From the Duke-National University of Singapore Graduate Medical School, Singapore; the Department of Psychiatry, Duke University Medical School, Durham, N.C.; the Department of Psychiatry, Texas Tech Health Sciences Center-Permian Basin, Midland-Odessa; the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and the Corporal Michael J. Crescenz VA Medical Center, Philadelphia.
Am J Psychiatry. 2018 Dec 1;175(12):1187-1198. doi: 10.1176/appi.ajp.2018.18040398. Epub 2018 Sep 17.
Specific challenges that profoundly affect the outcome of treatment for depression include 1) patient engagement and retention in care and optimization of treatment adherence, 2) optimization of symptom and side effect control by medication adjustments using measurement-based care procedures, 3) restoration of daily functioning and quality of life, and 4) prevention or at least mitigation of symptomatic relapse or recurrence. According to data from the Sequenced Treatment Alternatives to Relieve Depression study, some 10%-15% of patients will not return for treatment after an initial thorough evaluation visit; an additional 20%-35% will not complete the first acute-phase treatment step, and another 20%-50% will not complete 6 months of continuation treatment. Among patients who stay in treatment, over 50% exhibit poor adherence. Thus, most patients do not overcome the first two challenges. There are no systematic, widely agreed-upon psychosocial approaches to any of these four major challenges. The authors propose "patient-centered medical management" to address each of the four challenges, using psychoeducational, behavioral, cognitive, interpersonal, and dynamic models and methods. A renewed emphasis on the development and testing of systematic approaches to overcoming these common clinical challenges could enhance the chances of patient recovery and care system cost efficiencies. [AJP AT 175: Remembering Our Past As We Envision Our Future July 1933: Psychotherapeutics at Stockbridge Horace K. Richardson: "Frequently, in the simpler situations, very few interviews are required in order that he [the patient] discover for himself what part of the adaptive machinery is at fault, and for him to develop a technique of handling the maladjustment on a more satisfactory level in the future." (Am J Psychiatry 1933; 90:45-56 )].
具体的挑战，深刻地影响了抑郁症治疗的结果，包括 1）患者参与和保留在护理和优化治疗依从性，2）通过使用基于测量的护理程序进行药物调整来优化症状和副作用控制，3）恢复日常功能和生活质量，以及 4）预防或至少减轻症状复发或再发。根据缓解抑郁症的序贯治疗选择研究的数据，大约 10%-15%的患者在初次全面评估就诊后不会返回治疗；另外 20%-35%的患者不会完成第一个急性期治疗步骤，另有 20%-50%的患者不会完成 6 个月的维持治疗。在接受治疗的患者中，超过 50%的患者依从性较差。因此，大多数患者无法克服前两个挑战。对于这四个主要挑战，没有系统的、广泛认可的心理社会方法。作者提出了“以患者为中心的医疗管理”，以应对这四个挑战，使用心理教育、行为、认知、人际和动态模型和方法。重新强调制定和测试克服这些常见临床挑战的系统方法，可以提高患者康复和护理系统成本效率的机会。[《美国精神病学杂志》175 期：1933 年 7 月，回顾过去，展望未来，霍勒斯·K·理查森：“在许多简单的情况下，只需要很少的访谈，以便他[患者]自己发现适应机制的哪个部分出了问题，并开发一种在未来更满意地处理失调的技术。”（美国精神病学杂志 1933 年；90：45-56）]。
