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摘要


近三十年來由於安寧緩和醫療的發展,癌末病人在疼痛和其他症狀的控制上已有長足的進展,然而憂鬱的問題仍存在至少四分之一的病人身上,但是憂鬱症狀幷不等於「重鬱症」。探討癌末病人的憂鬱問題應區分清楚是「調適障礙合幷的憂鬱情緒」或是「重鬱症」。事實上「重鬱症」是一種嚴重影響病人生活品質的疾病,然而其在癌末病人中的診斷却非易事。最主要的困難在於沒有任何生理標記、身體表徵或診斷工具,可用來區辨是「調適障礙合幷憂鬱情緒」或「重鬱症」。 癌末病人的「重鬱症」診斷,必須著重其心理特徵:無助、無價值感、罪惡感、迴避人群、和自殺企圖,而非以生理或認知功能的改變作判斷。基本上,這必須靠醫療團隊高度的臨床敏感度與觀察力和良好的溝通技巧,才能幫助病人表達出內心的想法與感受,否則可能會有評估與診斷上的偏差。 在緩和醫療中,對憂鬱問題的理想處置除心理、社會與靈性的支持外,有時也會考慮到藥物的合幷使用,尤其是對「重鬱症」及疼痛緩解不佳的病人。原則上「調適障礙」以支持性的心理治療爲主,「重鬱症」則可配合抗鬱劑的使用。而抗鬱劑的選用是依據藥物副作用和病人現有的症狀而定。 僅管目前已有安全有效的抗鬱劑,臨床醫護人員在使用上仍有很多疑慮或誤解。事實上,只有很少的癌末病人使用抗鬱劑,而且常因太晚使用,以致沒有足够的時間讓它發揮功效。將來隨著對癌末病人憂鬱問題之身心機轉的瞭解,及其和疼痛之關連的進一步闡明,抗鬱劑的角色應會更加明朗,而當病人預期存活日不多時,精神興奮劑和抗焦慮藥物則不失爲較合宜的選擇。

並列摘要


The advancement in palliative care for management of pain and other symptoms of the terminal cancer patients in the past 30 years prove to be a major development in medicine. Nevertheless, at least a quarter of these patients suffer from depression. But ”depression” is not equal to ”major depressive disorder”. Major depressive disorder is a psychologically illness which will greatly affect ones quality of life. It is, however, not easy to identify whether a terminal cancer patient is suffering from ”major depression” or ”adjustment disorder with depressed mood” in the absence of overt physical signs, biological markers or the diagnostic tools. Therefore, to explore the problem of depression in these patients, we should differentiate them at first. To find out whether the terminally ill cancer patient has the disease of major depression, it should not base on the patient's change in physiological or cognitive function alone. It is important to identify the presence of psychological characteristics that include feeling of helplessness; lack of self worth; guilt; social withdrawal symptoms; and suicidal attempt. Confirmation of diagnosis relies heavily on care providers' sensitivity, alertness, keen observation and a good communication skill to elicit patient's innate feeling and their orbit of thinking. Failure to do so may result in discrepancies in the assessment and diagnosis of depressive illness among the terminally ill cancer patients. In principle of hospice care, psychological, social and spiritual support is the main treatment for all cancer patients with depression. However antidepressants are sometimes taken into consideration especially for patients with ”major depression” or those who have poor pain control. Supportive psychotherapy is mainly for adjustment disorder but it can also be a combined therapy for treating major depression. The choice to antidepressants depends on their side effects and the patient's condition. Although antidepressant has been proven to be safe and effective to use, but it is not uncommon to find clinician and nurses who misunderstand and doubt their usefulness. In fact, antidepressants are only prescribed to the minority among terminally ill cancer patients and in the vast majority of cases at a very late stage when there is insufficient time for therapeutic effect. With better understanding of the mechanism of depression and associations with pain among the terminally ill cancer patients in the future, it is hoped that the antidepressants will then play a much clear role for treatment process. For patients who are living in limited days, the psychostimulants and anxiolytics may be a better choice for them.

被引用紀錄


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