Depression is one of the diseases that most destroys and consumes the human will, and its impact on human economic, social and spiritual life is catastrophic.

However, to date, the understanding of depression in the world is very rudimentary. The pathogenesis, treatment pathway, and prevention and prognosis of depression are still a black box. For depression in various countries around the world, at most, it is symptomatic treatment, far from treating the cause, and it is still in the stage of experience and exploration.

Depression is getting closer and closer to people. Understanding depression and treating depression scientifically is the premise of depression treatment and rehabilitation. To this end, I had a conversation with Jiang Tao, the chief doctor of Beijing Anding Hospital, who specializes in the clinical treatment of mental diseases.

cognition

The pathogenesis of depression and the path of drug treatment for depression are still very vague.

You have been treating mental illness for 24 years, do you feel that the number of people with depression is increasing over the years?

This is a significant increase from before. There are two reasons: one is that the diagnostic criteria for schizophrenia have changed, in the past, the diagnostic criteria for schizophrenia were too broad, and the diagnostic criteria for depression and mood disorders were too strict. Second, the incidence of depression has indeed increased year by year in recent years, at a rate of about 10%.

Why is the incidence of depression increasing year by year?

This is related to the high pressure of social competition and the fast pace of life. Depression is much more closely related to the external environment than schizophrenia.

Does competitive pressure, the pace of life itself, cause depression?

No. Depression is the result of a combination of factors, including genetic, personality and social factors. The determinants are actually biological factors, i.e., genetic factors. Studies have shown that depression is 80% heritable, which means that if you carry the gene that causes the disease, you are 80% more likely to develop it.

So, if you have a family history of genetic defects; In addition, if you have a depressed personality and a stressful environment, you may have depression if you encounter any big stimulus.

There are also people who suffer from depression and cannot find any cause. There is no family history, there is no stress in life, and the personality is very good. That could be a genetic mutation.

How can you tell if a person has a depression gene?

It's hard to judge, because the genes for depression can't be determined. At present, the understanding of depression has not been able to penetrate into the cells, and only stays in the category of phenomenology.

But current research has proven that mental illnesses, whether depression, bipolar disorder, or schizophrenia, are related to neurotransmitters in the brain.

Yes. In the first half of the 20th century, researchers obtained the brains of some people who committed suicide with depression and found that the concentrations of three neurotransmitters (5-HT, norepinephrine, and dopamine) were lower than normal. These three neurotransmitters are very useful because their function is to transmit information between brain cells, and they are responsible for a person's emotions, will, desires, emotions, and so on.

If there are more or less of these three neurotransmitters, it can manifest as depression, bipolar or schizophrenia, and other brain disorders.

However, this is still only a description of the phenomenon. Correlation does exist, but why it is unclear. The pathogenesis of depression is complex, and there are only a few hypotheses, which are supported by some research results, but these hypotheses sometimes contradict each other or even deny each other.

There is now a tendency to think that depression is a heterogeneous group of disorders with different etiologies and pathogenesis, rather than a single disease. Each of them has its own causes and mechanisms, and there is no single cause or mechanism to explain them.

Can you see clearly through an instrument such as a microscope?

This thing is too microscopic, and it is actually in the organelles of central nervous cells. It changes in the mitochondria, endoplasmic reticulum, and nucleus. There are no instruments to observe it yet.

Slow progress in this area?

The United States did a "brainstorming" 10 years ago, specializing in the nervous system, invested a lot of money, and in the end did not achieve any creative results.

What about China?

Compared with developed countries, China's research progress in this area is poorer.

Some people say that what humans know about the brain is only the tip of the iceberg. Is this realistic?

Right. I also heard a saying: there are 10 billion brain cells in the human brain, and there are 10 billion stars in the universe, but at present, human beings know far less about the brain than they know about the planets of the universe.

In other words, our research on the pathogenesis of depression and our understanding of the path of drug treatment for depression are still very vague?

Let me use another analogy: diabetes is also difficult to treat, if the understanding of diabetes in contemporary medicine has reached the modern era, the understanding of brain diseases may still stay in BC.

diagnosis

If you draw a spectrum for mental illness, then depression is on the far left, schizophrenia is on the far right, and bipolar disorder is in the middle. From left to right, more and more detached from society.

If the medical understanding of depression is still so rudimentary, then isn't the treatment uncertain? For example, the first step, how to diagnose?

Diagnosis is a real challenge. The diagnosis of psychiatric diseases cannot rely on laboratory tests and instruments, but mainly on consultation. Consultation, on the other hand, is highly subjective. For example, if there is a doctor who has suffered from depression himself, he may subjectively perceive many people as depressed.

Depression and anxiety, bipolar disorder, and schizophrenia are sometimes difficult to diagnose because of the intersection of symptoms. If misdiagnosed, treatment can be counterproductive.

Before the knowledge of depression was popularized, about 20% of patients with depression were misdiagnosed as schizophrenia due to hallucinations and delusions. After the awareness of depression is improved, bipolar disorder depressive episodes are easily misdiagnosed as unipolar depressive episodes, which is commonly referred to as depression.

Bipolar disorder is a mood disorder that has both manic or hypomanic episodes and depressive episodes since onset. Although it and depression are both mood disorders, they differ significantly in terms of treatment principles.

The suicide rate of bipolar disorder is higher than that of depression, and if it is treated according to depression, it is difficult to treat because of resistance to antidepressant drugs; Second, after the depression is relieved, it will lead to a turn to mania, and the frequency of the onset will be significantly accelerated. The more frequent the attacks, the more difficult it is to treat, and the higher the risk of suicide.

What are the principles for a correct diagnosis?

Start with a detailed medical history. Accurate psychiatric examination, combined with the clinical experience of other similar patients, forms a basically accurate judgment over a long period of time.

For example, people with depression, bipolar, and schizophrenia differ in social interaction and social adjustment and social functioning. A patient with depression is actually closer to a normal person, and when you communicate with him, you can feel that he is very close to a normal person, his thinking is very clear, and his pain experience is also very high; Bipolar disorder has some manifestations that are out of the mainstream, and there will be some psychotic symptoms mixed in; People with schizophrenia basically have no normal thoughts, have terrible emotional expressions, and are completely out of a normal population.

If one were to draw a spectrum for mental illness, then depression was on the far left, schizophrenia was on the far right, and bipolar was in the middle. From left to right, more and more detached from society.

Is there a high misdiagnosis rate?

It should be quite high. Cities like North, Shanghai and Guangzhou have a relatively high recognition rate. In some remote grassroots hospitals, there are many misdiagnoses.

Medication

There are many variabilities in the clinical manifestations of depression, and different drugs have different properties; Different patients have different reactions to the same drug. When selecting drugs, it is necessary to grasp the properties of a certain drug and reasonably evaluate its effect on patients.

Diagnosis is prone to errors, what about medications?

Medication is also complicated. As mentioned earlier, depression is related to the concentration of three neurotransmitters (serotonin, norepinephrine, and dopamine) in the brain. Most of the drugs used to treat depression are developed to target these three neurotransmitters.

The discovery of isoniazid, the earliest drug for the treatment of depression, was purely accidental. At that time, isoniazid was an anti-tuberculosis drug, but when doing drug experiments, it was accidentally found that tuberculosis patients would improve their mood after taking isoniazid. Following this path, the first generation of antidepressant drugs was developed.

To date, antidepressant drugs have been continuously improved and have evolved over many generations. For example, a single class of drugs that act on serotonin is the SSRIs series, which includes six drugs, the most common of which is Prozac; Those that act solely on norepinephrine are called the NE series, such as reboxetine; The single action on dopamine is the DA series, such as bupropion; There are also SNRIs that have dual effects on serotonin and norepinephrine, such as venlafaxine; There are also norepinephrine and specific serotonin antidepressants, called the Nassa series, such as mirtazapine, and so on. Dozens of medicines in total.

If there are not drugs of the same kind or different kinds, they are arranged and combined, and there are more possible options.

What is the difficulty of choosing a drug? With so many kinds of drugs, how to choose drugs and determine the combination?

Depression is characterized by idiosyncrasies, and there is a variety of variability in clinical manifestations; Different drugs have different drug characteristics; The same drug is used in different patients, and the response is also different.

Therefore, it is still difficult for clinicians to choose drugs. It is necessary to grasp the properties of a certain drug and reasonably evaluate its effect on patients.

How to make a comprehensive judgment?

It is important to accumulate more clinical experience and read more clinical evidence-based literature. The more patients you see, the more clinical experience you have. Combined with the theoretical guidance of evidence-based medicine, patients can be divided into several types, and in the long run, some patterns can be found.

With so many medicines, can you say which one is better?

There is no obvious hierarchical relationship, you can choose which, the key depends on the efficacy, tolerability and safety of the drug for patients. As a doctor, you should mainly accumulate clinical experience and accumulate the feeling of medication.

How effective is the drug?

In general, for unipolar depression, the effective rate is still relatively high, close to 70%; In the case of bipolar depression, the response rate of antidepressants alone may be 40 to 50 percent, or even less.

If it doesn't work, what then?

If the antidepressant doesn't respond well or is not well tolerated, a change may be considered.

Dressing changes should be made with special care, carefulness, and various risks should be taken into account. The patient may be very uncomfortable. It is necessary to analyze the situation on a case-by-case basis.

Are there any patients you see who have no effect for two or three months?

Yes, of course. Some patients with treatment-resistant depression have the problem of treatment resistance to many antidepressants, which requires multi-faceted evaluation and judgment, and at the same time, according to the clinical experience obtained, reasonable selection of antidepressant drugs may change the clinical efficacy.

Can you use an instrument to find out which neurotransmitter the patient is missing, and then prescribe the right medicine?

There is currently no such instrument.

Among the types of depression, there is a type called refractory depression. What is the cause of this?

Some are clinically heterogeneous, genetically determined; There are also recurrent attacks caused by improper treatment.

What should I do if I encounter such a patient?

It's very difficult. But as long as you stick to the treatment, it will be more or less effective. However, the efficacy is not good, and the prognosis is poor.

I observe that you like the combination of medications. However, many doctors do not advocate combining drugs, believing that doing so will worsen the side effects of the drugs; And once it works, it is not known which drug works, which will affect the follow-up treatment.

A single form of depression does not require a combination of medications. However, if treatment-resistant depression is treated, the combination may work better. In particular, patients with bipolar depression need to take a combination of drugs. Reasonably prescribed antidepressants can be used for short periods of time on top of adequate use of mood stabilizers. However, SNRIs should not be used because they can stimulate you.

As for the interactions between the various drugs, it is important to note that there is a window period. You should be very clear about the pharmacology and toxicology of the drug, and at the same time have a judgment on the patient's tolerance. You can also ask the patient if he has allergies, if his family members also have depression, what kind of medicine he has taken, and how effective the medicine is. You combine these aspects when you choose your medicine.

It's complicated.

It's not complicated either. For doctors, by accumulating clinical experience and being familiar with the pharmacological characteristics and clinical efficacy of various drugs, they can make all-round judgments.

Many patients are reluctant to take medicine. Someone is carrying it at home. However, there are indeed people who carry it and slowly heal themselves.

Depression is a self-limiting disease, and it is true that some people can get better in a month or two without taking medicine. However, this needs to be observed dynamically, and if left untreated, it is likely to recur after a delay of one or two years, and it will be more severe. Some people, in old age, suddenly suffer from depression. If you ask him carefully, it turns out that he had it when he was in his twenties.

Why do I recur? When will it recur? Is it controllable?

It's uncharted territory. Depression recurrence is related to the activity of neurotransmitter receptors in the brain, as well as the metabolism of transmitters, as well as some processes of intracellular biosynthesis.

Are these agnostic factors?

Yes, many of the doctors who treat depression and other mental illnesses are unknown fields, and it takes a lot of clinical experience to guide the prediction of recurrence. For example, if a patient asks me if I can stop taking the drug in a few years, I can only give a reasonable recommendation based on the progression of the disease, the characteristics of the disease, the response to the drug, and the recovery of social functioning, and I cannot make a hasty decision to stop the drug.

insomnia

Sleep disorders are also a disease. There are many causes and many types of insomnia.

Another important issue with medication is insomnia. Nowadays, there are more and more people with insomnia, what is the relationship between insomnia and depression?

One of the most dangerous predictors of depression is insomnia. Patients with long-term insomnia are at high risk of developing depression.

What are the other dangers of insomnia?

The damage of insomnia to the human body is mainly mental and generally not fatal. However, people with insomnia are in a state of sleep deprivation for a long time, which can cause changes in perception, such as visual field changes, visual hallucinations, decreased digestive and sexual functions, memory loss, temper becoming irritable, personality changes, and can also induce hypertension, coronary heart disease, stroke, diabetes, and in women, it will also lead to dry skin, menstrual disorders and other diseases.

Sometimes, insomnia can also lead to organic diseases and can also weaken a person's immunity.

Many people don't pay attention to insomnia. One is to let it go; The second is to take sleeping pills as long as you have insomnia.

In the long run, this is not possible. There are many causes of insomnia, depression, bipolar disorder, schizophrenia, stress, anxiety, excitement, fear, all of which can cause insomnia. There are also many types of insomnia, some are difficult to fall asleep, some are early awakenings, and some are poor sleep quality.

So insomnia can't just take sleeping pills, which one you get?

Yes, there are many types of medications used to treat insomnia. At present, the commonly used drugs for the treatment of insomnia include sedative-hypnotic drugs, including *** class, benzodiazepines, non-benzodiazepines, and antidepressant drugs. Benzodiazepines alone, there are many drugs with different pharmacological characteristics, such as ***, fludiazepam, nitrazepam, ****, estazolam and so on.

Sleep disorders are also a disease. You can't just take medicine, you have to go to the hospital for treatment, find the cause of insomnia, and prescribe the right medicine.

Hospital, family and society

There are now only 20,000 psychiatrists in China, a shortage of 400,000; Community prevention and control is basically blank. Not only depression, bipolar and schizophrenia, but long-term treatment, prevention and rehabilitation should be done in the community.

Are there many patients in Anding Hospital now?

There are so many that people from all over the country come.

How many patients do you see in a day?

There are about 80 patients per day, and the outpatient hours are more than 8 hours a day. The patient can't finish watching and can't get off work at all.

Why is it so busy?

There is no way, there is now a shortage of 400,000 psychiatrists in China. There are currently only 20,800 licensed psychiatrists. There are a lot of doctors who do this job, but without this qualification, they don't have a license at all.

You have 80 patients a day, and each patient is allocated only a few minutes, right?

There are many patients who simply take medicine, and there are also many patients who come back for a return visit when they are in stable condition, and such patients are relatively fast. In the case of a complex patient at the first visit, a careful medical history is required for at least 15 minutes.

What is the cost of psychiatric treatment in a regular hospital in China?

It's cheap. Chief physician, with the title of professor, 14 yuan for a number; If there is no professor's title, it is 9 yuan; The deputy chief physician is 7 yuan; The attending physician is $5. The price of psychotherapy is lower, and the price of psychotherapy is 40 yuan for 20 minutes in Anding Hospital. In non-public hospitals, it can cost hundreds or thousands of dollars to do psychotherapy at every turn.

As a result, many people with depression do not receive professional treatment.

I have read that in 1990, only 5% of people with depression in China were treated, compared to 35% in the United States during the same period.

In 2003, a survey of Beijing showed that there were nearly 878,000 people with depression in the city's population of 12.78 million at that time, of whom nearly 423,000 were symptomatic.

The best treatment is prevention. What are the difficulties in preventing depression?

In fact, the prevention and control of all diseases should form an online prevention and control system, especially depression.

The effect of treatment is always limited, and it is important for the patient to prevent it himself. This is related to his education level, family concerns, and social concerns. Only by attaching importance to oneself and having family support and social support can we achieve personal prevention and control.

Without a social support system, 90% of patients are not well prevented by the patients themselves.

What is the current state of the social support system?

Social support is insufficient, government investment is insufficient, and public awareness of depression is insufficient.

It stands to reason that there should be three levels of prevention and control for depression. It's not in place right now.

What are the three levels of prevention and control?

It's hospitals, communities, families. Hospitals are only the primary prevention and control, and most of the long-term prevention and control must be done in the community and at home. At present, community prevention and control is basically blank. Not only depression, bipolar and schizophrenia, but also long-term treatment, important prevention and rehabilitation, should be done in the community.

Does it mean that because the prevention and control at the family and community levels are not done well, the pressure at the hospital level is particularly high, so you have to see more than 80 patients a day?

Yes, that's what it means.

If depression is left untreated, or if it doesn't work well, what happens to the event?

One is suicide, and the other is to become chronically depressed. The suicide rate is rising, and there are many unemployed people; The families of patients with depression have been dragged down, the social burden has increased, and the state has also suffered financial losses.

I know that there is a statistic: the total annual cost of depression in China is 51.37 billion yuan, of which 5.62 billion yuan is medical expenses, and in addition to "indirect costs", including the loss of patients who lose their jobs due to illness or have to change jobs.

Premature death due to suicide due to depression also brings financial losses. According to estimates, the indirect loss in rural areas is 4.303 billion yuan, far exceeding the 811 million yuan in urban areas. As for the consequences of chronic depression, it is impossible to calculate.

It is said that the suicide rate is very high among people with depression.

It is difficult to have an accurate estimate of the suicide rate. Anyway, for people with depression, the most important thing to prevent is suicide. There is an imprecise estimate that the final outcome of depressed patients is three thirds: one-third are cured, one-third become chronic, and one-third commit suicide.

What happens to chronic depression?

The patient will continue to be in a state of social maladjustment, with reduced interpersonal functioning and very severe impairment of social functioning. His intelligence may not decline, but his cognitive function has declined significantly, he has lost most of his ability to work, and he stays at home every day and cannot do anything.

This can also be referred to as a mental disability. If there are not one or two such people, the burden on the state finances will be great.

Is it so serious?

Of course. The whole society does not pay enough attention to depression, and does not pay enough attention to it. Even if the patient is close to us, we are not always aware of the problem, and the patient is not treated in a timely manner.

If one were to draw a spectrum for mental illness, then depression was on the far left, schizophrenia was on the far right, and bipolar was in the middle. From left to right, more and more detached from society.