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Article(id=1322168945176596702, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322168481081049284, articleNumber=null, orderNo=null, doi=10.12102/j.issn.1009-6493.2026.09.019, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1760025600000, receivedDateStr=2025-10-10, revisedDate=1774627200000, revisedDateStr=2026-03-28, acceptedDate=null, acceptedDateStr=null, onlineDate=1793159241240, onlineDateStr=2026-10-28, pubDate=1778342400000, pubDateStr=2026-05-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793159241240, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793159241240, creator=13701087609, updateTime=1793159241240, updator=13701087609, issue=Issue{id=1322168481081049284, tenantId=1146029695717560320, journalId=1220038315760373764, year='2026', volume='40', issue='9', pageStart='1425', pageEnd='1616', issueExtLink='null', onlineDate='null', pubDate='1778342400000', pubDateStr='2026-05-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793159130592, creator='13701087609', updateTime=1793159130592, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=1565, endPage=1571, ext={EN=ArticleExt(id=1322168945398894815, articleId=1322168945176596702, tenantId=1146029695717560320, journalId=1220038315760373764, language=EN, title=Application of outpatient short-term automatic recognition training in patients with comorbid anxiety and depression, columnId=1220689488284668633, journalTitle=Chinese Nursing Research, columnName=Comprehensive Study, runingTitle=null, highlight=null, articleAbstract=
Objective

To investigate the application effect of outpatient short-term automatic thought recognition training in patients with comorbid anxiety and depression,and to provide references for optimizing outpatient treatment strategies.

Methods

A total of 82 patients with comorbid anxiety and depression were divided into an automatic thought training combined with pharmacotherapy group(combined treatment group,37 cases) and a pharmacotherapy alone group(medication alone group,45 cases).The Hamilton Anxiety Scale(HAMA) and Hamilton Depression Scale(HAMD) were used as primary outcome measures.A linear mixed-effects model was used to compare symptom changes between the two groups from the first outpatient visit to the last outpatient visit.

Results

The linear mixed-effects model showed a statistically significant group-by-time interaction effect for HAMD total scores between the two groups(P<0.001).The combined treatment group showed greater changes in depression total scores at the end of 4 weeks and 8 weeks of treatment compared with the medication alone group(P<0.05).The combined treatment group also showed greater changes in anxiety total scores at the end of 8 weeks compared with the medication alone group(P=0.02).

Conclusions

In patients with comorbid anxiety and depression,combined automatic thought training demonstrates better clinical efficacy in symptom improvement compared with pharmacotherapy alone.

, authors=Junfang WU, Long CHENG, Meixia LI, Shanshan ZHAI, Jun CHAI, authorsList=Junfang WU, Long CHENG, Meixia LI, Shanshan ZHAI, Jun CHAI, authorCompany=null, correspAuthors=Junfang WU, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322168946086760674, articleId=1322168945176596702, tenantId=1146029695717560320, journalId=1220038315760373764, language=CN, title=门诊短程自动化思维训练在焦虑抑郁共病病人中的应用, columnId=1220689488938980091, journalTitle=护理研究, columnName=综合研究, runingTitle=null, highlight=null, articleAbstract=
目的

探讨门诊短程自动化思维识别训练在焦虑抑郁共病病人中的应用效果，为优化门诊治疗方案提供参考。

方法

将82例焦虑抑郁共病病人分为自动化思维训练联合药物治疗组（联合治疗组，37例）和单纯药物治疗组（单纯药物组，45例），以汉密尔顿焦虑量表（HAMA）和汉密尔顿抑郁量表（HAMD）为主要疗效指标，采用线性混合效应模型比较两组病人基线、治疗4周末、治疗8周末的症状变化。

结果

线性混合效应模型显示，两组HAMD总分组别与时间交互效应有统计学意义（P<0.001），联合治疗组在治疗4周末及8周末的抑郁总分变化高于单纯药物组（P<0.05），联合治疗组在8周末焦虑总分变化大于单纯药物组（P=0.02）。

结论

在焦虑抑郁共病病人中，联合自动化思维训练较单纯药物治疗在改善症状方面具有更好的临床效果。

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WU Junfang， E-mail：
武君芳,主任医师，E-mail：
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country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Taiyuan Central Hospital, Shanxi 030009 China), AuthorCompanyExt(id=1322530815649633067, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, companyId=1322530815632855849, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1太原市中心医院，山西 030009)])], figs=[ArticleFig(id=1322530821047702351, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=EN, label=Figure 1, caption=Changes in primary and secondary outcome measures between the two groups, figureFileSmall=xLXpqm119KM/WNVO9iwd0Q==, figureFileBig=dxNmGP8mNtY0Cnwy+yMCaw==, tableContent=null), ArticleFig(id=1322530821114811216, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=CN, label=图1, caption=两组主要结局指标和次要结局指标变化情况

（A、C、E、G为两组治疗4周末、8周末与基线期的HAMD、SDS、HAMA、SAS得分的变化量；B、D、F、H为两组HAMD、SDS、HAMA、SAS得分原始均值的变化趋势。*P<0.05）

, figureFileSmall=xLXpqm119KM/WNVO9iwd0Q==, figureFileBig=dxNmGP8mNtY0Cnwy+yMCaw==, tableContent=null), ArticleFig(id=1322530821207085905, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=EN, label=Table 1, caption=

Comparison of general data between two groups of patients

, figureFileSmall=null, figureFileBig=null, tableContent=
项目分类联合治疗组（n=37）单纯药物组（n=45）统计值P
年龄（岁）17.49±2.9516.80±3.06t=1.030.31
性别[例（%）]男17(45.95)16(35.55)χ2=0.530.47
女20(54.05)29(64.45)
文化程度[例（%）]文盲0(0.00)0(0.00)χ2=0.620.73
小学或初中2(5.41)1(2.22)
高中或中专12(32.43)16(35.56)
本科或专科23(62.16)28(62.22)
家庭经济情况[例（%）]良好15(40.54)21(46.66)χ2=0.110.74
一般22(59.46)24(53.34)
家庭居住地[例（%）]城市28(75.67)31(68.89)χ2=0.190.66
农村9(24.33)14(31.11)
发病情况[例（%）]首次16(43.24)14(31.11)χ2=0.810.36
复发21(56.76)31(68.89)
病程[例（%）]≤1年29(78.38)40(88.89)χ2=4.010.13
>1~5年5(13.51)5(11.11)
>5年3(8.11)0(0.00)
心理咨询史[例（%）]有4(10.81)10(22.22)χ2=1.150.28
无33(89.19)35(77.78)
家族史[例（%）]有7(18.92)6(13.33)χ2=0.150.70
无30(81.08)39(86.67)
使用药物最大剂量（mg）舍曲林78.38±25.1180.00±24.77t=-0.290.78
氟西汀30.81±10.1026.67±9.53t=1.890.06
帕罗西汀28.65±10.0427.56±9.81t=0.490.62
劳拉西泮2.21±0.982.35±1.65t=-0.540.59
奥沙西泮18.70±2.3617.90±2.00t=1.840.06
阿普唑仑0.62±0.150.69±0.13t=-1.930.05
艾司唑仑1.55±0.551.13±0.64t=3.19<0.01
), ArticleFig(id=1322530821282583378, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=CN, label=表1, caption=

两组病人基线资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
项目分类联合治疗组（n=37）单纯药物组（n=45）统计值P
年龄（岁）17.49±2.9516.80±3.06t=1.030.31
性别[例（%）]男17(45.95)16(35.55)χ2=0.530.47
女20(54.05)29(64.45)
文化程度[例（%）]文盲0(0.00)0(0.00)χ2=0.620.73
小学或初中2(5.41)1(2.22)
高中或中专12(32.43)16(35.56)
本科或专科23(62.16)28(62.22)
家庭经济情况[例（%）]良好15(40.54)21(46.66)χ2=0.110.74
一般22(59.46)24(53.34)
家庭居住地[例（%）]城市28(75.67)31(68.89)χ2=0.190.66
农村9(24.33)14(31.11)
发病情况[例（%）]首次16(43.24)14(31.11)χ2=0.810.36
复发21(56.76)31(68.89)
病程[例（%）]≤1年29(78.38)40(88.89)χ2=4.010.13
>1~5年5(13.51)5(11.11)
>5年3(8.11)0(0.00)
心理咨询史[例（%）]有4(10.81)10(22.22)χ2=1.150.28
无33(89.19)35(77.78)
家族史[例（%）]有7(18.92)6(13.33)χ2=0.150.70
无30(81.08)39(86.67)
使用药物最大剂量（mg）舍曲林78.38±25.1180.00±24.77t=-0.290.78
氟西汀30.81±10.1026.67±9.53t=1.890.06
帕罗西汀28.65±10.0427.56±9.81t=0.490.62
劳拉西泮2.21±0.982.35±1.65t=-0.540.59
奥沙西泮18.70±2.3617.90±2.00t=1.840.06
阿普唑仑0.62±0.150.69±0.13t=-1.930.05
艾司唑仑1.55±0.551.13±0.64t=3.19<0.01
), ArticleFig(id=1322530821420995411, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=EN, label=Table 2, caption=

Variance results of primary and secondary outcome indicators in the two groups at different treatment time points

, figureFileSmall=null, figureFileBig=null, tableContent=
组别时间例数HAMDHAMASDSSAS
联合治疗组基线3734.70±7.6422.00±6.2065.73±11.2356.94±13.06
治疗4周末3710.94±6.6411.43±5.4453.03±12.8045.54±12.54
治疗8周末379.05±9.789.81±6.2846.05±13.9146.40±14.22
单纯药物组基线4532.02±6.8118.35±6.4354.87±12.6546.31±13.21
治疗4周末4516.27±8.3810.31±5.7447.71±11.8238.38±10.71
治疗8周末4512.87±6.889.71±5.4539.93±10.8737.16±11.37
F时间值248.39①115.66①98.06①50.13①
F组别值0.014.11①10.30①13.31①
F交互值3.52①2.942.921.03
), ArticleFig(id=1322530821475521364, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=CN, label=表2, caption=

两组不同治疗时间主要结局指标和次要结局指标方差分析结果

, figureFileSmall=null, figureFileBig=null, tableContent=
组别时间例数HAMDHAMASDSSAS
联合治疗组基线3734.70±7.6422.00±6.2065.73±11.2356.94±13.06
治疗4周末3710.94±6.6411.43±5.4453.03±12.8045.54±12.54
治疗8周末379.05±9.789.81±6.2846.05±13.9146.40±14.22
单纯药物组基线4532.02±6.8118.35±6.4354.87±12.6546.31±13.21
治疗4周末4516.27±8.3810.31±5.7447.71±11.8238.38±10.71
治疗8周末4512.87±6.889.71±5.4539.93±10.8737.16±11.37
F时间值248.39①115.66①98.06①50.13①
F组别值0.014.11①10.30①13.31①
F交互值3.52①2.942.921.03
), ArticleFig(id=1322530821551018837, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=EN, label=Table 3, caption=

Parameter estimation results of linear mixed-effects model for primary outcome indicators

, figureFileSmall=null, figureFileBig=null, tableContent=
结局项目估计值标准误t值P
HAMD截距31.3314.2777.326<0.001
年龄-0.0660.201-0.3300.743
性别2.9411.2262.3990.019
组别-3.0321.704-1.7780.077
治疗4周末-20.7571.536-13.511<0.001
治疗8周末-23.6491.536-15.393<0.001
组别×治疗4周末5.0012.0742.4110.017
组别×治疗8周末4.4932.0742.1660.032
HAMA截距20.2033.4015.940<0.001
年龄-0.1180.161-0.7360.464
性别2.5080.9792.5620.012
组别-3.9861.301-3.0640.003
治疗4周末-10.5681.115-9.482<0.001
治疗8周末-12.1891.115-10.937<0.001
组别×治疗4周末2.5231.5051.6770.095
组别×治疗8周末3.5451.5052.3560.020
), ArticleFig(id=1322530821618127702, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168945176596702, language=CN, label=表3, caption=

主要结局指标线性混合效应模型参数估计结果

, figureFileSmall=null, figureFileBig=null, tableContent=
结局项目估计值标准误t值P
HAMD截距31.3314.2777.326<0.001
年龄-0.0660.201-0.3300.743
性别2.9411.2262.3990.019
组别-3.0321.704-1.7780.077
治疗4周末-20.7571.536-13.511<0.001
治疗8周末-23.6491.536-15.393<0.001
组别×治疗4周末5.0012.0742.4110.017
组别×治疗8周末4.4932.0742.1660.032
HAMA截距20.2033.4015.940<0.001
年龄-0.1180.161-0.7360.464
性别2.5080.9792.5620.012
组别-3.9861.301-3.0640.003
治疗4周末-10.5681.115-9.482<0.001
治疗8周末-12.1891.115-10.937<0.001
组别×治疗4周末2.5231.5051.6770.095
组别×治疗8周末3.5451.5052.3560.020
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门诊短程自动化思维训练在焦虑抑郁共病病人中的应用
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武君芳 , 程龙 , 李美霞 , 翟姗姗 , 柴珺
护理研究 | 综合研究 2026,40(9): 1565-1571
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护理研究 |综合研究 2026 , 40 (9) : 1565 -1571
门诊短程自动化思维训练在焦虑抑郁共病病人中的应用
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武君芳 , 程龙, 李美霞, 翟姗姗, 柴珺
作者信息
  • 1太原市中心医院，山西 030009
通讯作者:
WU Junfang， E-mail：
武君芳,主任医师，E-mail：
Application of outpatient short-term automatic recognition training in patients with comorbid anxiety and depression
Junfang WU , Long CHENG, Meixia LI, Shanshan ZHAI, Jun CHAI
Affiliations
  • 1Taiyuan Central Hospital, Shanxi 030009 China
出版时间: 2026-05-10 doi: 10.12102/j.issn.1009-6493.2026.09.019
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摘要
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目的

探讨门诊短程自动化思维识别训练在焦虑抑郁共病病人中的应用效果，为优化门诊治疗方案提供参考。

方法

将82例焦虑抑郁共病病人分为自动化思维训练联合药物治疗组（联合治疗组，37例）和单纯药物治疗组（单纯药物组，45例），以汉密尔顿焦虑量表（HAMA）和汉密尔顿抑郁量表（HAMD）为主要疗效指标，采用线性混合效应模型比较两组病人基线、治疗4周末、治疗8周末的症状变化。

结果

线性混合效应模型显示，两组HAMD总分组别与时间交互效应有统计学意义（P<0.001），联合治疗组在治疗4周末及8周末的抑郁总分变化高于单纯药物组（P<0.05），联合治疗组在8周末焦虑总分变化大于单纯药物组（P=0.02）。

结论

在焦虑抑郁共病病人中，联合自动化思维训练较单纯药物治疗在改善症状方面具有更好的临床效果。

抑郁焦虑共病  /  精神病人  /  自动化思维识别训练  /  负性情绪  /  症状管理
Objective

To investigate the application effect of outpatient short-term automatic thought recognition training in patients with comorbid anxiety and depression,and to provide references for optimizing outpatient treatment strategies.

Methods

A total of 82 patients with comorbid anxiety and depression were divided into an automatic thought training combined with pharmacotherapy group(combined treatment group,37 cases) and a pharmacotherapy alone group(medication alone group,45 cases).The Hamilton Anxiety Scale(HAMA) and Hamilton Depression Scale(HAMD) were used as primary outcome measures.A linear mixed-effects model was used to compare symptom changes between the two groups from the first outpatient visit to the last outpatient visit.

Results

The linear mixed-effects model showed a statistically significant group-by-time interaction effect for HAMD total scores between the two groups(P<0.001).The combined treatment group showed greater changes in depression total scores at the end of 4 weeks and 8 weeks of treatment compared with the medication alone group(P<0.05).The combined treatment group also showed greater changes in anxiety total scores at the end of 8 weeks compared with the medication alone group(P=0.02).

Conclusions

In patients with comorbid anxiety and depression,combined automatic thought training demonstrates better clinical efficacy in symptom improvement compared with pharmacotherapy alone.

depression-anxiety comorbidity  /  psychiatric patients  /  automatic thought recognition training  /  negative emotion  /  symptom management
武君芳, 程龙, 李美霞, 翟姗姗, 柴珺. 门诊短程自动化思维训练在焦虑抑郁共病病人中的应用. 护理研究, 2026 , 40 (9) : 1565 -1571 . DOI: 10.12102/j.issn.1009-6493.2026.09.019
Junfang WU, Long CHENG, Meixia LI, Shanshan ZHAI, Jun CHAI. Application of outpatient short-term automatic recognition training in patients with comorbid anxiety and depression[J]. Chinese Nursing Research, 2026 , 40 (9) : 1565 -1571 . DOI: 10.12102/j.issn.1009-6493.2026.09.019
正文
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焦虑抑郁障碍共病是精神科门诊最为常见的共病形式之一。既往研究发现，44.7%确诊为抑郁障碍的门诊病人同时符合焦虑障碍的诊断标准[1]，而重度抑郁障碍病人终生合并焦虑障碍的比例高达60%[2]。病人在出现焦虑障碍与抑郁障碍两种疾病各自特征的同时，通常表现出更为严重的情感低落、认知功能下降、躯体形式症状以及睡眠症状。此外，共病病人具有更高比例的自伤自杀行为，且复发风险较单一疾病更高[3]。在全世界范围内，青少年人群的焦虑抑郁共病率普遍较高，这导致了一系列严重的健康和社会问题。据报道，美国青少年焦虑障碍与抑郁障碍的终生患病率约为7.1%和3.2%，其中有超过75%的受调查人群报告了焦虑抑郁共病的情况[4]。欧洲青少年人群的焦虑抑郁共病比例略低于美国。来自德国的一项研究结果显示，约60%的抑郁障碍病人同时患有其他形式的精神疾病，其中以焦虑共病最为常见[2]。而荷兰抑郁与焦虑研究项目（Netherlands Study of Depression and Anxiety,NESDA）结果显示，67%的主要诊断为抑郁障碍的个体存在共病焦虑诊断；同样，在主要诊断为焦虑症的个体中，63%目前同时合并抑郁症[5]。一项针对我国中西部大学生焦虑抑郁的调查研究结果显示，焦虑抑郁症状共病的检出率为18.4%[6]。尽管在全世界范围内因文化因素、调查人群、研究方法等因素造成焦虑抑郁共病风险调查结果有所差异，但总体而言，高风险的焦虑抑郁共病是目前精神科诊断与治疗研究的重要临床问题。因此，深入探索该群体在共病基础上的症状严重程度及有效干预策略，对降低精神疾病负担、促进青少年心理健康发展具有重要的临床意义，也是当前精神科门诊治疗研究领域需重点突破的方向。
针对青少年焦虑抑郁共病的治疗研究主要关注认知行为疗法（cognitive behaviour therapy,CBT）。其中，自动化思维是CBT中的重要概念，指个体对事物的自动化想法源于个体对于自己、他人和环境所持有的核心信念[7]。而负性自动思维与焦虑抑郁症状的出现密切相关。研究发现，频繁的负性自动思维与抑郁症状的严重程度成正相关关系，负性自动思维越频繁、内容越消极，且这种关联在焦虑症状中同样存在，负性自动思维会加剧对潜在不良影响的过度感知[8-10]。焦虑与抑郁的自动化思维以消极或负性的侵入性想法为特征，而识别负性自动化思维是开展CBT的关键步骤。神经影像学研究发现，负性自动化思维与默认网络（default mode network,DMN）、突显网络（salience network,SN）和额顶网络（frontoparital network,FPN）之间的功能连接异常有关[11-12]，而上述3个网络所构成的“三网络连接模型”是解释焦虑与抑郁障碍神经机制的重要理论[13-14]。提示负性自动化思维是焦虑抑郁共病的典型特征，因此，识别负性自动思维是控制焦虑抑郁症状的关键因素。
自动化思维识别是CBT的核心训练内容的重要组成部分，因为自动化思维识别是“负性思维和情绪恶化”这一恶性循环的起点，是改善焦虑抑郁症状的关键中介因素。近年来，越来越多的临床研究进一步证实了自动化思维识别训练的临床价值，尤其是在联合治疗方案中表现出显著优势。有研究发现，以负性自动化思维识别为主要训练内容的CBT联合药物治疗更有助于缓解病人失眠、焦虑和抑郁症状[15]。因此，针对焦虑抑郁共病的病人开展短程的自动化思维识别训练有望提高整体临床效果。遗憾的是，我国精神医疗资源紧缺。据报告，我国患抑郁障碍病人仅9.5%接受过治疗，且仅0.5%获得充分治疗[16]。病人很难在精神科门诊中完成5~20次完整且专业的CBT治疗。鉴于自动化思维识别训练较其他复杂咨询技术更为简单易学，病人可以通过自助式表格完成对负性自动化思维识别的训练。因此，本研究聚焦青少年焦虑抑郁共病病人，探讨精神科短程自动化思维识别技术训练联合抗焦虑抑郁药物治疗在门诊焦虑抑郁共病病人中的应用效果。
1　对象与方法
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1.1　研究对象
选取2022年1月—2024年11月我院门诊收治的焦虑抑郁共病病人206例。纳入标准：1）年龄10~21岁；2）根据国际疾病分类（international classification of diseases,ICD-10）诊断标准，由2名副主任医师独立确诊为焦虑障碍和抑郁发作病人；3）病人同时满足汉密尔顿焦虑量表（Hamilton Anxiety Scale，HAMA）≥14分及汉密尔顿抑郁量表（Hamilton Depression Scale，HAMD）≥7分；4）焦虑和抑郁症状同时存在且持续时间≥2周，其中至少1种症状（抑郁或焦虑）的病程≥1个月；5）具备基本的语言表达能力和文字理解能力；6）签署知情同意书，未成年病人需家属陪同并签署知情同意书。排除标准：1）器质性精神障碍或药物作用所引发的继发性抑郁焦虑问题；2）存在酒精或药物滥用经历者；3）神经系统疾病或其他精神疾病；4）药物或酒精依赖；5）存在明显的自伤自杀行为；6）存在精神病性症状；7）存在重大躯体疾病或严重感染性疾病；8）入组前半年未参与系统心理治疗且未服用抗抑郁焦虑药物。终止标准为：1）无法完成4次门诊治疗或无法耐受联合治疗者；2）因药物不良反应更改药物种类剂量或停药者；3）研究期间妊娠者；4）出现严重躯体疾病或感染性疾病者；5）因特殊原因自愿退出研究者。研究采用随机对照试验设计，所有病人通过简单随机的方式被分为联合治疗组（自动化思维识别技术训练联合药物治疗）和单纯药物组。本研究经太原市中心医院伦理委员会同意批准开展研究（伦理编号：2023023）。
1.2　干预方法
两组病人均接受至少2个月的药物治疗。抗抑郁药物治疗选用选择性5-羟色胺再摄取抑制剂（SSRIs）类抗抑郁药物，包括舍曲林、氟西汀、帕罗西汀，1周内加至治疗剂量。抗焦虑药物联合使用苯二氮䓬类药物，包括劳拉西泮、奥沙西泮、阿普唑仑、艾司唑仑。在药物治疗期间，要求所有病人门诊就诊次数不少于4次。其中联合治疗组在门诊就诊期间，需至少完成4次门诊自动化思维识别技术训练，每次训练用时15~20 min。训练内容逐层递减，包括：1）介绍CBT和自动化思维的基本概念，帮助病人理解负性自动化思维的特征；2）引导协助病人完成自动思维监控表，帮助病人回忆情境、识别对应情绪、进行个性化分析；3）要求病人在随后的每周内完成5次以上的自动思维监控表填写（每天1次），帮助病人建立识别负性思维的能力。自动思维监控表包括5个问题：描述现实中什么事情导致了不愉快的情绪体验？识别到的思维和印象有哪些？对思维和印象的相信程度？体验的情绪是什么？情绪体验强度。受试者需就上述问题，在医生指导下进行描述和填写表格内容。随后由医生针对病人填写内容进行自动思维内容的分析与纠正。
单纯药物组在门诊就诊期间，由医生向其介绍心理学知识，并要求病人在随后每周内完成5次以上的药物使用记录作为对照控制程序。其他设置与联合治疗组保持一致。门诊训练过程用时5~10 min。所有病人分别在首次门诊、4周末（训练完成）、8周末（门诊或电话随访）完成症状指标的评估与采集。
1.3　观察指标
分别在基线期、治疗4周末及8周末3个时间点进行临床资料采集。本研究分别使用他评焦虑抑郁和自评焦虑抑郁的方式作为结局观测指标，主要观测指标为他评HAMA和HAMD总分及其前后变化，次要观测指标为两组焦虑抑郁症状自评量表得分及前后变化，包括焦虑自评量表（Self-Rating Anxiety Scale,SAS）和抑郁自评量表（Self-Rating Depression Scale,SDS）。以他评焦虑和抑郁得分和减分率作为治愈（治疗后总分≤7分且减分率≥75%）、显效（减分率50%~<75%）的评价标准。整体有效性以所有患者平均减分率作为评价标准。
1.4　统计学方法
统计分析使用R 4.3软件进行。定量资料完成正态性检验（Kolmogorov-Smirnov test,K-S test）和方差齐性检验（Levene test），符合正态分布的定量资料采用均数±标准差（x±s）描述；定性资料使用频数、百分比（%）描述，比较采用χ2检验。研究除报告符合方案分析结果外，进一步遵循意向性分析（intention-to-treat,ITT），所有随机化受试者均按最初分组纳入分析，失访者不予剔除；对于缺失数据，采用末次观测值结转法进行填补。使用线性混合效应模型对两组基线、治疗4周及8周末3个时间点的症状评分变化情况建模，年龄与性别作为协变量控制，事后检验使用Bonferroni校正。检验水准α=0.05（双尾检验）。
2　结果
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2.1　两组病人基线资料比较
基线期联合治疗组共98例，单纯药物组108例，4周末联合治疗组共77例，脱落率21.43%，单纯药物组88例，脱落率12.52%。8周末联合治疗组共37例，单纯药物组45例。排除随访丢失病例，最终82例病人纳入研究，其中联合治疗组共37例，单纯药物组45例。两组病人基线资料比较见表1。
2.2　两组临床治疗有效率比较
两组病人3个时间点的主要结局指标和次要结局指标总分分布均符合正态分布且方差齐性。主要结局指标方面，结果显示，联合治疗组治愈率为48.65%，显效率为81.08%，平均有效率为66.37%；单纯药物组治愈率为15.56%，显效率为71.11%，平均有效率为60.31%。联合治疗组和单纯药物组的显效率比较差异无统计学意义（χ2=0.62,P=0.43），但两组治愈率比较差异无统计学意义（χ2=3.23,P=0.07）。
次要结局指标方面，联合治疗组治愈率为77.02%，显效率为70.00%，平均有效率为62.16%；单纯药物组的治愈率为18.92%，显效率为66.66%，平均有效率为56.85%。联合治疗组和单纯药物组的显效率和治愈率比较差异均无统计学意义（P>0.05）。
2.3　线性混合效应模型分析结果
线性混合效应模型结果显示，联合治疗组和单纯药物组HAMD总分时间效应有统计学意义（F=248.38,P<0.001），提示采用两种治疗方法治疗4周和8周时病人HAMD评分均降低。进一步分析发现，HAMD得分交互效应有统计学意义（F=3.52，P<0.05）。联合治疗组在4周末和8周末的他评抑郁症状改善幅度优于单纯药物组（P<0.05）。ITT结果提示，联合治疗组在4周末和8周末的改善幅度均优于单纯药物组（P<0.05）。
联合治疗组和单纯药物组HAMA总分时间效应（F=115.66,P<0.05）和组别效应（F=4.11,P<0.05）有统计学意义。在ITT人群中，两组病人在基线期的临床资料比较差异无统计学意义（均P>0.05），提示两组基线可比。然而，完成方案分析病人的事后检验结果显示，两组基线期HAMA总分差异有统计学意义（P=0.002,Bonferroni校正）。此外，联合治疗组在4周末的他评焦虑症状改善幅度与单纯药物组比较差异无统计学意义（P>0.05），但在8周末的改善幅度优于单纯药物组（P<0.05）。提示经过治疗后，联合治疗组具有更优的临床效果。ITT结果提示，联合治疗组在4周末和8周末的改善幅度均优于单纯药物组（P<0.05）。
在次要结局指标中，联合治疗组和药物治疗组SDS总分时间效应（F=98.06,P<0.05）和组别效应（F=10.30,P<0.05）有统计学意义。在ITT人群中，联合治疗组和单纯药物组基线期SDS评分比较差异无统计学意义（P>0.05），但完成方案分析患者事后检验提示两组在基线期差异有统计学意义（P=0.001，Bonferroni校正）。进一步分析发现，联合治疗组在4周末和8周末的自评抑郁症状改善幅度优于单纯药物组（P<0.05）。联合治疗组和单纯药物组SAS总分时间效应（F=50.13,P<0.001）和组别效应（F=13.31，P<0.001）有统计学意义，但交互效应无统计学意义（F=1.03,P>0.05）。见表2、表3和图1。
3　讨论
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本研究探讨使用短程CBT核心的自动思维识别训练在门诊开展的可行性，并进一步对比自动思维识别训练联合药物治疗和单纯药物治疗在焦虑抑郁共病治疗过程中的临床效果。ITT分析显示两组基线临床资料均衡可比，保证了随机化分组效果。在符合方案分析人群中，联合治疗组的抑郁自评、焦虑自评和他评得分高于药物治疗组，提示联合治疗组病人基线症状更重。线性混合效应模型结果提示，联合治疗组HAMD、HAMA、SDS评分时间效应与组别效应有统计学意义，提示两组变化轨迹存在差异。尽管事后检验两组差异无统计学意义，但联合治疗组的减分幅度大于单纯药物组，且在8周末两组评分差异无统计学意义。这可能反映了自动化思维训练与药物联合具有协同增效作用，使症状较重的联合治疗组在短期内追赶并达到与单纯药物组相似的临床效果。既往研究发现，在焦虑和抑郁病人中，负性自动化思维与症状严重程度存在相关性[19-21]。此外，焦虑症病人出现的自动化思维和抑郁症呈现出内容与形式上的差异。前者主要为过度担忧、预期灾难性结果的自动化思维，而后者则主要为自我批评、否定性的自动化思维。有研究发现，尽管药物能够改善病人的临床症状，但治疗后并未改变病人的负性思维模式[22]。有研究通过对CBT治疗后的抑郁症病人进行多次随访发现，病人的负性思维模式转变具有长期稳定性[23]。本研究结果进一步论证了既往研究结论，发现识别了负性思维模式的病人，其抑郁症状的治愈率接近单纯药物治疗的3倍，而焦虑症状的治愈率也明显高于单纯药物组。
本研究发现，借助CBT的核心原理和技术开展基于门诊的短程自动化思维识别训练可能比单纯药物治疗具有更好的效果。自动化思维的识别和训练是CBT等心理治疗方法中的重要部分，其内容涵盖意识观察、挑战思维扭曲、实践替代性思维和认知重构。病人通过记录导致焦虑或抑郁的自动思维监控表，帮助他们改善消极、扭曲的自动化思维。尽管传统CBT中关于自动化思维的识别需要经过系统训练，但本研究发现，在门诊通过沟通技巧向病人传递关于自动化思维的概念和识别方式，即可在药物治疗的基础上提高病人症状缓解的可能性。另外，青少年是一类特殊的群体，焦虑抑郁症状更容易在成长发育和性格塑造中被掩盖，短程自动化思维训练的治疗方式操作简单、可及性高，未来有在更多场景中推广应用的潜力。负性自动化思维解释抑郁障碍的关键病理心理学因素，失调性认知是导致抑郁的易感性的关键因素之一，个体面对负性事件时产生的自动化思维更容易使其体验到抑郁情绪，应对应激事件时更多地体验到无望感，进一步采用消极的应对方式。本研究的焦虑自评未观察到与主要结局指标一致的治疗效果。一方面，焦虑抑郁共病病人常存在认知偏差和负性自我评价倾向，其对自身症状的主观感知与客观评估可能存在差异，自评量表易受病人当前情绪状态和主观体验的影响；另一方面，自动化思维训练的核心作用机制更侧重于改善负性认知模式，对抑郁症状的干预效果更为直接，而对焦虑症状的改善可能需要更长的干预周期才能显现。因此，以抑郁症状为主要特征的焦虑抑郁共病病人对自动化思维训练的适配性可能更高。提示未来的治疗决策可以针对症状进行分层，制定“抑郁优先、焦虑延长”的个体化训练策略，根据焦虑症状的缓解需要将治疗方案延长至8周。
4　本研究的局限性
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本研究使用线性混合效应模型对纵向数据进行拟合分析，该模型充分考虑个体差异等随机效应对研究结果的影响，弥补了传统重复测量方差分析的不足。然而，本研究存在一些问题。第一，由于门诊治疗无法与病人重复建立充分的依从关系，因此3次重复测量导致失访率较高，尤其是在联合治疗组更为明显，但值得指出的是，ITT分析与PP分析结果基本一致，说明失访未对研究结论产生实质性影响。第二，符合方案人群分析显示药物治疗组在基线期HAMA、SAS、SDS评分均低于联合治疗组，两组基线不匹配可能对疗效比较产生一定影响。第三，在次要结局指标中并未观测到与主要结局指标类似的结果，这可能与对焦虑抑郁症状的评价方式有关，受疾病影响，主观的症状评价可能存在报告偏倚。第四，病人治疗周期无法形成统一标准，对病人药物种类与剂量也无法做到统一，缺乏对训练结果质量的评价和量化，因此无法评价病人在治疗期间的训练结果，导致研究结果的推论性受限。

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doi: 10.12102/j.issn.1009-6493.2026.09.019
  • 接收时间：2025-10-10
  • 首发时间：2026-10-28
  • 出版时间：2026-05-10
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  • 收稿日期：2025-10-10
  • 修回日期：2026-03-28
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
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