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주요우울장애의 치료로서 경두개 직류자극술(Transcranial Direct Current Stimulation)의 현재

Current Update on Transcranial Direct Current Stimulation as Treatment for Major Depressive Disorder

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참고문헌

키워드

주제분류정신과학

초록

주요우울장애(major depressive disorder, MDD)의 치료를 위한 여러 가지 방법이 존재하지만, 약물 요법이 가장 보편적인 일차 치료 전략으로 남아 있다. 일차 치료에 대한 반응은 중등도(40~60%)이며, 항우울제 치료 후 증상 완화는 소수의 환자에서 달성된다(30~45%, 22~53%).1) 약물치료만으로MDD 증상의 관해에 이르지 못하는 환자의 비율이 상당하며, 또한 임신, 여러 신체 질환, 복용 중인 약물로 인해 MDD에서약물치료가 어려운 경우가 많다. 현재 약물치료 외에 MDD 치료로서 정신치료와 비약물적 생물학적 치료가 제안되고 있다. 정신치료는 경도에서 중증의 주요우울장애에 일차로 적용할 수 있는 치료로 제안되고 있지만 모든 우울증 환자에서적용하기는 어려움이 있다.2) 비약물적 생물정신치료로서 여러 가지 뇌 자극술(brain stimulation technique)이 제안되고 있으며, 여기에는 전기경련치료(electroconvulsive therapy, ECT), 뇌심부자극술(deep brain stimulation, DBS), 경두개 자기자극술(transcranial magnetic stimulation, TMS), 경두개 직류자극술(transcranial direct current stimulation, tDCS) 등이 제안되고 있다. ECT는 시행을 위해서 마취제, 근이완제의 투여가 필요하고, 정신건강의학과 전문의를 포함하여 간호사, 마취통증의학과전문의 등 다수의 의료진이 포함된 팀이 이루어져 진행되어야 하는 등의 제한점이 있다. DBS와 미주신경자극술(vagusnerve stimulation, VNS)은 수술적 처치가 동반되어 침습적인 방법으로 인한 제한이 있다.3) 따라서 MDD 치료에 있어 기존의 약물치료, 비약물적 생물정신치료, 정신치료 외에 새로운 치료 방법에 기대가 지속적으로 이어지고 있다. tDCS는 비침습적 뇌자극술로 특정 피질 부위에 지속적이고, 1 mA에서 2 mA의 약한 직류 전류를 두피에 위치한 전극을 통해 생성시킴으로써 작용한다.4)5) 1964년 Bindman 등6) 에 의해 발간된 직류 전류가 극성-의존적인 방식으로 쥐(rat) 의 뇌에서 자발적인 신경활성도를 조절한다는 보고에 이어몇몇 동물과 인간 연구에서 직류 전류를 적용한 결과에서 유래되었다.5) 이 1960년대 초기 연구들은 직류 자극을 통해 우울 증상을 감소시키는 일부 효용성을 보였지만, 혼재된 결과와 정신작용 약물의 발전으로 인해 이 치료법은 관심에서 벗어나게 되었다.7) 이런 연구 방향은 Nitsche와 Paulus8)에 의해21세기 초부터 tDCS를 적용하였을 때 양극과 음극의 분극이후 운동 피질의 흥분도의 뚜렷하게 구별되는 패턴의 발견과함께 다시 활성화되었다.9) 기존 치료의 대안 또는 보조로서tDCS의 적용 방식과 임상 연구 진행 방법에 대한 표준화가 필요하며. 이를 통해서 MDD 치료로서 tDCS의 효과를 입증하는 과정이 필요하다. 본 종설에서는 tDCS의 항우울 효과의 생물학적 기전에 대해 먼저 논의한다. 이어서 MDD 환자의 tDCS 치료에서 항우울 효과와 인지 기능 개선에 대한 메타 분석, 체계적 문헌 검토, 대조 시험, 공개 연구, 사례 보고를 포함한 기존 발간된 문헌을 검토한다. 그리고 MDD 환자에 적용을 위해 적합한 tDCS 프로토콜, tDCS 치료에 반응 여부를 예측하는 인자, MDD 치료에서 tDCS의 불리한 점, 부작용에 대해 논의한다.

Abstract

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation method that delivers 1-2 mA of current to the scalp. Several clinical studies have been conducted to confirm the therapeutic effect of major depressive disorder (MDD) patients with tDCS. Some studies have shown tDCS’s antidepressant effect, while the others showed conflicting results in antidepressant effects. Our aim of this review is to understand the biological bases of tDCS’s antidepressant effect and review the results of studies on tDCS’s antidepressant effect. For the review and search process of MDD treatment using tDCS, the US National Library of Medicine search engine PubMed was used. In this review, we discuss the biological mechanism of tDCS’s antidepressant effect and the existing published literature including meta-analysis, systematic review, control trial, open studies, and case reports of antidepressant effects and cognitive function improvement in patients with MDD are reviewed. We also discuss the appropriate tDCS protocol for MDD patients, factors predictive of response to tDCS treatment, the disadvantages of tDCS in MDD treatment, and side effects.

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