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Treatment-Resistant Bipolar DisorderA Review of Psychotherapeutic Approaches难治性双相障碍：精神治疗方法述评James C-Y Chou, MDDepartment of psychiatry, Mount Sinai School of Medicine in New York难治性双相障碍的概念为临床所熟知但缺乏标准的定义。
这一术语是否指的是对一种或多种标准治疗无反应，在多少剂量，以及双相障碍的那个相位仍不清楚。
难治性双相障碍大概通常是基于特定的治疗相位：躁狂或抑郁与急性期或维持期。
难治性（treatment resistance）是极为普遍的。
即使在最佳的维持治疗情况下，近半数症状缓解的双相障碍患者在标准治疗下（包括药物联合治疗）将会2年内复发。
基于证据的优化特定相位的治疗是至关重要的。
这可能包括根据反应来提高起初治疗的剂量，除非受到不良反应的限制。
急性期治疗通常延续到维持期。
决定首先使用哪种药物治疗或什么药物联合，以及给药剂量问题，就每个临床医生而言都需要良好地临床判断，因为掌控这些决策的证据匮乏。
传统上，锂和抗惊厥药物已经被用作急性躁狂的一线治疗；抗精神病药物仅用于难治性，严重性，或伴有精神病性症状的双相障碍患者。
这一惯例是基于锂和双丙戊酸钠使用的长期历史，而非疗效对比试验。
得到FDA批准的非典型抗精神病药物用于双相障碍的使用范围正在扩展；这些药物当前被认为是即使对于适度躁狂患者是一线治疗。
为了快速地减少难治性和提高病情稳定性，必须关注共病，例如物质滥用。
而且，必须停用使病情不稳定的药物治疗，例如抗抑郁药物。
基于证据的加强心理治疗在维持期显然是有益的。
对于确实难治性状况，也推荐氯氮平和电休克治疗（ECT）用于急性期和维持期的抑郁和躁狂治疗。
如果这些治疗失败，有人提出许多新型疗法，而且有一些已经在安慰剂对照试验中得到研究。
美国精神医学学会APA新版精神分裂症治疗指南中英文对照版第三部分Monitoring During Treatment With an Antipsychotic Medication抗精神病药治疗期间的监测During treatment with an antipsychotic medication, it is important to monitor medication adherence, therapeutic benefits of treatment, and treatment-related side effects. The patient’s clinical status can also be affected by changes in physical health, adjustments to other psychotropic and nonpsychotropic medications, and other factors, such as cessation or resumption of smoking.使用抗精神病药期间，监测用药依从性、疗效获益及治疗相关副作用非常重要。
患者的临床状态也可能受躯体健康状况、其他精神科药物及非精神科药物，以及停止/重新开始吸烟等因素的影响。
Adherence to antipsychotic treatment is a common problem that affects treatment outcomes. There are many barriers to treatment adherence as well as facilitators and motivators of adherence, each of which will differ for an individual patient (Hatch et al. 2017; Kane et al. 2013; Pyne et al. 2014). Thus, it is important to take a patient-centered approach in inquiring in a nonjudgmentalway whether the individual has experienced difficulties with taking medication since the last visit. (For a detailed discussion of factors related to adherence, see Statement 3.)抗精神病药治疗依从性是影响治疗转归的常见因素。
强迫障碍与CBT(认知行为疗法)心理治疗强迫障碍CBT强迫障碍（OCD）是一种焦虑性疾患，其特征是患者不断出现一些强迫念头，冲动或影像，导致极大的痛苦和困扰。
为了消除这些强迫念头所带来的焦虑，患者会不断进行强迫行为。
根据“精神疾病诊断与统计手册”第五版（DSM），OCD的诊断须符合一定的标准，包括出现强迫思考、强迫行为或两者兼具，强迫思维或行为是费时的，或引起临床上显著苦恼或社交、职业或其他重要领域功能减损等。
强迫思考和强迫行为是OCD的核心症状。
强迫思考是指持续且仿佛出现一些想法、冲动或影像，在困扰的症状干扰时，有时候个案的感受是侵入的、不想要的，这会对大部分的个案造成明显的焦虑或痛苦。
而强迫行为则是重复的行为或心智活动，个案必须响应强迫思考或根据某些必须严格遵守的规则，来被迫地做出这些动作。
这些行为和心智活动的目的是防止或减少焦虑或痛苦，或者预防发生一些可怕的事件或情况。
但是这些行为或心智活动，与其期望去抵消或预防的现实状况是不符合和的，或显然是过度的。
OCD的强迫思考的类型包括攻击、怕受污染、性、囤积（或节省）和宗教等。
攻击类型的强迫思考表现为害怕伤害自己或别人，或做出令自己无法控制的事情；怕受污染类型的强迫思考表现为怕脏、怕触摸、怕清洁剂、化学药品等各种污染物；性类型的强迫思考表现为出现不合理的性画面或思考，如对自己的小孩性侵犯；囤积（或节省）类型的强迫思考表现为认为每样东西都很重要，舍不得丢掉，因此堆积很多东西；宗教类型的强迫思考表现为担心冒犯神明，或担心道德上的对错。
XXX是一种有效的治疗OCD的方法。
XXX的基本思想是通过改变患者的思维和行为，来减轻他们的症状。
XXX的治疗过程包括认知重构、暴露和反应防御预防等。
认知重构是指帮助患者识别和改变他们的负面思维模式，以减少强迫思考的出现。
暴露是指让患者面对他们的恐惧和焦虑，并逐渐适应这些情境，以减少强迫行为的出现。
反应防御预防是指帮助患者学会有效地应对强迫念头和行为，以减少其对生活和职业的影响。
难治性抑郁症的管理临床实践指南英文全文共3篇示例，供读者参考篇1Clinical Practice Guideline for the Management of Treatment-Resistant DepressionIntroductionTreatment-resistant depression (TRD) is a common and challenging condition that affects a significant number of individuals worldwide. Despite the availability of multiple pharmacological and non-pharmacological treatment options, a subset of patients with depression fails to respond adequately to standard interventions. In recent years, significant progress has been made in understanding the pathophysiology of TRD and developing novel treatment strategies. This clinical practice guideline aims to provide evidence-based recommendations for the management of TRD in clinical practice.Diagnosis and AssessmentThe diagnosis of TRD should be made after a careful evaluation of the patient's symptoms, treatment history, and response to previous interventions. Assessment tools such as theHamilton Depression Rating Scale (HDRS) and the Montgomery-Åsberg Depression Rating Scale (MADRS) can be used to evaluate the severity of depressive symptoms. In addition, a comprehensive psychiatric evaluation should be conducted to rule out other psychiatric disorders that may mimic depression or contribute to treatment resistance.Pharmacological InterventionsFor patients with TRD, pharmacological interventions remain the mainstay of treatment. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs),serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs) are commonly used in the management of TRD. In cases where patients do not respond to first-line antidepressants, switching to another class of antidepressants or augmenting with other medications such as atypical antipsychotics, lithium, or thyroid hormones may be considered.PsychotherapyIn addition to pharmacological interventions, psychotherapy can also play an important role in the management of TRD. Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and mindfulness-based interventions have been shown to beeffective in treating depression and improving treatment outcomes in patients with TRD. Psychotherapy can be used as a standalone treatment or in combination with pharmacotherapy to enhance the effectiveness of treatment.Electroconvulsive Therapy (ECT)Electroconvulsive therapy (ECT) is a highly effective treatment option for patients with severe TRD who have not responded to pharmacological or psychotherapeutic interventions. ECT is typically reserved for patients with severe depressive symptoms, psychotic features, and suicidal ideation. ECT has been shown to produce rapid and sustained improvements in mood and is considered safe andwell-tolerated in the majority of patients.Ketamine and Other Novel Treatment ApproachesKetamine, a glutamatergic modulator, has emerged as a promising treatment for TRD. Intravenous ketamine administration has been shown to produce rapid antidepressant effects in patients with TRD, with improvements observed within hours of treatment. Other novel treatment approaches such as transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) are also being investigated as potential options for patients with TRD.ConclusionIn conclusion, the management of TRD requires a comprehensive and individualized approach that takes into account the patient's symptoms, treatment history, and preferences. This clinical practice guideline providesevidence-based recommendations for the management of TRD and highlights the importance of a multidisciplinary approach involving psychiatrists, psychologists, and other healthcare professionals. By implementing these recommendations in clinical practice, healthcare providers can improve treatment outcomes and quality of life for patients with TRD.篇2Clinical Practice Guidelines for the Management of Treatment-Resistant DepressionIntroductionTreatment-resistant depression (TRD) is a challenging condition characterized by a lack of response to standard antidepressant therapy. It is estimated that up to 30% of patients with depression do not adequately respond to initial treatment, and a proportion of these individuals may go on to develop TRD. Management of TRD requires a comprehensive approach thatincludes a combination of pharmacological andnon-pharmacological interventions. This document provides evidence-based recommendations for the management of TRD in clinical practice.Diagnostic EvaluationThe first step in managing TRD is to ensure an accurate diagnosis. This involves a thorough assessment of the patient's history, symptoms, and response to previous treatments. It is important to rule out other psychiatric or medical conditions that may be contributing to the treatment resistance. A comprehensive evaluation should also include a review of the patient's medication history, substance use, and psychosocial stressors.Pharmacological InterventionsWhen managing TRD, it is important to consider switching to a different antidepressant medication or augmenting with an additional agent. Some common strategies include:- Switching to a different class of antidepressant- Augmenting with a second-generation antipsychotic- Augmenting with a mood stabilizer- Adding a stimulant medication- Considering off-label use of ketamine or esketamineNon-Pharmacological InterventionsIn addition to pharmacotherapy, non-pharmacological interventions can play a valuable role in the management of TRD. These may include:- Cognitive-behavioral therapy (CBT)- Interpersonal therapy (IPT)- Mindfulness-based therapies- Electroconvulsive therapy (ECT)- Transcranial magnetic stimulation (TMS)- Vagus nerve stimulation (VNS)Treatment SettingPatients with TRD may benefit from treatment in a specialized mental health setting, such as a mood disorders clinic or an inpatient psychiatric unit. These settings provide access to a multidisciplinary team of mental health professionals who can collaborate on the patient's care. In severe cases, hospitalizationmay be necessary to ensure the safety and stability of the patient.Monitoring and Follow-UpRegular monitoring of symptoms and treatment response is essential in the management of TRD. Clinicians should closely monitor the patient's mood, energy level, appetite, and sleep patterns. It is important to assess for potential side effects of medications and to address any concerns or barriers to treatment compliance. Follow-up appointments should be scheduled at regular intervals to assess the effectiveness of the treatment plan and make adjustments as needed.ConclusionManaging TRD requires a comprehensive and individualized approach that addresses both pharmacological andnon-pharmacological interventions. By followingevidence-based guidelines and collaborating with a multidisciplinary team of mental health professionals, clinicians can help patients with TRD achieve remission and improve their quality of life.篇3Management Clinical Practice Guidelines forTreatment-Resistant DepressionIntroductionTreatment-resistant depression (TRD) is a challenging condition that affects a significant number of individuals worldwide. It is characterized by persistent symptoms of depression despite multiple treatment attempts with various antidepressant medications. Managing TRD requires a comprehensive approach that goes beyond traditional pharmacotherapy and includes psychotherapy, lifestyle modifications, and other interventions. This clinical practice guideline aims to provide healthcare professionals with evidence-based recommendations for the management of TRD.Assessment and DiagnosisThe first step in managing TRD is an accurate assessment and diagnosis. This includes a thorough evaluation of the patient's history, symptoms, and potential contributing factors. It is essential to rule out other medical conditions that may be causing or exacerbating the symptoms of depression. In addition, a comprehensive mental health assessment, including a psychiatric evaluation, should be conducted to determine theseverity of the depression and identify any comorbid psychiatric disorders.Treatment OptionsOnce a diagnosis of TRD has been established, treatment options should be tailored to the individual patient's needs. Pharmacotherapy remains a cornerstone of TRD treatment, with options including switching to a different antidepressant medication, adding a second medication, or trying a combination of medications. It is essential to monitor the patient closely for side effects and treatment effectiveness.In addition to pharmacotherapy, psychotherapy is an essential component of TRD management. Cognitive-behavioral therapy (CBT) has been shown to be effective in treating TRD by helping patients identify and change negative thought patterns and behaviors. Other types of therapy, such as interpersonal therapy (IPT) and psychodynamic therapy, may also be beneficial for some patients.Lifestyle modifications, such as exercise, diet, and sleep hygiene, can also play a significant role in managing TRD. Regular physical activity has been shown to improve mood and reduce symptoms of depression, while a healthy diet and adequate sleep can support overall mental health.Other treatment options for TRD include neuromodulation techniques, such as transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). These treatments are typically reserved for patients who have not responded to other interventions and may be effective in severe cases of TRD.Follow-Up and MonitoringRegular follow-up and monitoring are essential for patients with TRD to ensure treatment effectiveness and detect any potential side effects. Healthcare professionals should schedule regular appointments with patients to assess their symptoms, medication compliance, and overall well-being. It is crucial to involve the patient in treatment decision-making and encourage open communication about treatment outcomes.ConclusionManaging TRD requires a multidisciplinary approach that addresses the complex nature of the condition. This clinical practice guideline provides evidence-based recommendations for healthcare professionals to effectively manage TRD and improve patient outcomes. By utilizing a combination of pharmacotherapy, psychotherapy, lifestyle modifications, and other interventions, healthcare professionals can help patients with TRD achieve remission and regain their quality of life.。
强迫症文献综述一、定义强迫症（OCD）属于焦虑障碍的一种类型，是一组以强迫思维和强迫行为为主要临床表现的神经精神疾病，其特点为有意识的强迫和反强迫并存，一些毫无意义、甚至违背自己意愿的想法或冲动反反复复侵入患者的日常生活。
患者虽体验到这些想法或冲动是来源于自身，极力抵抗，但始终无法控制，二者强烈的冲突使其感到巨大的痛苦和焦虑，影响学习工作，人际交往甚至生活起居。
近年来统计数据提示强迫症的发病率正在不断攀升，有研究显示普通人群中强迫症的终身患病率为1%～2%，约2/3的患者在25岁前发病。
强迫症因其起病早、病程迁延等特点，常对患者社会功能和生活质量造成极大影响，世界卫生组织（WHO）所做的全球疾病调查中发现，强迫症已成为15～44岁中青年人群中造成疾病负担最重的20种疾病之一。
另外患者常出于种种考虑在起病之初未及时就医，一些怕脏、反复洗手的患者可能要在症状严重到无法正常生活后才来就诊，起病与初次就诊间可能相隔十年之久，无形中增加了治疗的难度，因此我们应当提高对强迫症的重视，早发现早治疗。
二、病因1、心理学机制1.1 OCD的人格特征：庞道记等圈在研究中则更具体地说明了OCD与强迫人格有一定关系，并提示，OCD患者有抑郁情绪。
缺乏自信．焦虑、紧张、追求完美、不安全、敏感多疑、不适应、自卑、自责、强迫观念、刻板等，与强迫人格突出表现不安全感、不完善感、小心多疑、尽善尽美、优柔寡断．既严于律己又苛求别人，做事一丝不苟，难得通融等的观点一致。
另外，OCD患者人格特征除了强迫人格外，常常共患其他类型的人格障碍史尧胜摘译的“强迫症与人格障碍的共病”中指出，OCD不伴人格障碍是少见的亚型，绝大部分临床病例共患人格障碍，最常见的为强迫型、回避型和偏执型人格障碍。
王振等研究则发现，共患人格障碍与OCD的难治性可能有一定关系。
从有关研究中OCD患者MMPI基本量表的因子分析结果可以看出，OCD主要负荷4个人格因子，即神经质：反映患者具有神经症性症状；精神质：反映患者存在严重的不能适应现实的心理特征，具有精神病性症状；多疑因子：反映患者存在敏感、多疑、情绪小稳等心理特征；社会内向因子：反映患者社交内向性、自恋、敏感被动、退缩等心理特征问。
