Wisner K L, Zarin D A, Holmboe E S, Appelbaum P S, Gelenberg A J, Leonard H L, Frank E
Women's Mental HealthCARE, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
Am J Psychiatry. 2000 Dec;157(12):1933-40. doi: 10.1176/appi.ajp.157.12.1933.
The Committee on Research on Psychiatric Treatments of the American Psychiatric Association identified treatment of major depression during pregnancy as a priority area for improvement in clinical management. The goal of this article was to assist physicians in optimizing treatment plans for childbearing women.
The authors' work group developed a decision-making model designed to structure the information delivered to pregnant women in the context of the risk-benefit discussion. Perspectives of forensic and decision-making experts were incorporated.
The model directs the psychiatrist to structure the problem through diagnostic formulation and identification of treatment options for depression. Reproductive toxicity in five domains (intrauterine fetal death, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity) is reviewed for the potential somatic treatments. The illness (depression) also is characterized by symptoms of somatic dysregulation that compromise health during pregnancy. The patient actively participates and provides her evaluation of the acceptability of the various treatments and outcomes. Her capacity to participate in this process provides evidence of competence to consent. Included in the decision-making process are the patient's significant others and obstetrical physician. The process is ongoing, with the need for incorporation of additional data as the pregnancy and treatment response progress.
The conceptual model provides structure to a process that is frequently stressful for both patients and psychiatrists. By applying the model, clinicians will ensure that critical aspects of the risk-benefit discussion are included in their care of pregnant women.
美国精神病学协会精神科治疗研究委员会将孕期重度抑郁症的治疗确定为临床管理中需要改进的优先领域。本文的目的是帮助医生优化育龄妇女的治疗方案。
作者的工作小组开发了一个决策模型，旨在在风险效益讨论的背景下，构建向孕妇提供的信息。纳入了法医和决策专家的观点。
该模型指导精神科医生通过诊断表述和确定抑郁症的治疗方案来构建问题。针对潜在的躯体治疗方法，审查了五个领域（宫内胎儿死亡、身体畸形、生长发育受损、行为致畸性和新生儿毒性）的生殖毒性。该疾病（抑郁症）还具有躯体调节功能障碍的症状，这些症状在孕期会损害健康。患者积极参与并对各种治疗方法和结果的可接受性进行评估。她参与这一过程的能力提供了同意治疗的能力的证据。决策过程中包括患者的重要他人和产科医生。随着妊娠和治疗反应的进展，该过程持续进行，需要纳入更多数据。
该概念模型为一个对患者和精神科医生来说通常都很有压力的过程提供了结构。通过应用该模型，临床医生将确保在对孕妇的护理中纳入风险效益讨论的关键方面。
