huotcz 2010-3-12 10:30
生活型態介入對恐慌症有效
作者：Jill Stein
出處：WebMD醫學新聞
March 1, 2010 (德國慕尼黑) — 根據發表於歐洲精神病學會第18屆歐洲精神科研討會中的資料，一種以生活型態為基礎的介入方式，由一線照護機構的職能治療師用於恐慌症的成人，效果至少和由一般開業醫師(GP)所提供的例行性照護一樣好。
英國諾威治東英格蘭大學的Rod Lambert博士向Medscape Psychiatry表示，在英國，恐慌症最常使用的治療方式是藥物和心理治療，不過，這兩種方法最多也只能獲得適度的結果，且通常有不佳的結果與高復發率。
Lambert博士等人，對符合精神疾病診斷與統計手冊(Diagnostic and Statistical Manual of Mental Disorders)第四版之恐慌症、且有或沒有曠野恐懼的18-65歲病患，比較了16週的生活型態介入以及例行性GP照護，生活型態介入包括飲食、液體攝取、運動，酒精、尼古丁與咖啡因的日常使用情形。
Lambert博士表示，目前的恐慌症治療指引建議使用藥物或心理治療(例如認知行為治療(CBT)或者諮商)，每種可以單獨使用或者合併使用，以獲得最佳的實證醫療，他參考的是英國國家臨床卓越研究中心(National Institute for Clinical Excellence，NICE)於2004年出版的指引，代表的是最新的恐慌症治療指引。
他指出，值得一提的是，儘管全國和全球健康倡議都指出例行性的生活型態實務可以影響將近50年的健康，但是，生活型態介入並未被納入臨床指引。
Lambert博士表示，約有20%的一線照護病患可能發生至少一次的焦慮異常；不過，目前的治療侷限在藥物和心理治療，對於這些盛行的狀況，生活型態介入提供一種更早期的治療選項。
【目標設定】
整體而言，有來自15個一線照顧機構的199名病患被轉介進行此研究。
研究對象被隨機分組接受例行性GP照護或者職能治療導向的生活型態介入方式。
在這16週的研究期間，被指定到生活型態組的病患與同一名職能治療師約診至多10次，約診時間一般為30-60分鐘。
在最初幾次約診時，治療師使用病患自我報告的心情狀態與生活型態日記回顧病患的生活型態，且向病患解釋不良行為如抽菸和不佳飲食對健康的不良影響，以及從事例行性運動和適當攝取液體對健康的幫助。
接著，在治療師監測與回顧病患的病程與恐慌症狀的改變之後，治療師與病患一起努力達到生活型態目標。
例行性GP照護是「非強制性的」，且明確使用GP實務紀錄，包括看護、處方與轉診。
初級結果測量是20週時的貝克焦慮量表(BAI)分數的改變，這個量表是廣為使用的焦慮嚴重度測量工具，在第20週時測量，就是在完成介入或GP照護之後4週。
BAI分數為0-7分表示極輕微之焦慮、8-15分表示輕微焦慮、16-25分表示中度焦慮、26-63分則是嚴重焦慮。
生活型態組有31名病患有完整資料，GP組有36人。
【持久的效果】
第20週時的評估結果顯示，BAI分數有顯著改善，生活型態組的平均分數從29.5減少到9.2，GP組從29.4減少到17.2 (P < .001)。
追蹤10個月時，生活型態組的分數依舊較佳；不過，兩組之間的差異並不顯著，兩組的分數分別是13.3和16.4(P = .167)。
Lambert博士指出，生活型態組在10個月時仍可能復發，因為研究並未包括維持約診。
他表示，我們相信，如果病患在16週介入之後，持續定期就診職能治療師，復發率可以更低。
Lambert博士表示，因此，我們的資料顯示，生活型態方式未能對所有病患皆有長期效果，因為其中約有三分之一回復到不佳的生活習慣與原本的焦慮模式。
不過，他指出，重點在於記住，其他恐慌症治療方式如藥物和CBT也可能會這樣。
我們應該記住，生活型態組有三分之二的病患獲得較佳的BAI分數，且維持到10個月時，而有持續的改善。
根據Lambert博士表示，使用生活型態介入讓病患於其中一些症狀有合理的解釋。
他表示，生活型態改變包括了減少症狀之影響的策略，然後，對恐慌症狀的恐懼消失，然後減少焦慮而恢復個人的控制，發展正向生活行為也對一般健康與心理健康有幫助。
最後，Lambert博士強調，雖然本研究中生活型態介入是由職能治療師執行，後續的研究可以確認其他健康照護專業人員在這方面的角色。
他表示，我們希望這類研究可以影響NICE的恐慌症治療指引，目前，治療指引中並未將生活型態納入考量。
【目前指引的缺點】
英國倫敦帝國學院精神科名譽教授Stuart Montgomery博士向Medscape Psychiatry表示，評估恐慌症新治療的研究，就像其他精神科和非精神科疾病一樣，都是無價的，而且，目前的NICE指引的確有缺點。
他表示，我們一定需要新療法，最好是效果更佳、使用更簡單、對病患更友善的方法，這些是顯而易見的。
Montgomery博士表示，NICE指引或許是世界上最糟糕的，因為它要求我們使用便宜但效果證據有限的俗名藥，目前，它們在推廣將citalopram作為所有憂鬱和焦慮異常的第一線治療，但是並沒有證據顯示citalopram對於恐慌症有效。
它或許是也或許不是，但是它絕無這種用法的試驗，所以，該指引建議使用一種未經核准的適應症作為官方政策，簡直是實證醫學的笑柄。Lambert博士與Montgomery博士皆宣告沒有相關財務關係。
歐洲精神病學會(EPA)第18屆歐洲精神科研討會：摘要768，發表於2010年2月28日。
[b][font=Arial][size=4]Lifestyle Intervention Shows Promise for Panic Disorder[/size][/font][/b][font=Arial][size=2]
[/size][/font][size=2][font=Arial][i]By Jill Stein
Medscape Medical News[/i]
March 1, 2010 (Munich, Germany) — A lifestyle-based intervention for adults with panic disorder that is implemented by occupational therapists in the primary care setting is at least as good as routine care by a general practitioner (GP), according to data presented at the European Psychiatric Association 18th European Congress of Psychiatry.
"Panic disorder in the UK is most often treated with medication and psychological therapy; however, both approaches yield modest outcomes at best and more often poor outcomes along with high relapse rates," Rod Lambert, DipCOT, CHSM, MA, PhD, University of East Anglia in Norwich, United Kingdom, told [i]Medscape Psychiatry[/i].
Dr. Lambert and colleagues compared a 16-week lifestyle intervention and routine GP care in patients 18 to 65 years of age who satisfied [i]Diagnostic and Statistical Manual of Mental Disorders[/i] (Fourth Edition) criteria for panic disorder with or without agoraphobia. The lifestyle intervention addressed diet, fluid intake, exercise, and the habitual use of alcohol, nicotine, and caffeine.[/font][/size]
[img=249,186]http://img.medscape.com/news/lambert_rod2.JPG[/img]
[b]Dr. Rod Lambert[/b]
[font=Arial][size=2]"Current treatment guidelines for panic disorder recommend medication or psychological treatment such as cognitive behavioral therapy (CBT) or counseling either as solo treatment or in combination as being the best evidence-based treatment," Dr. Lambert said. The guidelines he was referring to were issued by the UK’s National Institute for Clinical Excellence (NICE) in 2004 and represent the most recent guidelines on panic disorder.
Notably, lifestyle interventions are not included in clinical guidelines despite the fact that national and global health initiatives have advocated the notion that routine lifestyle practices affect health for nearly 50 years, he added.
"About 20% of primary care patients are likely to experience at least one anxiety disorder; however, current treatments are limited to medications and psychological therapies," Dr. Lambert said. "Lifestyle interventions offer an additional early-stage treatment option for these prevalent conditions."
[b]Goal Setting[/b]
Overall, 199 patients were referred for the study from 15 primary care practices.
Study participants were randomized to receive either routine GP care or an occupational therapy–led lifestyle approach.
Patients assigned to the lifestyle group met with the same occupational therapist up to 10 times during the 16-week study. Appointments typically lasted 30 to 60 minutes.
During the first few appointments, the therapist reviewed the patient’s lifestyle using self-reported mood and lifestyle journals and explained to the patient the adverse health effects of behaviors such as smoking cigarettes and maintaining a poor diet, as well as the favorable health effects of behaviors such as routine exercise and adequate fluid intake.
Subsequently, the therapist and patient jointly worked out lifestyle goals after which the therapist monitored and reviewed the patient’s progress along with changes in panic symptoms.
Routine GP care was "not constrained" and was identified using GP practice records of attendance, prescriptions, and referrals.
The primary outcome measure was the change in scores on the Beck Anxiety Inventory (BAI), a widely validated instrument for measuring anxiety severity at 20 weeks, measured at 20 weeks — 4 weeks after the completion of the intervention or GP care.
A BAI score of 0 to 7 indicates minimal anxiety, 8 to 15 denotes mild anxiety, 16 to 25 refers to moderate anxiety, and 26 to 63 reflects severe anxiety.
Complete data were available in 31 patients in the lifestyle group and 36 patients in the GP group.
[b]Durable Effect [/b]
At the 20-week assessment, results showed a significant improvement in BAI scores. Mean scores decreased from 29.5 to 9.2 in the lifestyle group, whereas scores were reduced from 29.4 to 17.2 in the GP group ([i]P[/i] < .001).
At 10-month follow-up, scores continued to be superior in the lifestyle cohort; however, the differences between the 2 groups were not significant. Scores were 13.3 and 16.4 for the 2 groups, respectively ([i]P [/i]= .167).
Dr. Lambert pointed out that relapses in the lifestyle group at 10-month follow-up may have occurred because the study did not include maintenance appointments.
"We believe that if patients continued to see the occupational therapist at regular intervals after the 16-week intervention, the relapse rate might have been lower," he said.
"Thus, our data demonstrate that the lifestyle approach may not be effective over the long term for all patients since about one-third of them returned to their prior lifestyle habits and anxiety patterns," said Dr. Lambert.
However, he added, it’s important to keep in mind that this is also the case with other recommended treatments for panic disorder, such as medication and CBT.
"We should also keep in mind that for two-thirds of patients in the lifestyle arm, favorable changes in BAI scores were maintained at 10-months follow-up and were associated with continued improvements."
According to Dr. Lambert, using lifestyle provides patients with a rational explanation for some of the symptoms they experience.
"If lifestyle changes are accompanied by a strategy to reduce the impact of these symptoms, then the fear of the panic symptoms disappears. Regaining control at a personal level by itself reduces anxiety, and developing positive lifestyle behaviors also has broader health benefits for general as well as mental health," he said.
Finally, Dr. Lambert emphasized that although the lifestyle intervention was implemented by occupational therapists in this study, further research may identify a role for other health care professionals in this regard.
"Hopefully, research like ours will have an influence on NICE treatment guidelines for panic disorder," he said. "At the moment, lifestyle is not given due consideration in treatment guidelines."
[b]Current Guidelines Flawed [/b]
Stuart Montgomery, MD, PhD, emeritus professor of psychiatry at Imperial College in London, UK, told [i]Medscape Psychiatry[/i] that studies evaluating new treatments for panic disorder, like other psychiatric and nonpsychiatric disorders, are always invaluable. What’s more, current NICE guidelines are deeply flawed.
"We always need new treatments, preferably ones that are better, easier to use, more patient-friendly, and those things are all obvious," he said.
"The NICE guidelines are probably the worst guidelines in the world because they ask us to use a generic cheap drug with limited evidence of efficacy — at this moment, they are pushing citalopram — as first-line treatment for all depression and anxiety disorders, and there is no evidence that citalopram is effective in panic disorder," said Dr. Montgomery.
"It may or may not be, but it’s never been tested for this use. So the idea that guidelines recommend using a drug for an unlicensed off-label indication as official government policy is to make a mockery of evidence-based medicine. “
[i]Dr. Lambert and Dr. Montgomery have disclosed no relevant financial relationships.[/i]
European Psychiatric Association (EPA) 18th European Congress of Psychiatry: Abstract 768. Presented February 28, 2010. [/size][/font]