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抗憂鬱劑可能使病人產生自殺意念或自殘行為之爭議

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发表于 15-9-2018 04:41 AM | 显示全部楼层 |阅读模式
本帖最后由 Cherish_Ying 于 15-9-2018 04:43 AM 编辑

朋友患重度憂鬱症,為多了解憂鬱症,我借了憂鬱症的書來看,其中一本醫師寫的書提到:

「美國食品藥品監督管理局(FDA)於九十六年五月公告,所有抗憂鬱劑應加刊「…服藥後可能產生自殺意念或自殘行為…」等警語,特別是24歲以下之青少年,在服用抗憂鬱劑時,應嚴密監控憂鬱症變化,尤其在用藥初期之二個月及停藥階段。

選擇性血清素回收抑制劑(SSRI)抗憂鬱藥劑[1]也有若干副作用,包括病患服用後會有自殺傾向,輕者則出現焦慮、失眠、噁心、頭痛、嘔吐等症狀。在英國,自1990年以來,服用克憂果而自殺的憂鬱症患者已超過五十人。而在美國,聯邦食品暨藥物管理局也要求克憂果藥商在包裝盒加註警語。」(鄭光男2012:54、59)[2]

抗憂鬱劑可能使病人產生自殺意念或自殘行為?我覺得這議題應認真探討,畢竟若是真的,後果嚴重。因此我找了一些文獻來看。先看警語來源的歷史脈絡:

「這是FDA在2004年時,根據藥廠的研究判定,服用某些抗憂鬱劑的年輕人,出現自殺想法與企圖(suicidality)的比例,會從2%增加到4%,因此要求藥廠在仿單裡特別強調這一點。

2007年時,FDA根據更大規模的研究有了以下修訂。小於十八歲,每一千位服用抗憂鬱藥物的病人,會增加14例的suicidality回報。19-25歲,則會增加5例。」(陳豐偉2014)

臨床研究顯示SSRI跟24歲以上成年人的自殺想法和行為沒顯著關係,對65歲以上族群則會減少自殺意念(Mauney 2018)。

據FDA精神病學藥品部門前任主任Dr. Thomas Laughren,FDA加上警語的初衷是:

The FDA’s intention at the time was to quell public fear and to ensure that doctors and patients to have a discussion about risks, and make sure physicians monitored their patients during vulnerable periods, particularly during the first few months when some people get worse before they get better. “The intention was never to discourage appropriate use.” (Sifferlin 2014)

2014年,「哈佛團隊發表在『英國醫學雜誌』(British Medical Journal)的研究認為,在黑盒警示放上藥物仿單後兩年,年輕病人開藥比例減少31%,但被發現的自殺行為多了21.7%,自殺成功人數多了33.7%。研究者將自殺人數增加與黑盒警示做了連結。」(陳豐偉2014)

曾撰文檢討FDA的警示是否恰當的美國TIME,「訪談了十七位精神醫學的重要人士,其中十一位主張撤下黑盒警示,另兩位認為媒體過度渲染、造成不必要的恐慌。贊成保持黑盒警示的四人,有三人曾在2004年參與FDA放上黑盒警示的決策過程。」(陳豐偉2014)

針對FDA對SSRI的警示,台灣和國際皆有不同想法。先看台灣。

鄭光男醫生(2012:61)認為「憂鬱症患者,可以不靠任何藥物治療,就可以好轉。只是看如何選擇。」(有別的治療法,詳見其書)

晶晶藥師(2017)認為:

「由於每個人體質,敏感程度都不相同,醫生開同一種藥你吃沒事,我吃卻反應很嚴重。我想特別提醒病人及照顧他的家屬,有幾個時間點非常需要注意:
一、病患剛開始吃藥的前兩個月。
二、醫生改變劑量的時候,包括增加劑量或減少劑量。
三、換另種藥物,兩藥交替的時間。
雖然藥物副作用很可怕,但民眾絶不可以自行冒然停藥,因為那更加危險。台灣有不少醫生願意幫助病患逐漸減藥,而且減藥過程中,會讓病患補充足量的營養食品,這種做法會緩解非常多減藥帶來的不適,而病患也最終可以成功斷藥並且擺脫憂鬱。」

陳豐偉醫師(2014)認為:

「治療憂鬱症,藥物是捷徑,也是目前健保體制下最節省資源的方法之一。但,藥物並不是對每個人都有效,也可能會惡化少數人的病情。對於一種有11%美國人在使用的藥物,已經經過大量人體實驗,我們不需要過度擔心嚴重副作用。服藥治療很難十全十美,不管對醫師或對病人來說,都是在考量「利大於弊」是否成立。這篇文章的重點其實是:不要太盲目相信媒體或網路上看到的資訊。即使是仿單上你可能沒注意到的黑盒警訊,背後也是有許多故事。」

黃名琪、李明濱(臺灣憂鬱症防治協會)(2005)認為:

「本會於2004年3月31日曾召開記者會,提供建議如下:
1. SSRI對於大多數憂鬱症病人有顯著的療效,並且有一定的安全性。病患千萬不要自行停藥,以致病情惡化。
2. SSRI對大部分的病人不會有嚴重的副作用。但是某些病人在服藥之初會有自殺意念,到底是藥物的副作用,或是憂鬱症本身的症狀之一,尚待釐清。
3. 國內外的文獻顯示,並沒因服用SSRI抗鬱劑產生自殺意念因而自殺成功的個案。
4. 建議醫師、家屬或病人在最初使用抗鬱劑時,必須密切注意有無出現自殺意念或憂鬱症愈來愈糟的情況。尤其兒童患者出現焦躁不安、失眠或憂鬱症狀更加嚴重時,要嚴加注意其情緒的變化並且隨時跟醫師討論。」

有關停藥注意事項,劉采艷藥師說明:

「大約20%的病人在連續服用抗憂鬱藥物六週後,突然停藥會發生突然停藥症候群(Antidepressant discontinue syndrome),症狀包括有類感冒症狀、失眠、失去平衡、感覺異常、易怒等,症狀雖不嚴重,但會持續一至二週,造成生活品質降低。

半衰期短的藥物較容易發生突然停藥症候群,例如:半衰期為21小時的Paroxetine較半衰期為84小時之Fluoxetine更容易引發停藥症候群。原則上,低劑量、短期服用可以較快速停藥,若已吃藥超過三個月,則應逐漸調降劑量來拉長停藥期。」

在國際,據美國時報報導,

… many experts say it’s time for the black box to go: that the warnings overstate the real risk and may deter doctors from prescribing them to people who could benefit from being on antidepressants. Depression, after all, is the biggest risk factor for suicide.

While the drugs may not be for everyone, most of the experts TIME spoke with agreed that the warnings deter depressed people from taking drugs that could improve their wellbeing.’ (Sifferlin 2014)

紐約大學精神病學教授兼臨床醫師Dr. Norman Sussman說的值得留意:’I am not enamored by these drugs. They have their limitations and they really don’t work for most people, but the ones they work for best are the ones who are the most seriously depressed.’ (Sifferlin 2014)

Johns Hopkin大學精神病學和兒科教授Dr. Mark Riddle表示:’We don’t want wild and crazy prescribing, but we don’t want good clinicians afraid to use useful drugs… Though I am generally a cautious person and most of my research is on side effects, I think the FDA needs to back off a little.’ (Sifferlin 2014)

Weill Cornell Medical College臨床精神病學Dr. Richard Friedman表示:‘There’s absolutely no evidence that [the boxed warning] has done any good. There’s certainly credible data that it’s done harm.’ 而FDA的Dr. Marc Stone則表示‘the data suggesting the black box should be removed is “extremely questionable; virtually meaningless.” ’ (Sifferlin 2014)

Nischal et al. (2012)表示SSRIs對小孩和青少年會增加一點自殺想法和企圖,但沒增加成功自殺的人數(completed suicides)。使用SSRIs的風險能預估和做臨床管控,因此建議臨床醫師在病人的初始治療期做緊密跟進,並警惕風險。

Taking account of the methodological limitations of these studies, the current evidence fails to provide a clear relationship between their use and risk of suicidality in adults. However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides. This risk can be anticipated and managed clinically. Clinicians are, therefore, advised to maintain a close follow-up during the initial treatment periods and remain vigilant of this risk. This advisory, however, should not deter clinicians from the use of effective dosages of antidepressants for a sufficient period of time, in every age group of patients, when clinically needed, and if found suitable otherwise.

Caution is advisable during prescription of antidepressants to patients, especially in children and adolescents, as it may precipitate suicidal ideation in some vulnerable patients.

However, this can be readily identified and managed clinically, and it should not deter clinicians from providing effective pharmacological treatment to those in need. (Nischal et al. 2012)

FDA也做類似建議:Physicians recommend treatment when the clinical need outweighs the risk. The FDA suggests patients of all ages who start taking antidepressants should be carefully monitored for clinical worsening, suicidality or unusual changes in behavior. (Mauney 2018)

不論如何,在美國有抗憂鬱劑使用和自殺之爭議(Mauney 2018):

JANUARY 2017
Naika Venant, 14, of Miami, hanged herself on Facebook Live a month after her doctor doubled her dosage of Zoloft. Venant started taking the antidepressant in 2015 when she was just 12 years old.

JULY 2014
Conrad Roy, 18, of Mattapoisett, Massachusetts, was prescribed and taking Celexa when he committed suicide by carbon monoxide poisoning. His girlfriend, 18-year-old Michelle Carter, was charged with manslaughter, with prosecutors arguing she used “emotional coercion” through a series of phone calls and text messages to convince Roy to take his own life. Carter started taking Celexa a few months before Roy’s death. A defense witness argued she “had no notion of the wrongfulness of what she was doing” because she was “involuntarily intoxicated.”

JULY 2010
Stewart Dolin, a former corporate lawyer at the Chicago law firm Reed Smith, stepped in front of a commuter train on July 15, 2010, while taking a generic version of Paxil. His widow, Wendy Dolin, was awarded $3 million in a lawsuit against GSK that claimed an adverse reaction to the antidepressant led to her husband’s suicide.

Mauney (2018)表示抗憂鬱劑能治療憂鬱,但有高風險,並提供其他治療建議:

Medication-induced suicide has taken the life of both younger and older patients. People take antidepressants in hopes of curing their depression. But without the proper warning of risks from doctors and manufacturers, the outcomes can be devastating.

Antidepressants can help treat depression, but come with high risks. Other medications may be prescribed, and doctors may recommend additional therapy. Cognitive behavioral therapy, where a patient speaks with a licensed mental health counselor, reduces the risk of repeated suicide attempts by 50 percent.

Taking proactive steps like speaking to a doctor or seeking hospitalization can save lives. Friends and family can help by recognizing symptoms or unusual behavior.

最後想說,我非醫療相關專業,只是一位想幫憂鬱症朋友而自行找資料的外行。我只是整理部分的不同說法給我朋友看,並盼她能和其主治醫師討論。我沒足夠醫療知識判斷誰對誰錯,只是想提醒我朋友和大家對抗憂鬱劑使用的警覺性。


[1] SSRI能透過增加血清素水平,恢復腦袋的化學平衡,但會導致情緒搖擺轉換,並可能加劇憂鬱或焦慮。服用超過建議用量的抗憂鬱劑或突然停止服用,會增加病人產生自殺意念和行為的機會(Mauney 2018)。

[2] 鄭光男(2012)也提到:

某些傳統抗精神病藥物一旦吃久,也許會造成「遲發性運動不能」。(這)是因為長期服用抗精神病藥物,造成人體神經傳導永久不可逆的改變。而且服用抗憂鬱劑,也會增加內出血或中風的風險,但知道這類資訊的人其實不多。

目前市面上的抗憂鬱藥劑,像是「百解憂、樂復得、克憂果」等藥物,就是屬於SSRI,會造成情緒低落、焦慮、顫抖、冷漠、噁心或嘔吐、嗜睡、頭痛…等副作用。因SSRI會造成血小板功能異常,凝血功能異常會增加體內出血的危險性,中風的風險提高到百分之四十。


參考

晶晶2017,為什麼憂鬱的人吃抗憂鬱藥可能自殺?自由時報
http://talk.ltn.com.tw/article/breakingnews/2067741

陳豐偉2014,抗憂鬱藥的副作用是想自殺?精神科醫師告訴你:這顆藥究竟能不能吃。良醫健康網
https://health.businessweekly.com.tw/AArticle.aspx?id=ARTL000017511

黃名琪、李明濱2005,新一代抗鬱劑與自殺。台灣憂鬱症防治協會
http://www.depression.org.tw/knowledge/know_info_part.asp?paper_id=45

鄭光男2012,《除了開藥單,我還能做什麼? 精神科醫師沒說的事》。台北:博思智庫

劉采艷,吃抗憂鬱藥會導致自殺嗎?
https://app.tzuchi.com.tw/file_hl/h2oop/op004.htm

Alexandra Sifferlin. 2014. Do Depression Drugs Still Need Suicide Warnings? Time
http://time.com/3575112/do-depression-drugs-still-need-suicide-warnings/

Anil Nischal, Adarsh Tripathi, Anuradha Nischal, and J. K. Trivedi. 2012. Suicide and Antidepressants: What Current Evidence Indicates. Mens Sana Monographs 10(1)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353604/

Matt Mauney. 2018. Suicide and Antidepressants. drugwatch
https://www.drugwatch.com/ssri/suicide/


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