Team:FZU-China/Interview

Interview

On April 28, PI Shaobin Guo of our FZU-China team and members Huimin Zhang, Shanyu Huang, and Jiale Hong went to the First Affiliated Hospital of Fuzhou Medical University to learn more about the treatment of clinical patients with depression. After a brief introduction of our subject, we interviewed psychotherapists and psychologists who diagnose and treat depression and learned about depression from two aspects: physiological treatment and psychotherapy.
We came to the hospital with the following questions in mind: What problems does China face in the diagnosis and treatment of depression? Because of the differences between China and Western countries, how different are the diagnosis and treatment of depression? Here, we learned some of the views of the doctors who are at the first line of depression diagnosis and treatment for many years and have a comprehensive understanding of depression.

I The interviewee

Dr. Zisen Zhuang

Dr. Zhuang graduated from Xiangya School of Medicine, Central South University (formerly Hunan Medical University) with a doctorate degree in "Psychiatry and Mental Health". He is currently an attending physician, psychotherapist, and member of the Chinese Medical Association of the Department of Psychology at the First Affiliated Hospital of Fujian Medical University. He is a member of the Fujian Mental Health Association, a Special Expert of Health Road Famous Doctor. He is an expert on the diagnosis and treatment of affective disorders, various neuroses, learning difficulties for adolescents, sleep disorders, and various psychosomatic incurable diseases, and has extensive clinical psychotherapy experience. He is responsible for the clinical teaching work of medical college students and advanced doctors.

II Interview session

1.Regarding the status quo of depression in China-"The prevalence rate has reached the international level"
Q: Is the prevalence of depression high? What is the difference between the proportion of patients in China and abroad?
Dr. Zhuang: According to the survey results from 2014 to the present, the occurrence of depression is about 3.5%. This number is very high. At present, about 350 million people worldwide suffer from depression, and depression is a highly recurring disease. The recurrence rate is as high as 80%, and about 1 million people die of depression and commit suicide every year. In the 1980s and even the 1990s, the prevalence of depression was only about one in a thousand from the results of China’s epidemiological surveys. By 2013, the survey results of depression prevalence in our country reached 3%, which is relatively close to the international level. From the perspective of gender ratio, female patients are more than male patients, and about 3.6% of Chinese women have depression. This figure is already in line with international levels.
Q: What is the standard procedure for patients with depression in China?
Dr. Zhuang: Actually, The notion that "I may have a mental illness" has only appeared in recent years in China. Usually, they will first go to a psychiatrist and get checked. If the psychiatrist thinks patients should undergo psychological consultation, then the cases will be referred to the psychologist, so that psychological consultation and drug treatment will be carried out at the same time. After that, patients will be desensitized in the later stage of the treatment to help them re-enter society. In the United States, communities will follow up automatically. Each community will form a connection with hospitals and have a complete set of procedures for receiving and referral of patients. However, due to the large population base in China, this is not yet possible.
2. Regarding the difficulty of diagnosing and curing depression-"Many drugs are ‘know the hows but not the whys’ " Q: What are the main methods of diagnosis and treatment for depression?
Dr. Zhuang: Depression is not like other medical or surgical diseases, which can be examined using CT, B-ultrasound, or blood test. At present, the diagnosis of depression is mainly based on doctors’ experience, the test results of various scales (ICD-11, DSM-5, PHQ-9), and the comprehensive diagnosis of imaging and genetic factors. Researchers around the world believe that there is still a lack of objective biological indicators to efficiently and accurately diagnose depression. Take your GABA as an example. There are indeed studies showing that the GABA measured from patients with post-suicide depression is significantly lower. Therefore, if you can diagnose depression by measuring the concentration of GABA in the blood in the future, it will be really helpful. With the discovery of more biological indicators, the diagnosis and treatment of depression will make great progress.
In terms of treatment, the current treatment methods mainly include drug therapy, physical therapy, and psychotherapy. Drug therapy is mainly developed based on 5-HT sites and norepinephrine sites, such as SSRI drugs, and these two drugs are mainly aimed at emotional symptoms and physical symptoms. The most commonly used physical therapy is electrical convulsions, which should have a history of fifty to sixty years and is a classic therapy; it is mostly used for refractory depression. Psychological treatment is through psychological counseling. If it is depression caused by an exogenous event, psychological enlightenment to the patient is helpful to the cure.
In fact, everyone has neglected the impact of depression on human cognitive function. The patient's academic performance and workability will decline because of this. Why would they decline? Because his/her cognition is affected, and the cognition is mainly manifested in the difficulty of making decisions and judgments, and it will have a negative impact on memory, thinking and planning ability, cognitive ability, and information processing ability. Therefore, researches on the treatment of cognitive symptoms are of great significance. Behind every symptom, some neurotransmitters or metabolites are causing the problem. Among them, the substances related to attention and judgment include dopamine and γ-aminobutyric acid (GABA), so the underlying logic of your iGEM project is quite good. Clinical studies on using GABA for the treatment of depression are rare now.
Q: What are the clinical deficiencies of the current treatment methods?
Dr. Zhuang: In terms of drug treatment, we have slowly discovered from treatments such as refractory depression in the past few decades that depression is a multi-site disease, except for the 5-HT sites and noradrenal glands just mentioned. The drug target for depression has also been directed towards melatonin and adrenocorticoid receptors, etc. However, most of the drugs currently used in clinical practice are based on treatment experience; for example, if a certain drug is effective on a group of patients, other patients will also use this drug in the next treatment, and sometimes we do not know the active ingredients of these drugs. The second point is that psychotropic drugs do have certain side effects, such as some tranquilizing drugs. In addition, new alternative medication is also a problem. Our department has not introduced any new medicines for 15 years, and we cannot introduce new medicines from abroad, as these new medicines are too expensive for us as imported medicines, and the national medical insurance cannot afford the cost of introducing new medicines. Therefore, it is of great significance to conduct major domestic research on the treatment of depression to discover new drugs.
The treatment of depression is determined by different conditions. The early stage of major depression is usually controlled by drugs, and the patients are treated with psychological counseling in the middle and late stages; while drug treatment is often not effective in treating mild depression, and the treatment method is mainly psychotherapy. Treatments using psychological counseling usually first addresses maintenance factors and susceptibility factors. Maintenance factors are ability defects (such as mental retardation, introversion) that lead to negative emotions. At the same time, ability defects that cannot be resolved within a short period of time will induce the reoccurrence of mental illness, and the susceptibility factors are mental illnesses induced by some inline factors, such as bipolar affective disorder related to heredity. On the other hand, psychological counseling has higher requirements for patients. First, patients must have a strong insight to conduct psychological counseling. Patients with severe depression may have lost their insights and cannot make a basic objective evaluation about themselves and their surrounding environment and psychological counseling, and in this kind of cases, psychological counseling may be ineffective; secondly, psychological counseling is also limited by education level, and it may not work well with the elderly and younger children; the other is the principle of voluntariness. Chinese people are usually lack of correct understanding of mental illnesses such as depression and it is always a hurdle for them to enter the consultation room.
Q: What are the side effects of current depression medications? Dr. Zhuang: Our hospital has a standard protocol for drug treatments. The side effects of psychotropic drugs occur mainly in the early stage of the treatment. Depression may be caused by metabolites or neurotransmitter disorders in the brain or other parts of the body, so after the drugs enter the body, they will start to rebalance these substances.
After the drug enters the body, some reactions of the body may occur in the early stage, such as dizziness, weakness of the body, or slower thinking reaction, etc. This reaction will gradually subside after a week or two. However, some patients are worried about these side effects because they have a great psychological burden. Therefore, doctors must do a good job of patient education when prescribing medicines. However, abuse of medications can happen, as the diagnosis of depression is mainly based on the experience of doctors. Some depressions are complicated. It may be necessary to use various drugs such as stabilizers, which may cause a financial or psychological burden on patients. In this way, some patients may discontinue the drug without authorization, and if a mental illness such as depression reoccurs after the unauthorized discontinuation of the drug, a larger dose of the drug will likely be required to achieve the initial effect. Therefore, if it is possible to increase the concentration of brain-derived neurons by other means, or to adjust the patient’s imbalanced neurotransmitters or metabolites to achieve the antidepressant effect, it is more than welcome.
Q: From the perspective of psychological factors, why do people with depression stop taking the medication without an authorization?
Dr. Zhuang: This is actually the logic that people are accustomed to. It may be that after taking the medicine, your condition has improved, so you think you do not need to continue taking it. However, the condition is often only improved rather than cured. Other reasons include that some patients cannot accept the side effects of taking medicine, and some patients cannot accept the fact of taking medicine.
3. About the significance of research-- breaking the confusion
Q: There are many studies on depression in recent years, but there are not many breakthrough clinical findings. Our idea is just one thought among many studies. Do you think our project is meaningful?
Dr. Zhuang: At present, almost all the treatments for depression and all the pathologies of depression do not have a sounding clinical basis. Many research results are in the stage of clinical hypothesis, so it is very meaningful for you to do this. The significance of doing research does not necessarily lie in that the results you have made are successful. Even if you fail, you can block the “road”, by telling other researchers that the development of drugs and treatments in this area is meaningless, then the negative results become meaningful as well. Pharmaceutical companies invest huge amounts of money and efforts on new drug discovery and development; If ineffective drugs are produced, the loss would be huge, possibly billions of dollars, or even more. So for depression, as well as all the other mental illnesses currently being studied, we do not have to worry about whether we can succeed in doing this thing, as long as you conduct sounding research, then it is meaningful.

III Summary

In China, there is no widely used clinical objective or biological indicators for the diagnosis of depression; even with the popularization of mental health education, the increase of attention on patient education, and the decrease of the psychological burden of taking medication, we are still facing the following challenges: the increase of the number of depression cases, the high sense of shame led to low willingness to face mental illness, the lack of mental health services resources, uneven geographical distribution, etc.
Depression, as a common but complex disease with a high reoccurrence rate, is an important research target in pharmaceutical companies. Also with the increase in the cases of depression worldwide, especially in the younger population, reduce the pain of patients with depression is of great significance.
During this hospital interview-study project, we learned a lot about the current situation of depression diagnosis and treatment from actual clinical doctors. We gained a much better understanding of depression, which in turn strengthened our determination to complete the project to contribute to the treatment and diagnosis of depression.

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