抑鬱症圍爐區(5)

我先頭量血壓上壓114 下壓68 係咪正常 可能唔係 低血壓？

我而家係講緊bipolar disorder with GAD喎, 你去睇下CANMET and ISBD 2018 guideline啦， antidepressant for bipolar depression你睇返step-bd啦

你以為用antidepressant 最大問題係manic switching ? 最大問題係long-term instability、rapid cycling, 根據Step-BD, antidepressant with mood stabilizer bipolar depression remission rate係24%, placebo-controlled係27%, lamictal根據gsk 畀人告迫住要放出嚟嘅research, 佢係對所有acute mood episode 冇效, reference係clinical psychopharmacology by S. NASSIR GHAEMI, 再者,用antidepressant 所有藥廠同埋書本,包括stahl prescription guide都只係話cautious, 而且我從來都冇講過係contraindicated

上壓正常,下壓係低，但係未去到低血壓， 不過你有頭暈，所以都係建議你盡早搵醫生檢查

你知唔知psy最緊要係individualized treatment?
佢食完有效冇side effect但係RCT話唔得就話佢都唔食得？
你究竟有冇真係practice過見過真patient
定係睇完RCT side effect prevalence rate同 remission rate 就當自己識曬
psy好多時啲study result 都唔係absolute
最緊要係個patient
SSRI唔得咪轉其他agent
連benzo 係prn用都唔知你真係識？

再講rapid cycling咪姐係switching to maniac
mood stabilizer 係一定要嘅main arm therapy
再加SSRI STEPBD的確話冇用
但係宜家個patient 有GAD再加depressive mood
SSRI 係點都會indicated (SSRI唔係淨係antidepressant, 仲係anxiolytic）
你都識講cautious咁係唔係全錯呀？
自打嘴巴？
連Maudsley都唔識我真係好懷疑你based on 咩profession去judge
同埋呢個世界唔係得STEP-BD㗎
仲有大大小小study用唔同antipsychotics lamotrigine lithium + augmentation with SSRI/SNRI/TCA/Mirtazapine 睇曬未？
patient 食完 Seroquel/Lamictal冇用 咁你又點做？
psy patient 好多時都有好多comorbid condition
佢宜家有GAD同埋somatic weakness 咁你係咪唔醫？
好啦你話pregabalin, 食完冇用咁點？又話SSRI全錯
你叫patient 用regular benzo 去control, 啫係迫佢上癮？
睇多啲trial 同 case report先啦

我幾時有講過我係醫生?
Benzo 一定要PRN, 我諗香港最少有一半psychiatrist routine practice都唔係咁, 你一時又話要individualization, 一時又話要跟guideline, you just can't have it all

再者,一隻藥得唔得係要睇好多個因素, 包括dose( 有時less is more), 食咗幾耐, 同埋究竟係partially responsive定係unresponsive, 咁先會考慮究竟係Augment 定係switch

Maudsley 係講純粹GAD喎, 如果加埋bipolar disorder,我相信佢一定會有唔同嘅睇法

STEP-BD 唔單只係同類型最大嘅研究, 更加係最中立嘅研究,同埋最接近real world, 因為佢唔係好似大多數研究咁係drug company funded, 佢係NIMH funded, n 嘅數目有夠大, 而且基本上冇exclusion, 佢係接受整個bipolar spectrum嘅depressive episode patients, 包括dsm-5所有四種

rapid cycling 同mania有咩分別,我建議你睇番DSM V

bipolar depression 除咗Seroquel (300-600mg)同Latuda(20-120mg), 香港係冇Vraylar, 再講埋畀你聽點解我唔建議OFC, 因為原本Eli Lilly 係擺咗幾百人去Olanzapine for bipolar depression phase 3 trial, 最後fail咗， 點知得幾十人嘅OFC 就成功咗, 因為佢係同類型第一隻藥物成功，所以fda開咗個特例, approved，Seroquel, Latuda, Vraylar 全部都要兩個n等於幾百嘅phase 3 trial先可以得到FDA approval

second line for bipolar depression 其實仲可以用Low dose lithium (300-450mg) lithium 有啲情況下係一隻less is more嘅藥

甚至仲可以試埋MRI guided rTMS

SSRI 已經係喺antidepressant入面最少risk, 但係依然存在, cyclothymia 同 bipolar 1 patient risk係會高啲, bipolar II 反而會低啲, 但係一開頭食完之後會更加焦慮, 之後先會慢慢好, 所以好多醫生一開頭會加埋benzo daily for weeks, eg. Xanax 0.5mg tds, 絕對唔係PRN

你講嘅其他antidepressant 既risk係更加高, remeron 同 TCA 唯一優勝之處就係一開頭唔會增加焦慮, 其實trittico都係

突然變左學術post

我淨係想呻下好攰 但係訓唔著

一堆野睇唔明

依家冇暈，但係個人一坐喺度就好懶，唔係幾想諗野，同好懶

依家冇暈，但係個人一坐喺度就好懶，唔係幾想諗野，同好懶

不如你都係盡快返去你以前個位精神科醫生度覆診啦

屋企人覺得冇問題

我擔心你復發， 聽落有啲似mild psychomotor retardation, 最緊要都係你自己覺得點, 屋企人嗰啲當係耳邊風啦

真係唔想再食返

冇人想食藥,但係如果有需要都要食

食番個雪球又會越滾越大

當然唔會啦, 今次可以揀番一啲容易戒嘅藥物， 藥物絕對唔係洪水猛獸， 係一種幫助， 令到你可以regain psychomotor同埋cognitive functions, 日常生活回復正常

其實會唔會唔關個病事，停藥都會有機會psychomotor retardation

我有呢D症狀會令自己更加焦慮鑽牛角尖，怕自己好唔返

咁就更加應該見醫生去處理

冇可能

有無聽過DPD, 係咪真係有