Wang Minzhong: Treatment of Patients with Depression and Anxiety in Department of Neurology——Using "Real First-line Drugs" to Help Patients "Reassure" | Big Coffee Interview · Issue 2

Introduction Patients with depression and anxiety are often first diagnosed in the Department of Neurology.
Clinicians have certain differences when treating such patients: some doctors tend to choose common drugs that may have a faster onset in the short term but relatively lack evidence-based evidence; and Some doctors prefer to use first-line antidepressant and anxiety drugs with rich evidence-based evidence alone or in combination.

As we all know, chronic physical diseases such as hypertension and diabetes should give priority to first-line drugs recommended by mainstream guidelines to achieve a balance between efficacy and safety.

Depression and anxiety are also chronic diseases that require long-term treatment and have a heavy burden of treatment.
Drug treatment particularly needs to take into account both efficacy and safety.

"Wide clinical use" may not equate to "real first-line drugs.
"
How to quickly identify depression and anxiety and choose "real first-line drugs" for treatment is a problem of clinical concern and urgent solution.

Against this background, the second issue of "Interview with Big Coffee" invited Professor Wang Minzhong from the Department of Neurology of Shandong Provincial Hospital to share exciting content around the first-line treatment of depression and anxiety.

Expert in this issue, Professor Wang Minzhong, Chief Physician, Shandong First Medical University Affiliated Provincial Hospital ➤ Chief Physician, Deputy Director, Neurology Department, Shandong First Medical University Affiliated Provincial Hospital ➤ Doctor of Medicine, National Second-level Psychological Counselor, Master Student Supervisor ➤ China Standing member of the Psychiatric and Mental Health Branch of the Society of Geriatrics ➤ Associate Dean of the School of Affective Disorder Education (Shandong) of the Neurologist Branch of the Chinese Medical Doctor Association ➤ Chairman of the Neuropsychological and Affective Disorders Professional Committee of the Shandong Association for Cerebrovascular Disease Prevention ➤ Shandong Province Medicine Vice Chairman of the Society of Psychosomatic Medicine ➤ Member of the Shandong Pain Medicine Association and Vice Chairman of the Sleep Disorder Professional Committee and Vice Chairman of the Neurorehabilitation Committee, etc.
➤ Responsible for and participating in many research projects such as the National Natural Science Foundation of China and the Shandong Science and Technology Research Program.
Among them, 4 subjects won the third prize of Science and Technology Progress Award of Shandong Provincial Science and Technology Commission.

Editor of the international magazine "World Journal of Clinical Cases", published 50 papers and compiled 5 professional books.

The following is a transcript of the interview-"Pay attention to the identification and treatment of patients with depression and anxiety" According to your observation, are there more patients with depression and anxiety in the neurology clinic, and what is the approximate proportion of all depressed patients? What are the common sociodemographic and clinical characteristics of this patient group? Among the neurology outpatients, depression patients are often accompanied by anxiety.
The "Guidelines for the Prevention and Treatment of Depressive Disorders in China" pointed out that comorbid anxiety disorders in patients with depression are very common (36.
1%-57.
5%); according to my observations in clinical work, comprehensive Anxious patients may account for about 2/3 of the patients with depression in the hospital outpatient department.

The common sociodemographic and clinical characteristics of patients with depression and anxiety are as follows: They often come to the clinic because of physical discomfort: patients often have dizziness, headaches, fatigue and insomnia, and mistakenly believe that they have a physical disease, so they come to the neurology department for medical treatment.
Some patients will doubt themselves.
With cerebral infarction, some patients suspect that they have intracranial space-occupying diseases and other somatization symptoms such as back pain, palpitation, chest tightness, hyperhidrosis, constipation, etc.

 The patient population covers multiple age stages: the patients are mostly middle-aged and young people, and it occurs in all age stages.

 Poor treatment compliance of patients: Patients often do not understand and do not want to admit their depression and anxiety problems, and are unwilling to take corresponding medications.

 It is easy for patients to stop the drug early, leading to high recurrence rate and difficult treatment: This requires clinicians to fully communicate the condition and expected treatment course with the patient on the one hand, and on the other hand to make appointments for regular follow-up visits and observe the improvement of various symptoms during the treatment Circumstances, effectively control the residual symptoms such as insomnia and anxiety, achieve clinical cure as soon as possible and carry out necessary maintenance treatments to reduce the recurrence rate.

Especially for patients with depression and anxiety symptoms, more attention should be paid to the improvement of their anxiety symptoms.

"Listening + consultation, sorting out the development and outcome of the disease.
" In the busy outpatient work, it is indeed challenging to identify, diagnose and evaluate patients with depression and anxiety in a short reception time.
How to evaluate patients with depression and anxiety? Patients with depression and anxiety come to the Department of Neurology.
The common causes are dizziness and fatigue and other somatization symptoms.
It is not easy to accurately determine the problem of the patient with a clear diagnosis.
This requires the doctor to have a kind of "ignorance" about the patient's disease.
The mentality of accepting patients and obtaining sufficient information can accurately determine the condition of the disease.
Do not "label" prematurely to make a diagnosis.

Only by gaining the patient's full trust and close cooperation can we identify whether it is a purely physical illness, or a comorbid anxiety and depression, or the patient's own psychological, emotional, and emotional problems.

Although anxiety and depression are common, they are difficult to be recognized clinically.

This situation often occurs because the doctor’s thinking only follows the symptoms described by the patient, and does not pay attention to the underlying disease roots behind the related symptoms.
Therefore, doctors in general hospitals need to increase their ability to identify patients’ psychological problems during consultations.
, And have the skills to conduct mental item inspections at the same time when necessary.

First of all, we must listen to the patients.

After receiving the patient, ask about the discomfort first, and then allow enough time for the patient to talk about the condition.
Under normal circumstances, leave at least a few minutes for the patient to talk about the condition after the consultation begins, and try not to interrupt it.

In the listening process, judge the crux of the problem and write down the doubts, and sort out the entire process of the patient's onset, development, diagnosis and treatment, and outcome.

However, intensive listening skills are acquired through gradual training.

Afterwards, a detailed consultation was conducted.

For the aspects that the patient did not say and the doubts found during listening, a hierarchical and step-by-step systematic consultation will be carried out.

Firstly, the consultation is conducted around the main core symptoms, so that the patient will describe in detail the scene before and at the onset of the illness and the inner feelings at the time; secondly, the patient has not explained clearly the onset of the illness, the development and changes of the disease, and the entire process of diagnosis and treatment.
Make clarifications, including consultations for identifying symptoms; finally, ask for psychiatric symptoms.

Considering that anxiety and depression often cause insomnia, you can start by asking whether the patient has symptoms such as difficulty falling asleep and waking up early.
In addition, you can also specifically ask whether the patient is interested in reducing anxiety, anxiety and fatigue, palpitation, chest tightness, and sweating.
Somatization symptoms of autonomic disorders such as abdominal pain, constipation, diarrhea, loss of appetite, etc.

The last step is to sort out.

If the patient has the above-mentioned various discomforts, the physical examination and auxiliary examination results are not consistent with the symptoms, and the patient is excessively worried about his physical health, and is depressed, then the patient may have anxiety and depression problems.

It is necessary to carry out further detailed investigations including whether there is family history, fear, and world-weariness, combined with clues for further inquiry.

From beginning to end, you should maintain a high degree of concentration, and always pay attention to observing the patient's behavior and other body language.

Finally, according to the patient’s syndrome, the severity of the disease and the duration of its existence, it is judged whether it has reached the diagnostic criteria for anxiety and depression.

If the patient’s depressive disorder is more prominent and accompanied by obvious anxiety, it is in line with the diagnosis of depression with anxiety, and it is necessary to judge the respective severity of depression and anxiety.

"The combination of antidepressant and anti-anxiety, both efficacy and safety.
" In your opinion, what kind of drugs with characteristics can be used as the first-line treatment for depression and anxiety in neurology? Many doctors believe that the evidence-based evidence of drugs is not important to the clinic, "it is a first-line drug to use it smoothly.
"
Do you agree with this view? What potential hidden dangers might this view bring? Department of Neurology The first-line treatment of depression with anxiety should choose drugs that can treat depression and relieve symptoms of anxiety.

Single-agent therapy often has a slower onset.
Combining anti-anxiety drugs on the basis of antidepressant therapy is an effective way to achieve better therapeutic effects.

 In clinical medication, Tandospirone is a good treatment choice for anxiety.

Tandospirone is a drug for the treatment of anxiety disorders.
It can effectively relieve anxiety symptoms and has fewer side effects.
Combining antidepressants can achieve good therapeutic effects more quickly, reduce residual symptoms, achieve clinical cure as soon as possible, and prevent recurrence.

The guidelines also recommend that tandospirone can be used as the first-line clinical drug of choice for the treatment of anxiety.

 Affected by medication habits, some clinicians may choose the commonly used medications they used to use before.

However, when treating patients with depression and anxiety, if you habitually choose drugs that treat depression alone, you will sometimes find that the drugs do not clearly improve the anxiety symptoms.
The residual anxiety symptoms make it difficult for the patient to achieve clinical cure, thus reducing the patient's satisfaction with treatment.

In addition, patients with residual anxiety symptoms have a higher risk of recurrence, which has a greater impact on the patients' work and life.

Therefore, for patients with anxiety disorders and patients with severe depression and anxiety, when the efficacy of antidepressant drugs alone is not satisfactory, direct selection or addition of first-line anti-anxiety drugs may be the best choice.

 Clinical practice has also confirmed that drugs with evidence-based evidence and guidelines recommended should be selected first, and drugs with definite efficacy and good safety can be used to obtain better clinical efficacy.

"The advantages and disadvantages of old-brand anti-anxiety drugs" As an old-brand anti-anxiety drug, benzodiazepines are often used alone or in combination with antidepressants to treat anxiety.

Based on your clinical experience, what are the advantages of benzodiazepines in clinical applications? What are the shortcomings of these drugs that limit their clinical application? Traditional benzodiazepine drugs can not only improve anxiety symptoms, but also treat insomnia, and have the advantage of faster onset.

However, benzodiazepines are dependent and resistant, and are only suitable for short-term applications.
They can be used in combination with other drugs at the beginning of the treatment of anxiety.
They can be gradually stopped within 4 weeks after the symptoms are relieved.
It has anti-anxiety effect and can reduce the occurrence of side effects.
Under special circumstances, it is not recommended to exceed 3 months.

"New drugs are increasingly being favored by clinicians to help relieve symptoms and functional outcomes.
" In recent years, the use of 5-HT1A receptor partial agonists such as tandospirone in general hospitals and psychiatric specialists has shown an upward trend.

In your opinion, what are the reasons for the increasing popularity of such drugs in clinical practice? Can you briefly share a case that impressed you briefly-the original study of tandospirone combined with antidepressants to help patients with depression and anxiety obtain ideal symptoms and functional outcomes? Tandospirone is a 5-HT1A receptor partial agonist, which is a new type of anti-anxiety drug.

Tandospirone overcomes the limitations of benzodiazepines, has fewer side effects, has good safety, and has a definite effect.
It can be used for a long time, so as to achieve the purpose of clinical cure and reduce disease recurrence as soon as possible.

In addition, the price of tandospirone is relatively moderate and patient acceptance is high.
In the process of clinical application, whether in general hospitals or psychiatric specialists, it has gradually been recognized by clinicians and welcomed by patients.

 Here is a typical treatment case: A patient who was admitted to the clinic suffered severe psychological problems after being severely hit by social pressures such as job changes and the death of a loved one at the same time, and then showed obvious anxiety symptoms such as excessive worry.
Insomnia and weight loss, unwilling to eat, unable to work normally, and began to worry about my physical condition, went to the hospital many times for many examinations, and suspected that I might be suffering from serious physical diseases such as gastrointestinal tumors.

Later, dizziness, difficulty concentrating, increased insomnia, loss of appetite, and then a more serious depression, decreased interest, and gradually became serious enough to require constant care by loved ones.

He moved to many hospitals and departments, but he did not achieve the ideal treatment effect.

 Later, I came to our neurology department for treatment and considered that it was in line with the anxiety and depression state.
On the basis of the patient's previous application of SSRI antidepressants, combined with tandospirone therapy, the patient's symptoms were quickly and effectively relieved, and 3 medications were used.
Months later, I regained my ability to live on my own, and later returned to work.

After persistent treatment and regular review, the current discomfort symptom disappearance scale test has reached the clinical cure standard, and maintenance treatment is ongoing.

 In this treatment case, we can find that for patients with depression and anxiety, when the application of antidepressants alone cannot achieve a better clinical effect, the combined application of anti-anxiety drugs can effectively control the condition and help the patient return to work more quickly And normal life.

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