一個不同的精神病學需要停產抗抑鬱藥物
A Different Psychiatry Is Needed for Discontinuing Antidepressants
一個初級保健醫生尋求我的建議。在他經歷痛苦的離婚時，他自己開了 20 毫克/天的帕羅西汀。他報告了他的情況如下：
A primary care physician looked for my advice. He had self-prescribed paroxetine 20 mg/day at a time when he was going through a painful divorce. He reported his case as follows:
“我看到我的許多患者從這種藥物中受益匪淺，我認為我可以成為其中之一。它實際上有所幫助：我感到有些解脫，幾週後我睡得很好。但是我和前妻的問題還沒有結束，試圖從我們的爭吵中拯救我們的孩子並不容易。所以我想我最好繼續服用帕羅西汀，作為一種保護。
“I had seen many patients of mine getting a lot of benefit from this medication and I thought that I could be one of those. It actually helped: I felt some relief and I experienced some sound sleep after several weeks. But my problems with my former wife were not over, and trying to save our children from our fight was not easy. So I thought I better kept on taking paroxetine, as a sort of protection.
“幾年後情況有所好轉，我決定是時候退出了。我知道我必須循序漸進，所以我拆分了 20 毫克的藥片。一場噩夢：身體症狀突然發作，注意力完全喪失（我什至不能當醫生）。我回到原來的劑量，事情變得更好了。我記得這也發生在我的一些病人身上；我曾向我熟悉的幾位精神病醫生尋求與我有類似問題的一些患者的建議，他們只是建議我這些患者只需回到他們以前服用的藥物即可。
“After a couple of years things were looking up a bit and I decided it was time to quit. I knew I had to do it gradually, so I split the 20 mg tablet. A nightmare: a flare up of somatic symptoms with total loss of concentration (I could not even work as a doctor). I went back to the original dose and things got better. I remembered that this happened also to some patients of mine; I had looked for advice to a couple of psychiatrists I was familiar with for a few patients who had problems similar to mine, and they just suggested me that those patients had simply to go back to the medications they took before.
“所以我想可能是我還沒準備好，等了幾個月。但同樣的事情又發生了。我再次諮詢了兩位精神科醫生中的一位，她說：“你只是在復發。繼續服用你的藥片。” 我知道這不是真的：什麼復發？我從來沒有經歷過我在病人身上看到的那種抑鬱症。我意識到我在無人區(no man’s land)，我得了病，但無處可去。作為一名初級保健醫生，我非常擅長將我的病人轉介到適當的專科護理。但我不能為自己做任何事。”
“So I thought that may-be I was not ready and waited a few months. But the same happened again. I checked again with one of the two psychiatrists and she said “You are simply experiencing a relapse. Keep on taking your tablet.” I knew it was not true: relapse of what? I had never experienced the type of depression I had seen in my patients. I realized I was in a no man’s land, that I had a disease, but there was no place to go. As a primary care physician, I became quite good in referring my patients to proper specialist care. But I could not do anything for myself.”
我在最近的書中描述的這個案例是目前被忽視的一個主要的全球醫療保健問題的例證。在美國，六分之一的人正在服用精神藥物。在 80% 的病例中，它是長期使用的，主要涉及新一代抗抑鬱藥，如 SSRI（如氟西汀）和 SNRI（如文拉法辛）。當患者想要停用這些藥物和/或他們的醫生決定是時候停止時，就會出現大量問題。大約有二分之一的患者會出現戒斷症狀，幾天或幾週後不一定會消退，可能很嚴重並具有威脅性。患者，如初級保健醫生，不知道該怎麼做。
This case, which I described in my recent book, exemplifies a major worldwide healthcare problem that is currently ignored. One person out of 6 in United States is taking psychotropic drugs. In 80% of cases, it is for long-term use and predominantly involves new generation antidepressants, such as SSRI (e.g., fluoxetine) and SNRI (e.g., venlafaxine). When patients want to take off these drugs and/or their physicians decide it is time to stop, substantial problems ensue. About one patient out of two experiences withdrawal symptoms, that do not necessarily subside after a few days or weeks and may be severe and threatening. Patients, like the primary care physician, do not know what to do.
您希望專家或專業中心有更好的評估和治療工具。而且，精神科醫生通常不知道該怎麼做，因為科學協會和期刊大量否認這個問題（“抗抑鬱藥不會引起依賴；只是慢慢逐漸減量而已；患者經歷的是無害的停藥綜合症”）。主要經濟利益（將處方推向最高劑量和最長時間的給藥）是這種否認的背後原因。
You would hope that specialists or specialized centers would have better tools for assessment and treatment. But also, psychiatrists often do not know what to do, because of massive denial of the problem by scientific societies and journals (“antidepressant drugs do not cause dependence; it is just a matter of tapering them slowly; what patients experience are harmless discontinuation syndromes”). Major financial interests (pushing prescriptions to the highest doses and most prolonged administrations) are behind this denial.
許多精神科醫生學到的是根據 DSM 進行診斷並以自動方式編寫一個或多個處方。一個問題是 DSM 適用於不再存在的患者（無藥物受試者）：今天來臨床觀察的大多數患者已經在服用精神藥物，這種情況很可能會影響症狀的表現和結果。然而，醫源性觀點不僅僅是被忽視：它是被禁止的。
What many psychiatrists have learnt is to perform a diagnosis according to DSM and to write one or more prescriptions in an automatic fashion. A problem is that the DSM applies to patients who no longer exist (drug-free subjects): most of the patients who come to clinical observation today are already taking psychotropic drugs and this occurrence is likely to affect the presentation and outcome of symptoms. Yet the iatrogenic perspective is more than just ignored: it is forbidden.
幫助患者克服困難需要出色的鑑別診斷技能；不僅對治療的潛在益處有深入的了解（抗抑鬱藥仍然是嚴重抑鬱症患者的救命藥物），而且對它們的脆弱性有深入的了解；以及對能夠進行自我治療的心理治療的進步的認識。我們還需要能夠理解每個個體病例可能不同（一個大小並不適合所有病例）並能夠使用臨床判斷來更好地理解現象的精神科醫生。
Helping patients to overcome their difficulties requires excellent skills in differential diagnosis; deep knowledge not only of the potential benefits of treatments (antidepressant drugs remain life-saving medications in severe depression), but also of their vulnerabilities; and awareness of the advances in psychotherapy that enable self-therapy. We also need psychiatrists who are able to understand that each individual case may be different (one size does not fit all) and to use clinical judgment for a better understanding of phenomena.
戒斷反應只是可能由使用抗抑鬱藥物引發的圖片的一部分（冰山一角）。可能與其他問題有關：非常嚴重的醫學副作用（例如，胃部不適和高血壓），維持期間對劑量增加沒有反應的有效性喪失，矛盾效應（深度冷漠），在沒有病史的患者中轉變為躁狂狀態雙相情感障礙、耐藥性（過去有用的藥物在一段時間後不再有效）、治療難治性。所有這些表現都是使用抗抑鬱藥可能出現的行為毒性狀態的表現，都是微妙的，需要統一的觀點。
Withdrawal reactions are only part of the picture that may be triggered by use of antidepressant medications (the tip of the iceberg). Other problems might be associated: very serious medical side effects (e.g., gastric disturbances and hypertension), loss of effectiveness during maintenance that does not respond to dose increase, paradoxical effects (deep apathy), switching into a manic state in patients without a history of bipolar disorder, resistance (a medication that was helpful in the past is no longer effective after an interval), refractoriness to treatment. All these manifestations, which are expression of a state of behavioral toxicity that may occur with use of antidepressants, are subtle and would require a unifying outlook.
// paradoxical effects https://en.wikipedia.org/wiki/Paradoxical_reaction
七十年代，當我在意大利讀醫科時，我有機會在紐約州羅切斯特度過暑期選修課，看喬治·恩格爾和約翰·羅馬諾的病人。他們培訓了幾代精神科醫生，他們本來能夠處理與使用抗抑鬱藥有關的主要醫療保健問題。但是這些精神科醫生都去哪兒了？我們需要更新恩格爾和羅馬諾的心身學方法。
In the seventies, when I was a medical student in Italy, I had the opportunity of spending a summer elective in Rochester, NY, seeing patients with George Engel and John Romano. They trained generations of psychiatrists who would have been able to deal with the major healthcare problems linked to use of antidepressants. But where have all these psychiatrists gone? We need to renew the psychosomatic approach of Engel and Romano.
過去二十年來神經科學的進步常常讓我們相信，精神病學的臨床問題很可能最終通過這種方法得到解決。就大型製藥公司的大規模宣傳而言，這種希望是可以理解的。然而，越來越多的精神科醫生想知道為什麼神經科學所承諾的治愈方法和臨床見解沒有發生。
The progress of neuroscience in the past two decades has often led us to believe that clinical problems in psychiatry were likely to be ultimately solved by this approach. Such hopes are understandable in terms of massive propaganda operated by Big Pharma. An increasing number of psychiatrists are wondering, however, why the cures and clinical insights that neuroscience has promised have not taken place.
很明顯，與使用抗抑鬱藥有關的問題無法通過被製藥業洗腦的過於簡單的精神病學來解決。需要一種不同的精神病學來解決與抗抑鬱藥物相關的問題和困難。這是我試圖在我的書最後一章的宣言中概述的精神病學，牛津大學出版社使用此鏈接提供：
https://oxfordmedicine.com/view/10.1093/med/9780192896643.001.0001/med-9780192896643-chapter-13.
It is clear that the problems related to the use of antidepressants cannot be solved by an oversimplified psychiatry brainwashed by the pharmaceutical industry. A different psychiatry is needed to address the problems and difficulties related to antidepressant drugs. This is the psychiatry that I have tried to outline in a manifesto in the last chapter of my book and which has been made available by Oxford University Press using this link: https://oxfordmedicine.com/view/10.1093/med/9780192896643.001.0001/med-9780192896643-chapter-13.
與使用抗抑鬱藥相關的醫療保健問題需要成為研究和資助的優先事項。我們對許多問題知之甚少。我們缺乏神經生物學研究，這些研究可能會闡明為什麼在相同的治療時間相同的情況下，某些患者會出現戒斷綜合症而其他人不會。我們缺乏探索持續性戒斷後障礙的發生、臨床特徵和神經生物學相關性的長期調查，也缺乏可能闡明戒斷綜合症與其他行為毒性表現（例如，難治性、效果喪失）之間關係的大型研究。
The healthcare problems associated with the use of antidepressants need to become a priority for research and funding. We know so little about a number of issues. We lack neurobiological investigations that may shed some light on why, with the same treatment for the same duration of time, certain patients develop withdrawal syndromes and other do not. We lack long-term investigations exploring the occurrence, clinical features and neurobiological correlates of persistent post-withdrawal disorders and large studies that may clarify the relationships between withdrawal syndromes and other manifestations of behavioral toxicity (e.g., refractoriness, loss of effects).
非常漸進的減量可能會降低戒斷現象的可能性的假設幾乎沒有可用的數據來支持它，並且與延長抗抑鬱藥毒性暴露的缺點背道而馳。迫切需要隨機對照試驗來比較治療戒斷綜合症的不同方法，包括心理治療策略。
The hypothesis that very gradual tapering may yield a lower likelihood of withdrawal phenomena has very few data available to support it and runs counter the disadvantage of prolonging toxic exposure to antidepressants. There is the pressing need of randomized controlled trials comparing different methods of managing withdrawal syndromes, including psychotherapeutic strategies.
作為納稅人，我們不能再容忍公共資金被浪費在無處可去的道路和永遠不會對臨床實踐和痛苦產生影響的項目上。現在是我們告訴政策制定者和主要意見領袖的時候了，“你的時間到了。我們有嚴重的問題，我們需要不同的精神病學。”
As taxpayers, we can no longer tolerate that public money gets wasted into roads to nowhere and projects that will never have an impact on clinical practice and suffering. It is time that we tell policymakers and key opinion leaders, “Your time is up. We have serious problems and we need a different psychiatry.”
//A Different Psychiatry Is Possible
https://oxfordmedicine.com/view/10.1093/med/9780192896643.001.0001/med-9780192896643-chapter-13
喬瓦尼·法瓦
Giovanni A. Fava，醫學博士，現任紐約州立大學布法羅大學精神病學臨床教授，同時也是精神病學和心理學領域的頂級期刊《心理治療和心身學》的主編，該雜誌是第一個發出警告的1994 年抗抑鬱藥的行為毒性研究。他在多個領域進行了開創性研究，例如幸福療法、藥物療法和心理療法相結合的序貫模型以及精神病學中的分期概念。
//幸福療法:
https://www.well-being-therapy.com/
來源:
https://www.madinamerica.com/2022/05/different-psychiatry-discontinuing-antidepressants/