中国生态环境现状

一例社交焦虑障碍患者的循证治疗姓名钱洁学号00 [病例]患者,女性,26岁.在一家外资企业工作,虽然业务工作表现尚可,但几乎从不参加聚会,吃饭和集体外出,每次皆找借口而回避.患者自中学时代便有不和群,不善交际,过度内向,怕见陌生人和害怕被注目.经常会脸红,曾被同学戏称为”害羞女生”.近三个月来症状明显加重,因为被提升为经理秘书经常要参加会议,文字准备工作较多,但患者发现在做记录写字或电脑打字时都会手抖,怕被人注意,经常要找借口请假不参加会议.为此,患者痛苦不堪.[评估患者情况并提出问题]该患者在社交场合显著持久的怕被人审视,在该情景中会焦虑,有明确的回避行为,这种症状自中学时代就有,近三个月来加重,符合CCMD-3的诊断标准,为典型的社交焦虑障碍患者.目前社交焦虑障碍的治疗主要分为心理治疗和药物治疗.心理治疗有认知行为疗法,森田疗法等,药物治疗有抗焦虑药,单氨氧化酶抑制剂,SSRI..以及两个相结合治疗.针对该患者的情况,提出以下问题:1).该种患者应该首选何种治疗方式?哪种效果更优? 2)药物治疗与心理治疗相比较在长期有效性与复发的问题上,何者更优.[文献证据检索]文献检索资源:数据库: Pubmed; The Cochrane library检索主题词: Phobic Disorders, social phobia, social anxiety disorder[检索结果]Pubmed中主题词检索Phobic Disorders,选中副主题词therapy和drug therapy.检索式为: (social phobia and drug therapy) AND systematic[sb]共检出31篇,以下4篇紧密相关.1. Psychological and pharmacological treatments of social phobia: a meta-analysis.J Clin Psychopharmacol. 2001 Jun;21(3):311-24. , .PMID: [PubMed - indexed for MEDLINE]2. Pharmacotherapy for social phobia.Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001206. Review.PMID: [PubMed - indexed for MEDLINE] , , .3. The evidence-based pharmacological treatment of social anxiety disorder.Int J Neuropsychopharmacol. 2003 Dec;6(4):427-42. Review. , , , .PMID: [PubMed - indexed for MEDLINE]4. Pharmacological treatment of social anxiety disorder: a meta-analysis.Depress Anxiety. 2003;18(1):29-40. , , , , , , .PMID: [PubMed - indexed for MEDLINE]Cochrane Library简单检索:social phobia共检出5篇,其中一篇相关.1. Psychological and pharmacological treatments of social phobia: a meta-analysis.J Clin Psychopharmacol. 2001 Jun;21(3):311-24.PMID: [PubMed - indexed for MEDLINE]为Pubmed中的第一篇.[评价证据]1.2001年, .的”社交焦虑障碍的心理治疗和药物治疗”的Meta分析中,对十一种治疗方法做了比较:完全对照组,药物安慰剂对照组,苯二氮卓治疗组,SSRI治疗组,单氨氧化酶抑制剂,注意力安慰剂组,暴露疗法组,认知治疗组,暴露加认知治疗组,社交技巧训练组,放松治疗组.得出的结论是:治疗社交恐怖症始终有效的是药物治疗,SSRI与苯二氮卓同样有效,且受试者退出率与其他组无显著差别,耐药性由于没有足够的随访数据的药物研究而无法评估,而心理治疗组虽然效果中等,但是随访长期效果好,疗效在治疗结束后仍然起作用.相比较之下, SSRI与苯二氮卓对与治疗社会恐怖症是有效的,至少在短期疗效显著.2.2004年等的一篇题为”社会恐怖症的药物治疗”的综述,主要以评估社会恐怖症药物治疗是否比其他治疗方法更加有效为目的做了分析.得出结论:分析后证据指出,与其他治疗方法相比较,药物治疗的短期疗效是肯定的,尤其是SSRI的疗效非常显著.并且,数据肯定了对药物治疗有效的受试者的长期效果.3.2003年, 等的一篇综述题为:社交焦虑障碍的询证基础上的药物治疗对发表的安慰剂对照研究和Meta分析做了研究.提出了三个问题:社交焦虑障碍的第一线药物是什么?治疗疗程应为多久?当有抗药性的情况出现应当如何处理?分析指出:SSRIs对大多数患者来说应为第一线药物,而对于治疗的最适疗程没有足够的可用信息.然而数据倾向于12-20周后停药的病人比继续接受治疗的更加容易复发.无足够实验室证据指出抗药性的病例的处理办法.临床经验显示SSRI无效的患者可能对大剂量的地西泮或者加巴喷丁有效,或者转用MAOIs, RIMAs, 地西泮或者加巴喷丁.另外,认知行为治疗可能是有帮助的.4.2003年, ,等的一项题为:社交焦虑障碍的药物治疗的Meta分析中,重点研究了药物治疗中各个药物间的疗效差异,得出结论,药物治疗有效依次为苯乙肼, 氯硝安定, 加巴喷丁, 溴法罗明,SSRI.这些药物间的疗效差别无统计学意义.但是,正规的方法分析有明显的证据支持SSRI和溴法罗明有明显的优势疗效.另外,在稳定性,安全性疗效和耐药性等多方面都显示支持SSRI作为第一线药物.[回答问题]问题1) 该患者应首选药物治疗还是心理治疗?第一篇文章中明确指出: :治疗社交恐怖症始终有效的是药物治疗,并且与心理治疗做了对照研究.综合以上四篇文献分析,各项证据都指向于首选SSRI类药物作为第一线药物,对这类药物的疗效耐药性安全性都有一定的肯定.并且有对照研究表明,药物的疗效要优于心理治疗疗效.故对该病人而言,可以首选SSRI类药物.问题2) 药物治疗与心理治疗相比较在长期有效性与复发的问题上,何者更优.?第一篇文章中指出: 心理治疗组虽然效果中等,但是随访长期效果好,疗效在治疗结束后仍然起作用.但纵观以上文献摘要,药物治疗的长期有效性及复发的问题没有明确的结论,与心理治疗相比较没有数据明确支持何者更优.但是心理治疗的效果与安慰剂组相比也是有效的. [制定用于患者的方案]首选SSRI类药物治疗,可以以心理治疗作为辅助治疗.[效果评价][摘要]摘要1. A meta-analysis of psychological and pharmacological treatments for social phobia was conducted to evaluate whether the various treatments differ in their efficacy for treating social phobia, whether they are more effective than wait-list and placebo controls, whether rates of attrition differ, and whether treatment gains are maintained at follow-up. A total of 108 treatment-outcome trials for social phobia met inclusion/exclusion criteria for the meta-analysis. Eleven treatment conditions were compared: wait-list control, pill placebo, benzodiazepines (BDZs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, attention placebo, exposure (EXP), cognitive restructuring (CR), EXP plus CR, social skills training, andapplied relaxation. The most consistently effective treatments for social phobia were pharmacotherapies. BDZs and SSRIs were equally effective and more effective than control conditions. Dropout rates were similar among all the active treatment conditions. Assessment of the durability of treatment gains for pharmacotherapies was not possible because an insufficient number of drug studies included follow-up data. The treatment gains of psychological therapies, although moderate, continued during the follow-up period. BDZs and SSRIs seem to be effective treatments for social phobia, at least in the short term. Recommendations for future research include assessing the long-term outcome for pharmacotherapies and evaluating the inclusion of a cognitive-behavioral treatment during the drug tapering period.摘要: Social phobia (SP), or social anxiety disorder, is a prevalent and disabling disorder. There is growing evidence that SP is mediated by specific neurobiological factors, and increased interest in the use of medication in its treatment. OBJECTIVES: To assess the effects of pharmacotherapy for Social Phobia, and to determine whether particular classes of medication are more effective and/or acceptable than others in its treatment. SEARCH STRATEGY: Studies of the pharmacotherapy of SP were identified using literature searches of the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2004), MEDLINE (1966 to 2003) and PsycLit (1966 to 2003). In addition, published and unpublished RCTs were requested from SP researchers and pharmaceutical companies and additional studies of any language were sought in reference lists of retrieved articles. SELECTION CRITERIA: All RCTs of the pharmacotherapy of SP were considered for the review. DATA COLLECTION AND ANALYSIS: The quality of selected RCTs was independently assessed by 2 raters on the CCDAN Quality Rating Scale, with the same raters collating data on treatment response and SP symptom ratings. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class (SSRIs - selective serotonin reuptake inhibitors; MAOIs - Monoamine oxidase inhibitors; RIMAs - reversible inhibitors of monoamine oxidase A), from which dichotomous and continuous measures were calculated, heterogeneity was assessed, and subgroup/sensitivity analyses undertaken. MAIN RESULTS: 36 RCTs of a range of medications were included in the analysis (4268 participants), of which 26 were short-term (14 weeks or less). A funnel plot provided evidence of publication statistics for responder status (assessed using the Clinical Global Impressions scale change item (CGI-C)) from 25 short-term comparisons demonstrated superiority of various medication agents over placebo (relative risk of non-response (RR) = ; 95% CI = , ; random effects model). Response to treatment by serotonin reuptake inhibitors (N = 11; RR = ; 95% CI = , , MAOIs (N = 3; RR = ; 95% CI = , and RIMAs (N = 6; RR = ; 95% CI = , supported the value of these agents. However, the SSRIs were significantly more effective than the RIMAs (Deeks' stratified test of heterogeneity (Deeks 2001): Qb = ; p < .Summary statistics for SP symptoms from 16 comparisons using the Liebowitz Social Anxiety Scale (LSAS) showed a statistically significant difference between medication and placebo (weighed mean difference = , 95%CI = , , with this effect once again most evident for the SSRIs. Medication was also significantly superior to placebo in reducing SP symptom clusters, comorbid depressive symptoms, and associated disability. The value of long-term medication treatment in treatment responders was supported by 3 comparisons from maintenance studies (relative risk of non-response = ; 95% CI = , and 5 comparisons from relapse prevention studies (relative risk of relapse = ; 95% CI = , .REVIEWERS' CONCLUSIONS: This review provides evidence that medication can be effective in treating SP over the short term, with the strongest evidence of treatment efficacy observed amongst the SSRIs. Furthermore, the data support continued pharmacotherapy in medication responders over the longer-term. Nevertheless, the possibility of publication has to be acknowledged. Additional issues for future research include the use of medication in children and adolescents with SP, and in SP with comorbid psychiatric disorders.摘要3. Social anxiety disorder (SAD) is a highly prevalent and often disabling disorder. This paper reviews the pharmacological treatment of SAD based on published placebo-controlled studies and published meta-analyses. It addresses three specific questions: What is the first-line treatment of SAD? How long should treatment last? What should be the management of treatment-resistant cases? Based on their efficacy for SAD and common comorbid disorders, tolerability, and safety, SSRIs should be considered as the first-line treatment for most patients. Less information is available regarding the optimal length of treatment, although individuals who discontinue treatment after 12-20 wk appear more likely to relapse than those who continue on medication. Even less empirical evidence is available to support strategies for treatment-resistant cases. Clinical experience suggests that SSRI non-responders may benefit from augmentation with benzodiazepines or gabapentin, or from switching to MAOIs, RIMAs, benzodiazepines or gabapentin. Cognitive-behavioural therapy may also be a helpful adjunct or alternative.摘要4. Placebo-controlled trials have evaluated the efficacy of several medications in the treatment of social anxiety disorder but information regarding their relative efficacy is lacking. We compared the efficacy of medications systematically studied for the treatment of social anxiety disorder using meta-analytic techniques. The methodology included a database search of articles published between January 1980 and June 2001 and manual searches of bibliographies in published manuscripts. Trials were included if they reported outcome data on the Liebowitz Social Anxiety Scale (LSAS) or a categorical measure of responder status. Data were extracted independently by two authors. The Q statistic was used to assess homogeneity across trials. All analyses were conducted using intent-to-treat data. There was substantial heterogeneity across trials. The medications with largest effect sizes were phenelzine [effect size, ; 95% Confidence Interval (CI), clonazepam (effect size, ; 95% CI, gabapentin (effect size, ; 95% CI, brofaromine (effect size, ; 95% CI, and the selective serotonin reuptake inhibitors (SSRIs; effect size, ; 95% CI, There were no statistically significant differences between medications or medication groups. However, formal methods of interim monitoring adapted for meta-analyses suggested strongest evidence of efficacy for SSRIs and brofaromine. Several medications are efficacious for the treatment of social anxiety disorder. The stability of the SSRI effect size estimate in conjunction with other evidence for safety and tolerability and their ability to treat comorbid conditions supports the use of SSRIs as the first-line treatment. Direct comparisons of SSRIs vs. other promising medications deserve consideration. Copyright 2003 Wiley-Liss, Inc.。