Establishment of Integrated Diagnosis and Treatment and Whole-Course Management Model of Major Depressive Disorder

Huai ZHANG, Xiong CHEN, Chunqi AI

Mental Health Center, Taihe Hospital (Hubei University of Medicine), Shiyan 442000, China

Abstract Integrated diagnosis, treatment and whole-course management model of major depressive disorder (MDD) is an integrated drug-psychological-physical comprehensive treatment model based on rapid biological-psychological-social evaluation for treating patients with major depressive disorder. This paper comprehensively evaluates the clinical efficacy and biochemical indexes of patients, and carries out symptom evaluation, problem classification, disease diagnosis and etiological analysis of visitors from the three dimensions about physiology, psychology and society. Then, according to the symptoms and causes of different dimensions, this paper formulates personalized drug, psychological and physical therapy programs, and constantly optimizes and adjusts the treatment plan in the treatment process, so as to cure both the symptoms and the root causes, providing a reliable strategy for the treatment of clinical MDD, and establishing a standardized characteristic model for further promotion and application of this technology. At present, the project has been used in the member units of Taihe Medical Group and Shiyan City and its surrounding areas, the market response is good, and will be gradually promoted to the whole country in the later stage.

Key words Major depressive disorder, Integrated therapy, Whole course of disease, Management model

1 Incidence and background of major depressive disorder

Depression is a kind of mood disorder or affective disorder disease with the core symptoms of low spirits, lack of interest and hypodynamia, which is characterized by high illness incidence, high recurrence, high disability possibility and high death rate[1]. Major depressive disorder (MDD) is a common and complex mental illness. The main symptoms include depression, despair, anxiety, apathy, autonomic nervous system symptoms, cognitive impairment and, in some cases, delusions and suicidal ideation. An epidemiological survey in the United States shows that the lifetime prevalence of depression can reach 16.2%, making it the fourth largest disease in the world[2-4]. It is a refractory disease (treatment-resistant depression), and drug treatment is ineffective or has little effect for about 30%-60% of patients[5]. In addition to antidepressant therapy, psychotherapy and cognitive behavioral therapy, there are also electrical stimulation in the treatment of major depressive disorder, including modified electroconvulsive therapy (ECT), transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), epidural electrical cortex stimulation (EECS) and deep brain stimulation (DBS).

2 The research progress in the treatment of major depressive disorder at home and abroad

The treatment of major depressive disorder (MDD) is one of the thorny problems in psychiatry, mainly because of its poor drug response and high refractory[11]. At present, the main treatment methods for patients with major depressive disorder are increase of original drug dose, replacement strategy, combined treatment and so on. Drug therapy is still the main treatment, and selective serotonin reuptake inhibitor (SSRI) has become first-line drug for clinical treatment of depression because of its stronger selectivity to serotonin transporter[12]. Studies have reported that the remission rate of escitalopram in SSRI drugs for major depressive disorder is only 55.00%-60.61%[13]. Domestic scholars reported that the effective rate of using SSRI drugs alone in the treatment of major depressive disorder was 9.09%-36.00%[14-15], and nearly 33.3% of the patients stopped the treatment of antidepressants in the first month of treatment[16], mainly due to their poor drug response and high resistance. The treatment strategy for patients with major depressive disorder is to increase the dose of the original drugs and course of treatment, switch to other antidepressants, combine with other antidepressants, add synergists and non-drug treatments. As the treatment of major depressive disorder is carried out on the basis of a sufficient course of treatment, increasing the dose of the original drug and course of treatment will aggravate the side effects of patients to a great extent. At the same time, it will reduce the compliance of patients and affect the curative effect, and switching to other drugs may cause patients to lose their confidence in the treatment, so most scholars[17]recommend that changing a medical prescription be considered only on the basis that the original drugs are completely ineffective. If the original drug is partially effective, combination therapy or synergist should be considered first.

Physiotherapy is also an alternative. Foreign researchers believe that modified electroconvulsive therapy (MECT) is a more safe, effective and ideal treatment. It has been reported that[11]the effective rate of MECT in the treatment of major depressive disorder can reach 90%, especially in patients with severe suicidal tendency. If there is no contraindication of electroconvulsive therapy, MECT should be the first choice. And electroshock has been proved to be more effective than drug therapy in the acute phase, and can be used as an effective treatment for major depressive disorder[18]. Huang Haifengetal.[19]treated 41 patients with major depressive disorder using MECT for 12 weeks, and the total effective rate was 90.2%. Jiang Xiangzhietal.[20]treated 48 patients with major depressive disorder using MECT for 4 weeks, and the effective rate of 60% was significantly better than that of 17.4% in the control group. Based on magnetic resonance spectroscopy (MRS), Michaeletal.[15]found that glutamate in the corresponding brain region of 12 patients with major depressive disorder increased significantly after effective electrotherapy, indicating that electrotherapy can change the metabolic state of the brain region to achieve the therapeutic effect. Then Michael observed an increase in the content of N-acetylaspartate, which represents the activity and function of neurons, in the corresponding brain regions of 28 patients with major depressive disorder after effective electrotherapy, suggesting that modified electroconvulsion has neurotrophic effect.

3 Discussion on the establishment of integrated treatment and whole-course management model of major depressive disorder

The integrated treatment and whole-course management model of major depressive disorder holds that the occurrence and development of any psychological problems and diseases are the result of the interaction between "physiological-psychological-social" factors. Therefore, symptom assessment, problem classification, disease diagnosis and etiological analysis should be carried out from the three dimensions of physiology, psychology and society. Then, according to the symptoms and causes of different dimensions, we should formulate personalized drug, psychological and physical therapy programs, respectively, and constantly optimize and adjust the treatment plan in the process of treatment to cure both symptoms and root causes. The first step in the "integrated treatment and whole-course management model of major depressive disorder" is based on ICD-11 and DMS-5, and the Taihe Emotional Index (THEI) Rapid Assessment Scale independently developed by Taihe Hospital in Shiyan City, comprehensively considering the results of clinical symptoms, course of disease, neurobiological examination and psychological evaluation, combined with the rich clinical experience and professional knowledge of the mental health center team to finally evaluate and diagnose the psychological problems, and clarify the psychological problems of the visitors. Comprehensive treatment can cure both the symptoms and the root causes. Drugs and physiotherapy such as rTMS, MECT, EEG biofeedback, acupuncture and moxibustion can quickly help visitors control symptoms and relieve pain. Medium-and short-term psychotherapy and counseling can enable visitors to learn some ways to deal with stress events. Medium-and long-term psychotherapy and counseling can help visitors and their families improve their personality, accept and tolerate each other, and master the ability to maintain a healthy mental state and a happy life. All psychological problems are caused by a variety of biological-psychological-social factors. Susceptibility factors such as heredity, growth experience and primary family are like seeds planted at the bottom of your heart. Over time, all kinds of acute and chronic stress events in the family and workplace are like chemical fertilizers, catalyzing the growth of these seeds into twisted branches that you don’t expect. As long as you master the method of self-regulation, or seek the help of professionals, you can still let the tree of life grow according to the law.

It is impossible to cure 100% of any psychological problem without relapse. Our clinical cure is mainly to improve the symptoms, improve the quality of life and reduce the probability of recurrence. The "integrated treatment and whole-course management model" is based on the "bio-psycho-social" comprehensive diagnosis model to give patients with major depressive disorder a scientific "drug-psycho-physical" comprehensive treatment. This greatly improves the clinical cure of major depressive disorder and reduces the risk of recurrence of MDD, while continuing to help patients and their families learn to maintain a healthy mental state and maintain a happy life. The "integrated treatment and whole-course management mode" constantly evaluates and optimizes the treatment plan in the course of treatment.

The specific mode of operation is as follows: (i) The first stage (1-3 weeks). Stage goal: to relieve acute stress symptoms, improve mood and sleep status, relieve psychological stress, and eliminate physical discomfort. SSRI drugs and psychotherapy methods such as crisis intervention, delayed exposure and focus solving were selected, and physiotherapy such as MECT, repetitive transcranial magnetic stimulation, music relaxation training, EEG biofeedback and acupuncture were selected. (ii) The second stage (4-6 weeks). Stage goal: to solve practical problems or improve symptoms, and combine with drug, physical and psychical therapy to improve the overall efficacy. Drug therapy, cognitive behavioral therapy, interpersonal therapy and other psychotherapy were continued to be selected, and physical therapy such as music relaxation training and EEG biofeedback were selected. (iii) The third stage (6-8 weeks). Stage goal: to fully restore social function, improve personality, promote physical and mental health, and prevent relapse. The side effects of drugs were observed, drugs were gradually discontinued, and psychological counseling intervention methods such as psychodynamic therapy, career planning, emotional guidance of marriage and love and physical therapy such as music relaxation training and EEG biofeedback were selected.

4 Conclusion

In the past three years, a team of experts from the Mental Health Center of Shiyan Taihe Hospital, have established a characteristic "integrated treatment and whole-course management model of major depressive disorder" based on the "bio-psycho-social" comprehensive diagnosis model, combined with the international diagnostic standards for mental disorders (ICD-11 and DMS-5), as well as the advanced "drug-psycho-physical" comprehensive treatment model. Previous studies[21-28]have been reported in detail. This characteristic technology adopts the model of integrated health therapy and whole-course management to treat patients with major depressive disorder, which has achieved good results, and provides a reliable strategy for the treatment of clinical MDD. At the same time, we summarize and actively improve the characteristic technology in order to further popularize and apply this technology.