Malhi Gin, Adams Danielle, Moss Beverley, Walter Garry
Department of Academic Psychiatry, CADE Clinic, Royal North Shore Hospital, NSW, Australia.
Australas Psychiatry. 2010 Jun;18(3):230-7. doi: 10.3109/10398560903358846.
This paper reports on a brief survey of clinicians' judgements when making treatment decisions in the context of diagnostic uncertainty. Specifically, attitudes and opinions were sought from practising consultant psychiatrists regarding two key areas of clinical decision-making in first episode psychosis (FEP), namely, when to initiate medication and, how long to continue treatment.
Interviews were conducted with consultant psychiatrists using a combination of structured and semi-structured questions that examined and explored pharmacological treatment decisions in FEP.
Twenty-three consultant psychiatrists participated in the interviews. The threshold to initiate pharmacological treatment was lower when a risk to self or others is present, when symptoms are primarily positive, when the patient is in distress, or where there is a family history of mental illness. Atypical antipsychotics are routinely used as front-line medication in FEP and the choice of medication is determined largely by their likely side effect profile. However, the greater the perceived efficacy, the greater the anticipated tolerability burden. The ideal duration of treatment is considered to be 1-2 years in instances of full remission, and 5 years where only a partial response has been achieved or where recovery has not been sustained.
The 'first episode' represents a unique period in the management of psychosis where by definition there is no history of pattern of illness, diagnostic certainty is rare, and the patient usually does not have any prior exposure to medications. Therefore, each management decision needs to be considered following a risk benefit analysis which takes into account the context of the individual.
本文报告了一项关于临床医生在诊断不确定情况下做出治疗决策时的判断的简要调查。具体而言，旨在了解执业精神科顾问医生对首发精神病（FEP）临床决策两个关键领域的态度和意见，即何时开始用药以及治疗应持续多长时间。
采用结构化和半结构化问题相结合的方式，对精神科顾问医生进行访谈，以研究和探讨FEP中的药物治疗决策。
23名精神科顾问医生参与了访谈。当存在对自身或他人的风险、症状主要为阳性、患者处于痛苦之中或有精神疾病家族史时，开始药物治疗的阈值较低。非典型抗精神病药物通常被用作FEP的一线药物，药物的选择很大程度上取决于其可能的副作用。然而，感知到的疗效越高，预期的耐受性负担就越大。在完全缓解的情况下，理想的治疗持续时间被认为是1 - 2年；在仅取得部分缓解或未维持康复的情况下，则为5年。
“首发”代表了精神病管理中的一个独特时期，根据定义，此时没有疾病模式的病史，诊断确定性罕见，且患者通常没有任何先前的用药经历。因此，每个管理决策都需要在考虑个体情况的风险效益分析之后做出。
