparmacotaerapy.
SH.Gamkrelidze, I.giorgobiani, E.Kavsadze, M.Arveladze, Tbilisi, Georgia
An opposite, or "negative placebo effect, has been observed when patients believe their health will get worse. Research has confirmed that a fake treatment, made from an inactive substance like sugar, distilled water, or saline solution, can have a "placebo effect"--that is, the sham medication can sometimes improve a patient's condition simply because the person has the expectation that it will be helpful. For a given medical condition, it's not unusual for one-third of patients to feel better in response to treatment with placebo. The phenomenon of an inert substance resulting in a patient's medical improvement is called the placebo effect. The phenomenon is related to the perception and expectation which the patient has; if the substance is viewed as helpful, it can heal, but if it is viewed as harmful, it can cause negative effects, which is known as the nocebo effect. The basic mechanisms of placebo effects have been investigated since 1978, when it was found that the opioid antagonist naloxone could block placebo painkillers, suggesting that endogenous opioids are involved.
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