憂鬱症很少被正確診斷及治療的原因很多，包括：
1.
患者常常不覺得「憂慮」，反而常以「非特異性的身體症狀來表現
2.
處在「崩潰」邊緣，消耗加倍的心力去維持生活和工作表面正常
3.
媒體及社會大眾對於精神病的「污名化及標籤化（stigmatization）」，引發患者潛意識的否認，對於「討論自身憂鬱情緒」的恐懼
4.
憂鬱症的病理特質常被誤解，有時甚至精神科及心理衛生工作人員也會有不正確的觀念及態度。
|
|
1.
台灣的憂鬱症患者，只有五分之一患者就醫
2.
憂鬱症患者提早中斷治療比例太高
3.
對於憂鬱症的認識與投資不足
臺灣常見身心疾患20年內之盛行率增為2倍，期間自殺率、失業率、離婚率皆平行升高。我們應該更「全面性、整體性」來思考，追求「社會進步和經濟成長」而犧牲「精神健康」的嚴重問題。
4.
我們需要一個全民的抗憂鬱運動
台灣社會非常需要全國性的「去污名化」運動！精神醫學除了診斷和治療精神病患之外，更應致力於社會運動，推展精神健康智識給社會大眾。 |
|
國家政策把有限的健保支出用在住院和急性藥物療法，自然就無法照顧到心身病患整合性治療之需求；雖然藥物治療是憂鬱症治療的主流，但如果醫師只能用藥、只會用藥、只相信用藥，最後長期追蹤到的患者，都只剩下「吃藥有效」和「想要拿安眠藥」那一類病患。
這樣的惡性循環，使得台灣的身心病患即使有良好教育及經濟能力，還是得不到「更安全有效、更創新整合、更有尊嚴」的身心治療。由於政府對於「打著宗教靈性旗幟抹黑醫學、販售沒有科學驗證療法」的惡性醫療促銷，常常缺乏規範，無助無望的病患只好病急亂投醫，延誤病情，甚至走上絕路。
|
|
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」？
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。「藥物治療」投入研發經費最高，而政府對藥物上市的規範也最清楚，實証研究資料最為豐富，自然成為憂鬱症治療的主流。其次，「心理治療」雖然缺乏很好的「隨機分配控制組」的研究，但由於臨床效果明顯，也被廣泛接受。
對於「運動、光照、和魚油」，雖然有眾多支持的傑出研究，但是也有研究並不支持（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）。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。
|
|
為何台灣醫療保險制度容易造成鎮靜安眠藥濫用的問題？
1.
「病患就醫偏好為中心」
2.
「論量計酬來給付」
3.
「健保限制價格高的主線用藥」
4.
「耗時費力的治療給付過低」
改善失眠和焦慮最標準的做法：「不是使用鎮定安眠藥」：
1.
「第一重點在於找出潛在病因並治療核心疾患」
2.
「第二重點是非藥物治療」：「認知行為治療」和「睡眠衛教」
|
|
公共電視「我們與惡的距離」電視劇，從「精神病患無差別殺人」事件，延伸出引人深思「精神疾病污名化」的深刻故事。無差別殺人令人髮指，一般民眾很難理解：「受害者和加害者兩造都是悲劇」。去除污名化最困難的是情感層面的衝突，以戲劇呈現則是最好的方式。
精神科醫師花很多的心力，協助患者面對社會偏見，這些偏見造成病患在求職、社交、教育、甚至是在就醫時遭受歧視和排斥；甚至被保險公司拒保或被企業排擠而被迫離職！事實上，污名化起源自對精神疾病的恐懼和無知，加上媒體戲劇性地「妖魔化」精神病患…。這些被現代科學視為繆誤觀念的潛在歧視，仍不斷對病患的造成烙印和傷害。
|
|
為什麼多吃魚有利於憂鬱症的治療？中國醫藥大學「身心介面研究室」的同仁，致力於憂鬱症及抗鬱療法的研究，多次獲得國際知名研究獎項，他們的研究結果，有利於探索、了解飲食和情緒的神祕關係。
台灣的衛生單位並沒有嚴格規範保健食品，不像處方藥物的品質穩定，病患選購或即使是醫師推薦的產品，常常品質參差不齊。台灣病患在「非藥物治療」的選擇，完全沒有可以信賴的法令規範和完善保障。
精神科醫師如果對產品不熟，不一定要介入病人選擇，但要密切幫病患持續評估病情，記錄病患自行服用的補充品相關作用，即使具有明確實証的omega-3或藥物治療，對於信任感較低的病患，在診斷、治療和溝通都應該以「態度保守、界限清楚和病人自主」為原則。
|
|
知名醫學期刊 JAMA Internal Medicine 刊登強調替代性療法重要性的文章（JAMA
Intern Med. 2014;174）！該研究除了支持冥想靜坐對於壓力相關的焦慮和憂鬱有顯著的療效之外，更建議臨床醫師要能夠教導病患做冥想靜坐。，在適當評估之下，可以建議「快節奏、急性格和求完美的」特質的病患練習。
呼吸法靜坐時，呼吸的節奏會自然地慢下來，使身體進入更放鬆和平衡的狀態。兩種最簡易的靜坐的技巧：數息、觀息（作者：楊定一、楊元寧
；摘自天下雜誌出版 2014）
|
|
蘇冠賓教授與身心介面實驗室（Mind-Body Interface Laboratory, MBI-Lab）對於憂鬱症病因及治療之研究不遺餘力。根據世界衛生組織的預測，憂鬱症將成為是本世紀戕害人類健康、造成人類失能最嚴重的疾病，面對全球憂鬱症所帶來的重大負擔，目前以藥物為主的治療模式完全無法達成令人滿意的療效。因此，該團隊最終希望所有的研究結果將來可以運用於憂鬱症的臨床分類、病因及做為預防及治療的參考，並以增進人類的身心健康為最終的目標。
https://cobolsu.blogspot.com/2015/10/blog-post_41.html
|
（註：根據ExpertScape的統計，作者蘇冠賓教授是台灣「憂鬱症」研究領域中排名第一的專家；蘇教授長年投入精神醫學的大腦研究，更多身心保健文章可參考蘇冠賓醫師部落格： https://cobolsu.blogspot.com/）
Top 8 Issues in Major Depressive Disorder
ReplyDeleteApril 22, 2022 Sidney Zisook, MD
https://www.psychiatrictimes.com/view/individuals-cite-exercise-gaming-as-top-ways-to-address-mental-health-issues
When asked to comment on what I consider some of the key issues in the world of major depressive disorder (MDD), these are what came to mind. Here is my idiosyncratic top 8.
1. Accessibility. Despite the prevalence of disability, chronicity, morbidity, comorbidity, and premature mortality associated with MDD, most individuals with MDD receive inadequate—if any—treatment. Low-income and minority groups are especially unlikely to receive treatment. But even in high-income countries, World Mental Health surveys showed that only 22% of all individuals with 12-month MDD received minimally adequate treatment.1 Several factors contribute to this lack of treatment, including stigma about mental health in general and mental health care in particular; lack of knowledge about the availability and effectiveness of treatments; and the shortage of mental health providers both globally and in the United States.
Out-of-pocket expenses may be prohibitive for many individuals. Even if an individual has mental health insurance, it is increasingly difficult to find a provider, especially a psychiatrist, who accepts insurance these days. For those few providers who do accept insurance, they are often booked with long waiting lists and available times do not work for individuals with children or who are working. Thus, unmet needs include increasing efforts to destigmatize mental health and its treatment; educate the public and health care providers on the recognition, diagnosis, and effective treatments of MDD and its variants; increasing the mental health workforce; and providing better mental health care coverage for all.
Top 8 Issues in Major Depressive Disorder
ReplyDeleteApril 22, 2022 Sidney Zisook, MD
https://www.psychiatrictimes.com/view/individuals-cite-exercise-gaming-as-top-ways-to-address-mental-health-issues
2. Diagnostic challenges. Diagnostic reliability has been a problem since DSM-1 and remains so through DSM-5-TR. MDD is a heterogeneous construct that limits communication, prognostic accuracy, and drug development, and it may be a key reason none of the current treatments are effective for more than about a third of those diagnosed with MDD. There are 227 possible combinations of symptoms that can meet DSM-5 criteria for MDD, and 2 different patients can be diagnosed with MDD without a single overlapping symptom.2
Attempts to subtype MDD by clinical features (anxious, mixed, atypical, catatonic, melancholic, psychotic), onset (1st episode, recurrent, childhood, seasonal, premenstrual, peri-partum, menopausal, late life), trigger (autonomous or after life adversity), state (prodrome, episode, response, remission, recovery, treatment resistant, difficult to treat), comorbidity (substance use, posttraumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, eating disorders, borderline personality disorder, pain, chronic and disabling general medical and neurological conditions), and other associated features (early life adversity, suicidality, neurocognition, isolation, poverty, cultural diversity) by and large have not identified specific treatment targets.3
Other questions remain. For example, why 2 weeks for the diagnosis? It may not make sense to wait 2 weeks to diagnose an individual with a history of severe, life-threatening episodes and a very recent onset of anhedonia, feelings of worthlessness, and suicidal thoughts. On the other hand, it may be wise to wait more than 2 weeks for first onset with mild symptoms ostensibly triggered by overwhelming interpersonal, health, or environmental stress. And why not include such common and disruptive symptoms as physical or psychic pain, anxiety, cognitive problems, irritability, or rumination?
The diagnosis of MDD does not yet map very well with underlying biology or treatment outcomes. The National Institute of Mental Health (NIMH) Research Domain Criteria (RDOC) was an attempt to improve upon our current symptom based diagnostic system, but it has not been widely accepted or implemented by many clinicians. There are no easy solutions, but the quest to find a more reliable diagnosis for this all-important condition must continue.
Top 8 Issues in Major Depressive Disorder
ReplyDeleteApril 22, 2022 Sidney Zisook, MD
https://www.psychiatrictimes.com/view/individuals-cite-exercise-gaming-as-top-ways-to-address-mental-health-issues
3. Relationships to burnout and bereavement. Two additional diagnostic issues of import in contemporary psychiatry are the relationships of MDD to burnout and bereavement. About 40% of health care workers experience distressing symptoms of burnout, likely even more so since the start of the COVID-19 pandemic. As someone working in the physician wellness arena, I see many physicians complaining of burnout, some of whom come to me on previously prescribed antidepressant medications, which have essentially no positive effect on burnout, and others who present with significant underlying MDD that has been misattributed to burnout.
This diagnostic confusion is at least in part explained by overlapping clinical features, such as unhappiness, low energy, poor sleep, and a defeatist attitude. But burnout is predominantly a job-related condition, the core feature of which is mental and emotional exhaustion related to ongoing work stress. MDD, on the other hand, is a persistent, pervasive, and pathological mental condition, the core features of which are unhappiness and the inability to find joy in anything. In burnout, self-esteem is preserved while feelings of low self-worth and even of worthlessness often predominate one’s self-view in MDD. In contrast to the experiences of those with MDD, individuals with burnout often retain the capacity to laugh, to appreciate the comfort and support of relatives and neighbors, to be consoled, and to recognize that what they are going through will lessen in time. The importance of differentiating burnout from depression may not be primarily an either/or proposition—wondering if something is burnout or MDD—but one of identifying when an individual who presents with features and symptoms of burnout may also have MDD. Failure to do so risks the potential of missing the detection and opportunity to provide effective treatment for individuals suffering a serious, if not life-threatening, mental disorder.4
The DSM relationship between bereavement and MDD has had a somewhat convoluted history. In a well-intentioned effort to avoid medicalizing ordinary grief and the subsequent over-prescription of antidepressants, the DSM-III introduced the “bereavement exclusion,” which cautioned against diagnosing MDD after the death of a loved one. But subsequent research suggested that major depressive syndromes following bereavement did not meaningfully differ in nature, course, or outcome from depression of equal severity in any other context, or from MDD appearing out of the blue. Disqualifying a patient from a diagnosis of MDD simply because the clinical picture emerged after the death of a loved one risks closing the door on potentially life-preserving interventions.5
The DSM-5 provides useful guidance on when to diagnose MDD in the post-bereavement period. For example, in bereavement-related grief not accompanied by MDD, loss and preoccupation with the deceased person are the predominant themes and self-esteem is usually preserved. In contrast, in MDD, persistent and pervasive unhappiness and the inability to enjoy anything are the predominant themes, and feelings of worthlessness and self-loathing are common. In ordinary grief, waves of emotional pain are usually accompanied by positive emotions and fond recollections of the deceased. In MDD, pervasive misery and unhappiness are the norm. Despite these differential diagnostic guidelines, the DSM-5 does not compel the diagnoses of MDD after bereavement, but instead allows for clinical judgement by retaining the V-code “uncomplicated bereavement.”
Top 8 Issues in Major Depressive Disorder
ReplyDeleteApril 22, 2022 Sidney Zisook, MD
https://www.psychiatrictimes.com/view/individuals-cite-exercise-gaming-as-top-ways-to-address-mental-health-issues
4. Initial and next-step treatments. Despite many clinicians’ best efforts to select the antidepressant medication most likely to benefit their patient, many patients cannot tolerate a high enough dose to optimize benefits, and of those who do, only about half to two-thirds respond and only about a third achieve remission. Even among those who remit, relapse and recurrence are the norms, often within weeks to months after remission, and many more times over the life span. At least a third are considered to have treatment-resistant depression (TRD). Individuals with TRD have a much more debilitating form of illness than those with MDD, including increased mortality from suicide as well as all-causes mortality.8 Yet clinicians do not yet have solid, evidence-based, optimal pharmacologic choices for either first-step or next-step treatments. Given the prevalence of MDD and its associated morbidity and mortality, the search for optimal first-line and next-step treatments should be a national priority.
5. Difficult to treat depression. The concept of TRD, based solely upon failure to achieve remission with 2 or more adequately delivered medication trials, may have outlived its usefulness. A broader, perhaps more empathic, concept of difficult to treat depression (DTD) has been proposed to replace TRD.9 DTD is defined as “depression that continues to cause significant burden despite usual treatment efforts.” It takes into account not only symptomatic remission and response, but also treatment intolerance, “poop-out,” relapse, recurrence, functioning, and quality of life.
In the DTD model, treatment combines optimization of symptom control, maximizing function and minimizing treatment burden where remission cannot be obtained.10 Although TRD may be seen to suggest a defeatist attitude to treatment, DTD is a more open concept that incorporates life-long management and fosters a collaborative approach between the physician, the patient/family members, and other providers to overcome difficulties and challenges. A patient-centered approach to life-long disease management, based on shared decision-making around all aspects of treatment, is recommended.
Top 8 Issues in Major Depressive Disorder
ReplyDeleteApril 22, 2022 Sidney Zisook, MD
https://www.psychiatrictimes.com/view/individuals-cite-exercise-gaming-as-top-ways-to-address-mental-health-issues
7. Training. An abundance of literaturedocuments the superiority of antidepressant medication plus psychotherapy over medication alone for MDD. Yet, when it comes to training the next generation of psychiatrists, we are observing a monumental paradox. Since 2013, the Accreditation Council for Graduate Medical Education (ACGME) standards and requirements for psychotherapy training in psychiatric residencies call for developing competencies in the areas of cognitive-behavioral therapy (CBT), psychodynamic psychotherapy, and supportive psychotherapy in both brief and long-term formats, with optional experiences in group and couples/family therapy. Yet, currently, fewer psychiatrists than ever are providing psychotherapy to patients with MDD, or any diagnoses for that matter.13 Fifty percent of psychiatrists do no psychotherapy, and only 10% regularly provide psychotherapy along with medications.14 This current state and evolving trend is unacceptable. The ACGME requirements have not served their purpose,15 and future training may benefit from fewer top-down mandates and more trust in training programs to implement their own standards and innovations.
8. Physician burnout, depression, and suicide. Physician distress is increasingly recognized as a professional and public health crisis. High rates of suffering including career dissatisfaction, secondary trauma or second victim phenomena (in psychiatry, often related to coping with patient suicide), burnout, substance abuse, depression, and suicide are all receiving national attention and calls for action.16 While there has been outpouring of attention to recognize and attenuate physician burnout, far less attention has been allocated to the recognition and treatment of MDD in physicians. Yet, perhaps the most actionable prevention strategy for suicide is prompt recognition in optimal treatment of MDD.
Physicians have rates of MDD similar to the rest of the population, but are no more likely—perhaps less likely—to access treatment. This is due, in part, to continued stigma related to mental illness, but also to fears regarding the consequences of diagnosis and treatment on standing in the professional community and licensing, promotion, and insurance concerns. No doubt, avoidance of treatment relates to the high suicide rates noted in physicians. Distinguishing features of physician suicide include: Female physicians die by suicide more often than other females in the general population; suicide is the leading cause of death among male residents and the second leading cause of death among female residents; physicians are more likely to have a job problem (hence, attention to improving well-being and reducing burnout cannot be overestimated); a higher proportion of physician and nurse suicide deaths are by overdose compared with the general population; depression is as significant a risk factor as among nonphysician suicide deaths; and physicians who took their lives were no more likely to be receiving mental health treatment compared with nonphysicians who took their lives.17,18