03/06/2015

改善憂鬱症從日常生活做起

改善憂鬱症從日常生活做起

蘇冠賓
中國醫藥大學 精神醫學教授兼任醫學院副院長
台灣營養精神醫學研究學會 理事長

很多病人會問醫師,「除了吃藥,還有沒有其他輔助的方法可以的改善病情」?「運動、陽光、吃魚,到底對憂鬱症有沒有幫助」?本文將探討這些相關議題,嘗試把「研究結果轉譯到臨床運用的可行性」,結合藥物治療及心理治療,對憂鬱症的整合性療法做簡易的介紹。

正統醫學首重實証,而實証醫學又以「隨機分配且有控制組」的研究最為可信(註一)。憂鬱症的治療中,因為藥廠可以投入研發實驗的經費最高,而且政府對藥物上市的規範也最清楚,所以「抗憂鬱症藥物(antidepressants)」實証研究資料最為豐富。其次,「心理治療」雖然缺乏很好的「隨機分配且有控制組」的研究,但由於臨床效果明顯,也被廣泛接受。至於其他療法是否建議病人實踐,也都應該根據實証醫學的結果。

對於「運動、光照、和魚油」,我們都可以找到支持這些建議的「隨機分配且有控制組」的傑出研究,但是也有另外一些研究並不支持(複雜性疾病臨床實驗上的常態現象),或者某些研究方法根本不適合臨床上的建議(例如:特定認証的運動訓練師、特殊的營養素組合或劑量、特殊的光照儀器等等)。因此,臨床醫師要能夠傾聽病人的期待,思考「研究結果轉譯到臨床運用的可行性」,指引病人促進健康。


(作者與國際合作團隊發表論文,推動以大腦保健為目的日常生活介入,Ref. 4)



首先,「魚油」保健和病患的「飲食及營養」息息想關,「營養醫學」已漸受主流精神醫學之重視(注二)。不論病患是否實際服用魚油補充品(N-3脂肪酸),僅僅是病患開始注意營養攝取或避免飲食中人工添加物、毒素或污染,也都有益改善生活型態和身心均衡。N-3脂肪酸的抗憂成分以EPAeicosapentaenic acid)為主,建議治療劑量在每天服用含 EPA 超過1為原則,四週後效果不夠時可以加至2,服用時應該在醫師的評估下,留意腸胃不適或凝血功能上的影響。基本上,良好的魚油濃縮和精鍊過程可以去除重金屬污染,所以如果服用的是魚油膠囊則比吃魚更加安全。病患可以自行選購優良製藥 GMP的任何產品,只要成分穩定,療效應該不會受到製造廠商或原料來源的影響。值得注意的是,台灣的衛生單位並沒有對N-3脂肪酸的販售做嚴格把關,台灣市面上多數的產品並沒有經過衛生單位抽檢,品質不一,因此選擇時要格外留意。

我們最近成立了「國際營養與精神醫學研究學會(ISNPR)」,目的在推動營養科學在精神醫學上的應用研究,以造福病患,提供病供更多有效療法的選擇(Ref. 2, 3)。除了魚油之外,維生素中的B1 (thiamine)、B9 (folate)、B12DS-腺苷基甲硫氨酸(S-adenosylmethionine,即SAMe)、膽鹼(choline)、鐵質(iron)、鋅(zinc)及鎂(magnesium),也都有充分的研究支持其抗鬱的功能。

「運動」方面,個人在看診當中,總是會與症狀較穩定的病人討論「適合個人的運動方式」。運動最重要的是「循序漸進」,避免運動傷害;對於生理機能不佳者不要強求,對於藉口一堆者也不要勉強。能跑步的病人,常常表示數週規律的跑步,除了改善憂鬱,也可以減少憂慮及焦慮相關的身體症狀(例如便祕、腸躁、胸悶、心悸、痠痛等)、改善疲勞增強體力、改善睡眠品質及體重過重;老人家若有退化性關節問題,可以考慮「慢呼吸」、靜坐冥想、合併「慢節奏」的伸展、深蹲、太極或游泳。如果能夠找到受過心理 相關訓練的專業瑜珈治療師,瑜珈對於憂慮焦慮、壓力失眠的治療也都有不錯的臨床試驗佐証。

5 of the best exercises you can ever do (Health Report from Harvard Medical School)

最後是「光照」療法,在光照量不足的國家有販售專門用來做光照治療的機器,在台灣陽光明媚,似乎沒有那個需求。然而,對於足不出戶或長期在室內工作的病患,可以建議在早晨或下午的陽光之下,「刻意」曝露至少十分鐘,其療效不僅僅是光照和維生素D的合成,就如同運動及魚油一樣,也還有促進免疫功能、改善新陳代謝、甚至保健心血管健康各方面的好處。

很多病人會問醫師,「除了吃藥,還有沒有其他輔助的方法可以的改善病情」?「運動、陽光、吃魚,到底對憂鬱症有沒有幫助」?由於憂鬱症的複雜性,沒有任何一種神奇的療法可以對所有病患都有效。如果病人對單一療法效果不足(例如藥物治療或心理治療),醫師不妨用開放的態度、實証醫學的精神、以及最高的安全標準,來接納病患嘗試整合性療法。哈佛醫學院也在其官方網頁,宣導醫護人員認識了解實証醫學基礎下的日常生活介入,包括飲食型態、運動習慣、壓力管理、社交和溝通技巧...等(Ref 5)。

(哈佛健康網宣導醫護人員認識了解實証醫學基礎下的日常生活介入,Ref 5)

醫師若能運用專業,協助病患做四到六週詳細的評估,一旦效果不錯,可以增加臨床經驗;如果效果不明顯,也可以建議病人不要浪費時間和金錢。由於所有憂鬱症治療(包括藥物或心理治療)的療效效應空間(effect size)相當有限,所以即使研究証實某項治療有效,也要避免讓病患對新療法有過度期待,雖然有許多病患從營養醫學的新療法中獲得極大的幫助,卻也有病患和家屬因為不實廣告的過度渲染而付出極大的代價,因此,接觸最正確、客觀的資訊,才是善用整合療法的最好策略。

有些醫護人員會說:「因為我不懂這些、而且我也沒有時間做這些...,講這些的人都不是正統,因為只有藥物治療有科學根據!」這樣的態度都是造成病患及病屬對精神醫療質疑的主因。精神科醫師大多不希望被誤解為「過度強調藥物」的醫師,然而在極為不足的健保制度及資源環境下,充分「了解並善用其他實証療法」來幫助病患,的確是「健保制度偏差」環境下的台灣精神科醫師很大的挑戰!臨床醫師能以開明和實証的態度,來提供多元性和整合性的照護絕對遠比單一治療更能成功協助病患邁向康復大道。


附註:
1.       上網蒐尋的關鍵字為:randomized, controlled, double-blind, placebo, sham, randomized-controlled trial (RCT)
2.        Sarris J, Logan A, Akbaraly T, Amminger GP, Balanzá-Martínez V, Freeman MP, Hibbeln J, Matsuoka Y, Mischoulon D, Mizoue T, Nanri A, Nishi D, Ramsey D, Rucklidge JJ, Sanchez-Villegas A, Scholey A, Su KP, Jacka FN. Nutritional Medicine as Mainstream in Psychiatry. Lancet Psychiatry 2015 Mar; 2(3): 271-4
3.        Sarris J, Logan A, Akbaraly T, Amminger GP, Balanzá-Martínez V, Freeman MP, Hibbeln J, Matsuoka Y, Mischoulon D, Mizoue T, Nanri A, Nishi D, Ramsey D, Rucklidge JJ, Sanchez-Villegas A, Scholey A, Su KP, Jacka FN. International Society for Nutritional Psychiatry Research consensus position statement: nutritional medicine in modern psychiatry. World Psychiatry (Accepted)
4.        Sarris J, Nishi D, Xiang YT, Su KP, Bannatyne A, Oliver G, Kua EH, Ng CH. Implementation of psychiatric-focused lifestyle medicine programs in Asia. Asia Pac Psychiatry. 2015 Dec;7(4):345-54. 
5.       Home » Harvard Health Blog » Intensive lifestyle change: It works, and it’s more than diet and exercise - Harvard Health Blog (Monique Tello, MD, MPH, Intensive lifestyle change: It works, and it’s more than diet and exercise) https://www.health.harvard.edu/blog/intensive-lifestyle-change-it-works-and-its-more-than-diet-and-exercise-2017082112287

6.       哈佛大學這幾年一直非常積極在推動Lifestyle intervention(例如營養、太極運動)在身心疾病的預防與輔助療法!(1) The no-drug approach to mild depression by Harvard Health Publishing (https://www.health.harvard.edu/mind-and-mood/the-no-drug-approach-to-mild-depression); (2) Omega-3s for anxiety? (https://www.health.harvard.edu/mind-and-mood/omega-3s-for-anxiety); (3) Eating more fruits and vegetables may help men with memory loss (https://www.health.harvard.edu/mind-and-mood/eating-more-fruits-and-vegetables-may-help-men-with-memory-loss); (4) Omega-3 fatty acids for mood disorders (https://www.health.harvard.edu/blog/omega-3-fatty-acids-for-mood-disorders-2018080314414); (5) An Introduction to Tai Chi: https://www.health.harvard.edu/staying-healthy/the-active-ingredients-of-tai-chi; https://www.health.harvard.edu/exercise-and-fitness/an-introduction-to-tai-chi

6.      哈佛大學 Harvard Health Blog 對運動之建議:The new exercise guidelines: Any changes for you? Lauren Elson, MDLauren Elson, MD (https://www.health.harvard.edu/blog/the-new-exercise-guidelines-any-changes-for-you-2018121415623)





         

4 comments:

  1. 哈佛大學這幾年一直非常積極在推動Lifestyle intervention在身心疾病的預防與輔助療法!
    來自哈佛大學醫學院對於憂鬱防治的「非藥物推廣」及「太極運動」的介紹

    The no-drug approach to mild depression by Harvard Health Publishing (https://www.health.harvard.edu/mind-and-mood/the-no-drug-approach-to-mild-depression)

    Omega-3s for anxiety? (https://www.health.harvard.edu/mind-and-mood/omega-3s-for-anxiety)

    Eating more fruits and vegetables may help men with memory loss (https://www.health.harvard.edu/mind-and-mood/eating-more-fruits-and-vegetables-may-help-men-with-memory-loss)

    Omega-3 fatty acids for mood disorders (https://www.health.harvard.edu/blog/omega-3-fatty-acids-for-mood-disorders-2018080314414)

    An Introduction to Tai Chi:
    https://www.health.harvard.edu/staying-healthy/the-active-ingredients-of-tai-chi
    https://www.health.harvard.edu/exercise-and-fitness/an-introduction-to-tai-chi

    ReplyDelete
  2. Harvard Health Blog 對運動之建議:The new exercise guidelines: Any changes for you? Lauren Elson, MDLauren Elson, MD (https://www.health.harvard.edu/blog/the-new-exercise-guidelines-any-changes-for-you-2018121415623)


    It’s likely you already know that regular exercise helps prevent chronic disease, such as diabetes and heart problems, while improving your overall health, mood, and quality of life. It can sharpen mental function, boost concentration, and help you sleep. And the new exercise and physical activity guidelines issued by the federal government’s Office of Disease Prevention and Health Promotion show that the dose required to gain these benefits is not hard to achieve. The new guidelines are better tailored for age and ability, too.

    What should your exercise goals be?
    The amount of exercise and mix of activities recommended varies depending on age and ability, as described more fully below. It ranges from a high of three hours daily — for preschoolers, who tend to love activity — to 150 minutes a week.

    Unfortunately, 80% of the population is not meeting the guidelines. Each year in the US, an estimated 10% of premature deaths and $117 billion in healthcare costs are associated with inadequate physical activity.

    Besides saving money on healthcare, there are many personal benefits to staying active. The new guidelines highlight other new evidence-based findings related to physical activity and exercise.

    What changed in the new exercise guidelines?

    Overall, move more, sit less. Work toward reducing the amount of time you spend sitting every day. If you have a desk job, get up to walk around regularly, or try chair yoga or a few desk exercises.

    ReplyDelete
  3. Mindfulness And Meditation Will Now Be Part Of The Curriculum In 370 Schools In England

    http://www.trueactivist.com/mindfulness-and-meditation-will-now-be-part-of-the-curriculum-in-370-schools-in-england-t1/

    by: True Activist Posted on March 29, 2019

    Most of the time, when children act out by kicking and screaming expletives, it is because they do not understand what they are going through, and cannot find a better way to release their feelings. When a child acts out, know that it is most likely because they are struggling to understand complex emotions that they are feeling for the first time in their lives.

    Schools in England have started to tackle this problem in a new way, and that is by teaching mindfulness and meditation in the classroom to improve the youth’s overall mental health. In 370 schools across the country, children will be taught how to meditate, techniques for muscle relaxation and breathing exercises for mindfulness. The secondary school students will also get a more hands-on education to learn about awareness and how to increase this in their everyday lives. This program is being done under the mental health study that the British government is running up until 2021.


    https://cdn.mindful.org
    Apart from the increasing number of young children that are showing signs of early onset depression and anxiety, NHS reports have also shown that 1 in 8 British children have mental disorders. Despite these facts, only 1 out of 5 children with mental issues are able to get access to treatment.

    England isn’t the only country that has added mindfulness as a subject among schools. In 2016, a school in Baltimore decided to replace detention for an area where the children could go to an practice some breathing and stretching exercises instead. This is a way to keep the students calmer in order to increase their focus within the classroom.


    https://cdn.mindful.org
    A student that was sent to the ‘mindful moment room’ for pushing and name-calling a fellow classmate describes it to CNN as: “I did some deep breathing, had a little snack, and I got myself together. Then I apologized to my class.”

    The school believes this is an improved manner the problem, rather than punishing and embarrassing the child in front of their peers, which was probably the cause of the problem from the very beginning.

    Teaching children how to deal with emotions will most likely be very foreign and uncomfortable, but it will reap the benefits in the end. The goal is to have the children master the habit of clearing their mind from stress and anxiety, and being present and more focused in class.

    Do you think all schools should teach mindfulness and meditation?

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  4. Proper posture the tai chi way (Harvard University)

    https://www.health.harvard.edu/staying-healthy/proper-posture-the-tai-chi-way

    If you're like most people, your posture could use some improvement. But how do you do that? The classic advice is to stand straight, with your head up, shoulders back, and belly in. While these are reasonable adjustments, tai chi takes a different approach that may be more effective. It aims to align the body in ways that afford safe, unstrained, and graceful postures—not the military-like, one-size-fits all, rigid stances many think of as good posture.

    Instead, in tai chi, good posture centers around the principle of verticality. That means the head is centered over the torso, the torso rests over the hips, and the hips are centered over the legs and feet, your base of support. Here's how to do it.

    1. The spine is literally the backbone of verticality, so let's start there. Tai chi classics say, "The spine should be like a necklace of pearls hanging from heaven." Your goal should be to elongate the spine while still allowing for its natural curves. This can reduce wear and tear on the discs between your vertebrae. In this position, your head will also sit squarely on top of your spine instead of jutting forward— a common profile that you will see if you take the time to observe others. Your head weighs about 10 to 12 pounds, but just a slight tilt forward more than doubles the amount of strain on your neck muscles. Get into typical texting position, and your muscles must work five times as hard. No wonder your neck and upper back are tight and achy. Proper alignment helps prevent that.

    2. The next area to focus on comprises the waist and pelvic region, which connect the upper body and lower body. In tai chi classics, this area is called the "commander." It's the central, coordinating hub where all movements originate. Muscle imbalances in this area have been associated with pain in the back, knee, and even neck, along with affecting your gait and balance. Maintaining tone and flexibility in the muscles and other soft tissues of the hip and pelvic area facilitates good posture and movement patterns and reduces pain.

    3. At the foundation of good posture are your feet, but you rarely hear about them in traditional posture advice. If alignment is off at your feet, though, the imbalance travels up the body, possibly causing painful problems along the way. Western thinking usually attempts to correct these misalignments with products like shoe inserts, but tai chi works to naturally correct imbalances and improve range of motion. While specifics vary with different tai chi movements, in general you should keep your weight centered over the balls of your feet and all of your toes, and point your feet in the direction of your kneecaps. The result is a healthier posture that works for you without forcing your body into uncomfortable positions.
    So, the next time you want to improve your posture, skip the stiff stance and focus on your spine, pelvic region, and feet.

    ReplyDelete