本帖最後由 goodcat1111 於 2009-9-10 09:27 編輯
作者：Pauline Anderson
出處：WebMD醫學新聞
August 24, 2009 — 一篇新研究發現，由受訓過的治療師提供的即時線上認知行為治療(cognitive behavioral therapy，CBT)，成功治療憂鬱症病患的效果比一般的初級照護好。
隨機控制試驗顯示，接受此介入方式的憂鬱症病患，其恢復的機會是僅接受一般執業醫師提供之一般照護(包括處方抗憂鬱藥物以及支持和諮商)患者的近2.5倍。
第一作者、英國大學社區醫學部臨床講師David Kessler醫師在接受Medscape Psychiatry訪問時表示，此一介入模式可以有效解決失能病患、公共場所恐懼症患者(agoraphobic)、或居住於郊區者、母語非英語者接受治療的問題。
Kessler醫師表示，不過，並非所有的病患都適合接受線上治療。
該文獻登載於The Lancet期刊的全球心智健康(Global Mental Health)特別版。
2005年10月1日至2008年2月29日間，研究者在英國三個中心的55個綜合診所招募18至75歲的病患。憂鬱症的診斷定義為貝克憂鬱量表(Beck Depression Inventory)評分超過14分，使用國際疾病分類第10版(International Statistical Classification of Diseases 10th revision)進行確認。
完成基本的問卷之後，149名參與者被隨機指派到介入組(線上CBT加上執業醫師的一般照護)，另外148人被指派到控制組(列於線上CBT的等候名單，接受一般照護)。
【嚴重憂鬱】
超過三分之二的研究對象是女性，他們的平均年紀為34.9歲。多數研究對象有嚴重憂鬱症；開始時，68%的介入組以及70%的控制組，貝克憂鬱量表評分大於28。
Kessler醫師表示，這些人的問題已經有很長一段時間了。
除了其中4個人，其他人全部都有憂鬱診斷之外的其他精神異常診斷，如廣泛性焦慮異常(generalized anxiety)、恐慌症(phobia或panic disorder)。
該介入方式包括10堂55分鐘的課程，研究對象和治療師藉由線上打字進行溝通。病患在整個試驗中的治療師是同一人。Kessler醫師解釋，這很像是一個和朋友進行的即時訊息對話，在此則是治療師，你打字後治療師會回應，之後你也回覆，就這樣反覆交談。
【維持收穫】
在介入組，113名病患完成4個月的追蹤，控制組完成的有97人。此時，相較於控制組，介入組的病患比較有可能恢復(定義是貝克憂鬱量表評分<10) (38% vs 24%；勝算比2.39；95%信心區間1.23 – 4.67)。這些斬獲維持到在8個月時的第二次追蹤，介入組和控制組的恢復比率分別是42%和26%(勝算比2.07；95%信心區間1.11 – 3.87)。
Kessler醫師表示，在開始時憂鬱症狀越嚴重的病患，介入的效果越大。這很重要，因為有些人認為輕微憂鬱者使用心理治療是可行的，只是效果沒有嚴重憂鬱者那麼好。
線上介入有幾個優於面對面治療的優點。Kessler醫師表示，除了讓不容易接受治療的病患可以接受治療外，對於治療師和病患來說，在計畫接受治療的時間上更有彈性與方便。
雖然研究時的線上介入並未包括Skype或其他影像聊天軟體，Kessler醫師表示，這或許是可以進行後續研究的問題。
【反思片刻】
不過，他表示，是實際寫下他們的想法而不是討論它們會更有幫助。有些認為這可以幫助大家坦然面對。Kessler醫師表示，如果你寫下某些事務，你必須思考並且編輯它；換句話說，就是所謂的反思片刻。
他論及後設認知警覺，或稱之為警覺一個人的思考觀念。Kessler醫師表示，這個觀念是，你跳開自己的想法，並加以檢視。當你憂鬱時，你有時候會有一些糟糕的負面想法，例如「沒有人愛我」，但是當你退後一步想想，可能並非如此。
Kessler醫師表示，研究顯示，經歷過創傷事件的憂鬱病患，可藉由寫下事件而獲得舒緩。他指出，在早期的心理分析，治療師不讓病患直視他們的眼睛。
但是線上治療不適合每個人。Kessler醫師表示，有些人不會使用電腦，有些人不會打字，有些人希望看到對談的人。我不認為我們要假定這個對每個人都有用。
Kessler醫師表示，線上即時治療可適用憂鬱之外的精神疾病，例如焦慮。此外，線上方式可以提供CBT之外的治療方法給病患。
【心理治療率持平】
編輯評論中，資深研究員、團體健康精神科專家Gregory E Simon醫師以及團體健康研究中心的資深研究員Evette J. Ludman博士指出，過去20年，憂鬱症的藥物治療比率大幅增加，而個人心理治療的比率持平，甚至降低。
他們表示，線上治療適用於無法接受經訓練或認證之行為治療師治療的病患，且比較彈性、方便，也可以不用每1到2週才面對面諮商1小時，可以有時間較短但較頻繁的接觸。
他們寫道，這類新的溝通科技可以促成心理治療方面相當需要的變革。傳統治療師可能會擔心病患可隨時選擇上線的、來自海外的認知行為中心或線上聊天中心的電話。但是健康照護提供者的期待可能和證據不同。證據注重在病患的臨床好處與經濟價值，而非提供者的訴求或價值。
作者們宣告沒有相關財務關係。
Online CBT May Be Better Than Usual Care for Depression
By Pauline Anderson
Medscape Medical News
August 24, 2009 — Online cognitive behavioral therapy (CBT), delivered in real-time with a trained therapist, is more effective than usual primary care in successfully treating patients with depression, a new study has found.
The randomized controlled trial showed that patients with depression accessing this intervention were almost 2.5 times more likely to recover than were those receiving only usual care from their general practitioner, which typically consists of a prescription for antidepressants as well as support and counseling.
This type of intervention could go a long way toward solving the problem of access to therapy for patients who are disabled, agoraphobic, or living in a rural area, or whose first language is not English, said lead author David Kessler, MD, clinical lecturer, Department of Community Based Medicine, University of Bristol, United Kingdom, in an interview with Medscape Psychiatry.
However, not all patients are keen to receive online therapy, said Dr. Kessler.
The article appeared in the Global Mental Health special edition of The Lancet.
Between October 1, 2005, and February 29, 2008, researchers recruited patients aged 18 to 75 years with depression from 55 general practices in 3 centers in England. A diagnosis of depression was defined as a score of 14 or more on the Beck Depression Inventory and was confirmed using the International Statistical Classification of Diseases 10th revision.
After completing a baseline questionnaire, 149 patients were randomly assigned to the intervention group (online CBT in addition to usual care from their general practitioner) and 148 to the control group (usual care while on a waiting list for online CBT).
Severe Depression
More than two thirds of study participants were women, and their mean age was 34.9 years. Most study participants had severe depression; at baseline, 68% of the intervention group and 70% of the control group had a Beck Depression Inventory score of greater than 28.
"These are not people who were just off color for a few days," said Dr. Kessler.
In addition to a diagnosis of depression, all but 4 participants also had another psychiatric diagnosis such as generalized anxiety, phobia, or panic disorder.
The intervention consisted of 10 55-minute sessions during which participants and therapists communicated through online texting. Patients maintained the same therapist throughout the trial. "It's like having an instant messaging conversation with a friend, or a therapist in this case, where you type in something and the therapist types in a response, and it's backwards and forwards like that," explained Dr. Kessler.
Gains Maintained
In the intervention group, 113 patients completed 4-months of follow-up, as did 97 patients in the control group. At that time, those in the intervention group were more likely to have recovered (defined as a score of <10 on the Beck scale) than were those in the control group (38% vs 24%; odds ratio, 2.39; 95% confidence interval, 1.23 – 4.67). These gains were maintained at the second follow-up — at 8 months, the rates were 42% for the intervention group compared with 26% for the control group (odds ratio, 2.07; 95% confidence interval, 1.11 – 3.87).
The effect of the intervention was greater in participants with more severe depressive symptoms at baseline, said Dr. Kessler. "This is important because there are some people out there who say that psychotherapy is okay if you've got mild depression but may not be as effective for severe depression."
An online intervention has several advantages over face-to-face therapy. In addition to making therapy available to patients who cannot easily access a therapist, it offers a great deal of flexibility to both therapist and patient in terms of planning convenient times for sessions, said Dr. Kessler.
Although the online intervention in the study did not include Skype or other video chat elements, Dr. Kessler said this might be a topic for future research.
Moment of Reflection
However, he said, actually writing about their thoughts rather than talking about them is more helpful to some people. Some feel that it allows them to be more honest. "If you write something down, you have to think about it and edit it a little bit; in other words, there's a moment of reflection," said Dr. Kessler.
He talked about the concept of "meta-cognitive awareness," or of being made aware of one's thoughts. "The idea is that you stand back from your own thoughts and have a look at them," said Dr. Kessler. "When you're depressed, you sometimes have these awful negative thoughts — for example, 'nobody loves me' — but when you stand back and have a look at that, it may not be quite accurate."
Research shows that people who have experienced a traumatic event get relief when writing about that event, said Dr. Kessler. He noted that in the early years of psychoanalysis, therapists did not allow patients to make eye contact with them.
But online therapy is not for everyone. "Some people can't use computers, some people can't type, some people want to see the person they're talking to," said Dr. Kessler. "I don't think we should pretend for a second that it's great for everybody."
Online real-time therapy could work for psychiatric illnesses other than depression; for example, anxiety, said Dr. Kessler. In addition, the online approach could offer therapies other than CBT to patients, he said.
Psychotherapy Rates "Flat"
In an accompanying editorial, Gregory E Simon, MD, senior investigator and group health psychiatrist, and Evette J. Ludman, PhD, senior research associate, Group Health Research Institute, Seattle, Washington, pointed out that rates of drug treatment for depression have increased dramatically over the past 20 years, whereas rates of in-person psychotherapy "are flat to declining."
Internet-based treatment, they said, could serve patients who have no access to trained or certified cognitive behavioral therapists and offers flexibility, convenience, and briefer and more frequent contacts than 1 hour face-to-face consultations every 1 to 2 weeks.
Such new communication technologies could provoke much-needed innovation in psychotherapy, they wrote. "Traditional therapists might be horrified by the prospect of an overseas cognitive behavioural call centre or live-chat centre, available whenever patients choose. But the expectations of health-care providers are not the same as evidence. And the evidence that matters concerns clinical benefit and economic value to patients, rather than appeal or value to providers."
The authors have disclosed no relevant financial relationships.
Lancet. 2009;374:628–634, 594–595. |
|
