1 Duke-National University of Singapore Medical School, Singapore.
2 Department of Psychiatry & Behavioral Sciences, Duke University, School of Medicine, Durham, NC, USA.
Aust N Z J Psychiatry. 2019 Feb;53(2):109-118. doi: 10.1177/0004867418808585. Epub 2018 Oct 31.
The report considers the pros and cons of the most commonly used conceptual model that forms the basis for most clinical practice guidelines for depression. This model promotes the attainment of sustained symptom remission as the treatment goal based on its well-established prognostic and functional importance. Sustained remission is very unlikely, however, after multiple treatment attempts. Our current model propels many clinicians to continue to change or add treatments despite little chance for remission or full functional restoration and despite the increasing risk of more adverse events from polypharmacy. An alternative 'difficult-to-treat depression' model is presented and considered. It accepts that the treatment aims for some depressed patients may shift to optimal symptom control rather than remission. When difficult-to-treat depression is suspected, the many treatable causes of persistent depression must be assessed and addressed (given the importance of remission when attainable) before difficult-to-treat depression can be ascribed. The clinical and research implications of the difficult-to-treat depression model are discussed.
Suspected difficult-to-treat depression provides a practical basis for considering when to conduct a comprehensive evaluation. Once difficult-to-treat depression is confirmed, treatment may better focus on optimal disease management (symptom control and functional improvement).
本报告考虑了最常用的概念模型的优缺点，该模型是大多数抑郁症临床实践指南的基础。该模型基于其明确的预后和功能重要性，提倡将持续缓解症状作为治疗目标。然而，在多次治疗尝试后，持续缓解的可能性非常小。我们目前的模型促使许多临床医生继续改变或添加治疗方法，尽管缓解或完全功能恢复的机会很小，而且由于药物联合使用的风险增加，出现更多不良事件的风险也会增加。提出并考虑了一种替代的“难治性抑郁症”模型。它接受这样一个事实，即一些抑郁症患者的治疗目标可能会转向最佳症状控制而不是缓解。当怀疑为难治性抑郁症时，必须评估和解决持续抑郁的许多可治疗原因（因为缓解在可达到时非常重要），然后才能归因于难治性抑郁症。讨论了难治性抑郁症模型的临床和研究意义。
疑似难治性抑郁症为何时进行全面评估提供了一个实用的基础。一旦确诊为难治性抑郁症，治疗可能更好地侧重于最佳疾病管理（症状控制和功能改善）。
