Recently, I have been exposed to several cases in a row, and I have gained some insight into the complexities of the treatment of mental illness.

Some of these cases were cured quickly, while others fluctuated repeatedly or had no effect for a long time. I thought about it and thought that it could be explained by the concept of "treatment window".

Misdiagnosis is inevitable

From the existing medical practice, the effectiveness of psychiatric drugs is obvious. It's like pulling the lamp rope, and with a "click", the light will turn on - taking medicine is equivalent to pulling down the switch, as long as the medicine is in place, the patient's symptoms will naturally be alleviated.

Of course, this requires a series of prerequisites. For example, for the lights to be on, there must be electricity, and the wiring must be unobstructed; In the same way, for patients to take effect, first of all, the medicine should be symptomatic, and secondly, the patient should take the medicine according to the doctor's instructions.

But reality is always much more complex than theory. From what I've observed, a single mental illness is not refractory to treatment. For example, if unipolar depression is severe, symptoms can be relieved in about 6 to 8 weeks with one or two antidepressants (mostly selected in the SSRIs series) according to the plan; Even if you are really lucky, one or two changes to the medicine will always work. It is then maintained for a few months, or it can be clinically cured and enter the tapering phase.

Biphasic is more difficult to treat. Bipolar is difficult to treat first of all because it is difficult to diagnose.

Bipolar is preceded by unipolar depression, and patients rarely experience manic or hypomanic episodes. Many patients do not vaguely recall themselves or have signs of hypomania until years later when they look back on their medical history. About one in five bipolar patients also begins with mania, which in turn can be misdiagnosed as schizophrenia.

Because of this, most bipolar patients are misdiagnosed. Statistics from European and American countries show that bipolar patients take an average of 8 years to be diagnosed. 69% of bipolar patients have been misdiagnosed with unipolar depression, anxiety disorders, schizophrenia, personality disorders, and substance dependence.

Second, bipolar, even if diagnosed, is much more complicated to treat than monophasic. The main reason is that bipolar patients always wander or oscillate between the poles of depression and mania, and if they are combined with depression, anxiety, obsessive-compulsiveness, or personality disorders, addictive behaviors, and various symptoms are mutually restricted, it will be difficult to start with the treatment.

The patient's own condition is also a constraint that cannot be ignored. For example, some patients have poor liver function or high blood sugar, and certain drugs cannot be used; Some patients have a weak constitution and poor tolerance to the side effects of drugs, and their options will be reduced.

The concept of a "treatment window".

From this, I came up with the concept of a "treatment window".

I believe that if a complex mental illness is combined with multiple symptoms and the patient's individual situation is complex, the time and space for treatment will be limited.

This healing time and space may be likened to a window. The treatment window for a single disease is large, and it can be effective no matter how it is treated; For every point in the complexity of the disease, the treatment window is narrowed by one point; To a certain extent, the limited window will be obscured by horizontal and vertical wooden strips, and it will change all the time. The difference between a psychiatrist and a psychiatrist is whether he can seize this fleeting opportunity to throw drugs into the window.

First, he must be able to identify the symptoms as they are (they are often obscure or vague); Secondly, he must grasp the macro picture, consider the whole picture, and deal with various symptoms comprehensively. The main points are indispensable, and the order must not be messed up. Otherwise, they will take care of one or the other, "press the gourd and scoop up" to hedge the treatment effect.

"Historical Records: The Biography of the Marquis of Huaiyin" cloud: "When the time comes, it will not come again." "Timing is the kind of thing that once lost, it will never come back. When it comes to treating mental illness, timing is so important.

For example, the patient's own internal environment, including his or her psychological state, is a variable. If he is in good physical condition and full of vitality, he is better able to tolerate side effects of the drug; The opposite is bad. At this time, the judgment of the treatment window is to look at the range of blood concentration in the patient's body. As long as the concomitant medication does not exceed the upper limit of the treatment window, you can seize the opportunity to use drugs boldly.

Medication is an art

Finally, I use my own example to illustrate this problem:

Two years ago, I had bipolar and was not recognized by the doctor. After half a year of delay, his condition deteriorated, and he fell into deep depression and almost became a state of sub-stupor.

Later, I sought medical treatment from Dr. Jiang Tao, and he guessed that I might be biphasic based on the information that my treatment was ineffective for half a year; And based on my low motivation at the time, I was judged to be deficient in norepinephrine.

So, he first used reboxetine, which has a strong stimulating effect on norepinephrine, with the intention of lifting me up from deep depression, and at the same time testing to see if I would be irritable and bipolar; In order to prevent possible irritability, lithium carbonate is used to prevent accidents. The latter is an established mood stabilizer that is the traditional medicine for the treatment of biphasic and at the same time has a synergistic effect.

I speculate that his consideration at the time should be: if I were biphasic, lithium carbonate would be the escort for reboxetine; If it is not biphasic, lithium carbonate can act as a synergist to assist reboxetine in its work.

After a week, my condition did not improve in the slightest. Jiang Tao judged that I was too depressed, and added the antidepressant sertraline of the SSRIs series to work together. After 10 days, the drug suddenly took effect, and the haze of half a year was swept away. Jiang Tao saw that I was getting better so quickly, judged that I had signs of irritability, and was convinced that it was biphasic, so he immediately adjusted the medication on a large scale, stopped reboxetine, which had made a significant contribution, and halved sertraline; At the same time plus olanzapine depressive mania.

A week later, a new mood stabilizer, lamotrigine, which is biased towards antidepressants, was added to prevent depression from turning too the pressure. Since then, the treatment regimen has stabilized and gradually entered the tapering cycle.

The whole process, the grasp of the treatment window, the priority is clear, and the sequence is orderly; Bearing and turning, such as flowing clouds.

Isn't it that when any technique is cultivated to a certain level, it will be beautiful?

Mental illness is not always bad, and it can have positive meanings. It allows you to stop moving fast, take stock of your life, re-examine yourself and discover yourself, so that you can face the world with more confidence.