How does a real-world child psychiatric clinic diagnose and treat attention deficit hyperactivity disorder?

AIM: To investigate child and adolescent psychiatrists'(CAPs) attention deficit hyperactivity disorder(ADHD) and oppositional defiant disorder(ODD) diagnoses and treatments in real-world clinical practice. METHODS: The medical records of 69 ADHD children(mean age = 9.5 years), newly referred to the ADHD clinic, were reviewed for their scores of parent- and teacher-reported Vanderbilt ADHD Diagnostic Rating Scales(VADRSs), CAPs' diagnoses of ADHD and ODD, and CAPs' treatment recommendations. Among 63 ADHD subjects who completed both parent and teacher VADRSs, we examined the agreement of the parent and teacher VADRSs. We also examined the concurrent validity of CAPs' ODD diagnoses against the results from the VADRSs. In addition, we compared CAPs' treatment recommendations against established ADHD and ODD guidelines.RESULTS: Among 63 ADHD subjects, the majority of the subjects(92%) met full ADHD diagnostic criteria at least in one setting(parent or teacher) on the VADRSs. Nearly half of the patients met full ADHD diagnostic criteria in two settings(parent and teacher). Relatively low agreement between the parent and teacher VADRSs were found(95%CI:-0.33 to 0.14). For 29 children who scored positive for ODD on the rating scales, CAPs confirmed the ODD diagnosis in only 12 of these casepositives, which is considered as a fair agreement between CAPs and VADRSs(95%CI: 0.10-0.53). For 27 children with no ODD diagnosis made by either CAP or VADRS, more than half of them were recommended for medication only. In contrast, where CAPs made the diagnosis of ODD, or where the parent or teacher VADRS was positive for ODD, almost all of the patients received recommendations for medication and behavior therapy.CONCLUSION: CAPs' ADHD diagnoses have strong concurrent validity against valid rating scales, but ADHD's most common comorbid condition- ODD- may be underrecognized.

Neuroimaging studies of cognitive remediation in schizophrenia:A systematic and critical review

AIM To examine the effects of cognitive remediation therapies on brain functioning through neuroimaging procedures in patients with schizophrenia.METHODS A systematic, computerised literature search was conducted in the PubM ed/Medline and PsychI nfo databases. The search was performed through February 2016 without any restrictions on language or publication date. The search was performed using the following search terms: [("cogniti*" and "remediation" or "training" or "enhancement") and("fMRI" or "MRI" or "PET" or "SPECT") and(schizophrenia or schiz*)]. The search was accompanied by a manual online search and a review of the references from each of the papers selected, and those papers fulfilling our inclusion criteria were also included.RESULTS A total of 101 studies were found, but only 18 of them fulfilled the inclusion criteria. These studies indicated that cognitive remediation improves brain activation in neuroimaging studies. The most commonly reported changes were those that involved the prefrontal and thalamic regions. Those findings are in agreement with the hypofrontality hypothesis, which proposes that frontal hypoactivation is the underlying mechanism of cognitive impairments in schizophrenia. Nonetheless,great heterogeneity among the studies was found. They presented different hypotheses, different results and different findings. The results of more recent studies interpreted cognitive recovery within broader frameworks, namely, as amelioration of the efficiency of different networks. Furthermore, advances in neuroimaging methodologies, such as the use of wholebrain analysis, tractography, graph analysis, and other sophisticated methodologies of data processing, might be conditioning the interpretation of results and generating new theoretical frameworks. Additionally, structural changes were described in both the grey and white matter, suggesting a neuroprotective effect of cognitive remediation. Cognitive, functional and structural improvements tended to be positively correlated.CONCLUSION Neuroimaging studies of cognitive remediation in patients with schizophrenia suggest a positive effect on brain functioning in terms of the functional reorganisation of neural networks.

Anhedonia and Reward System: Psychobiology, Evaluation, and Clinical Features

Anhedonia can be defined as a condition in which the hedonic capacity is totally or partially lost. From a psychobiological perspective, several researchers proposed that anhedonia has a putative neural substrate, the dopaminergic mesolimbic and mesocortical reward circuit, which involves the ventral tegmental area, the ventral striatum and part of the prefrontal cortex. Anhedonia is, besides depressed mood, one of the two core symptoms of depression;furthermore it is one of the most important negative symptom in schizophrenia. Anhedonia is also present in substance use disorders as part of the abstinence symptomatology, and interrelations between hedonic capability, craving and protracted withdrawal have been found, particularly in opiate-dependent subjects. Although anhedonia is regarded as an important symptom in psychopathology, so far it has received relatively little attention. In general, two main approaches have been utilized to investigate and assess anhedonia or hedonic capacity: laboratory-based measures and questionnaires. Among measurement scales, the most commonly used are the Snaith-Hamilton Pleasure Scale (SHAPS), the Fawcett-Clark Pleasure Scale (FCPS), and the Revised Chapman Physical Anhedonia Scale (CPAS). Nevertheless, other measurement scales, particularly used within broader psychopathological dimensions, are the Anhedonia-Asociality subscale (SANSanh) of the Scale for the Assessment of Negative Symptoms (SANS) and the Bech-Rafaelsen Melancholia Scale (BRMS). In this paper we analyze these different scales, individuating their strengths and limits and their current clinical applications.

Empowerment according to Persons with Severe Mental Illness: Development of the Netherlands Empowerment List and Its Psychometric Properties

Objectives. It is unclear whether and to what extent purportedly empowering practices in mental health care, like rehabilitation programs, recovery-supporting mental health care environments and peer-run services, contribute to the process of empowerment. Several American empowerment questionnaires have been developed in recent years, facilitating the measurement of empowerment outcomes. Given likely major transatlantic cultural differences in a value-sensitive concept such as empowerment, this article describes the development of the Netherlands Empowerment List (NEL) and its psychometric properties. Methods. Patients in Dutch mental health services provided meaning to the empowerment concept from which the NEL was derived. Based on 531 completed questionnaires, analyses in agreement with COSMIN criteria examined aspects of internal consistency, content validity, structural validity, convergent validity, discriminant validity, reproducibility and responsiveness of the NEL. Results. The NEL is a 40-item self-report questionnaire with six subscales: Social support, Professional help, Connectedness, Confidence and purpose, Self-management and Caring community. Internal consistency (Cronbach’s alpha = 0.94), aspects of validity, reproducibility (intraclass correlation = 0.79) and responsiveness were good. Correlation with existing scales was the highest for the Mental Health Confidence Scale (r = 0.78) and the lowest for the Boston Empowerment Scale (r = 0.61). Conclusion. The NEL appears to be a suitable instrument to capture the dimension of empowerment in European mental health settings.

A randomized controlled trial of ketorolac for prevention of headache related to electroconvulsive therapy

Background and Purpose: Headache is one of the most common side effects of electroconvulsive therapy (ECT), with a reported prevalence as high as 45%. Typical pharmacologic measures include aspirin, acetaminophen, or nonsteroidal anti-inflammatory medications. Among the latter, ketorolac may be especially advantageous in that it can be administered intravenously right before a treatment. The primary aim of this study was to measure the efficacy of intravenous ketorolac administration for the prevention of post-ECT headache at the first treatment session. Methods: Sixteen patients were assigned to the control group, while eight patients were assigned to the ketorolac treatment group (8 males, 16 females;mean age ± standard deviation = 46 ± 13.5 years). Statistical analysis consisted of a one-way analysis of variance using the two-sample test. We utilized a post-ECT headache severity scale from zero (no headache) to 3 (severe headache). Results:The mean score for the control group was 1.3 (±1.1), while the mean score for the ketorolac treatment group was 1.2 (±1.1), p = 0.86 (not significant). Conclusions: Ketorolac administration does not decrease the incidence of post ECT headache at the first treatment session. It is possible that ketorolac may be effective at subsequent treatments for patients with particularly bothersome headaches after the first treatment. Implications: Ketorolac should not be routinely used at the first treatment session to prevent headache associated with ECT.

前庭疾病国际分类概述

2006年,为了全面启动前庭疾病国际分类(ICVD)的工作,Bárány学会分类委员会(CCBS)召开第一届会议。考虑到ICVD工作历程的复杂性,Bárány学会需要建立一个系统的内部流程以及促进与其它协会达成共识的工作流程,最终,针对前庭疾病临床诊断与研究的关键问题,CCBS开始着手制定ICVD的工作规则和框架(于2015年以前庭疾病国际分类概述英文版一文发表),包括4个层面的内容:(1)症状和体征;(2)综合征;(3)功能障碍和疾病;(4)发病机制。截至目前,CCBS在前庭症状的定义(2009)、前庭性偏头痛(2012)、前庭疾病国际分类概述(2015)、良性阵发性位置性眩晕(2015)、梅尼埃病(2015)、前庭阵发症(2016)、双侧前庭病变(2017)、持续性姿势-感知性头晕(2017)的相关专家共识已经陆续发表。在此背景下,我们此次将CCBS 2015年发表的《前庭疾病国际分类概述》一文进行了翻译(中文版发表版权已获取),以飨读者。希望能够使国内更多的同仁了解CCBS有条不紊的ICVD工作历程,对我们的工作亦有所启示!当然,我们也透过CCBS目前所做的ICVD的相关工作,更加清晰地理解到我们面临的问题及应该如何更好地去开展眩晕/前庭专业的工作!这一点,是非常重要的!

Systematic review: The placebo effect of psychological interventions in the treatment of irritable bowel syndrome

AIM To determine the placebo response rate associated with different types of placebo interventions used in psychological intervention studies for irritable bowel syndrome. METHODS Randomized controlled trials comparing psychological interventions(stress management/relaxation therapy(cognitive) behavioral therapy, short-term psychodynamic therapy, and hypnotherapy) for the treatment of adult patients with irritable bowel syndrome(IBS) diagnosed with the Manning or Rome criteria with an adequate placebo control treatment and reporting data on IBS symptom severity were identified by searching Pub Med, Embase, the Cochrane Library, CINAHL and Psyc INFO databases. Full-text articles that were written in English and published between 1966 and February 2016 in peer-reviewed journals were selected for the present review. Placebo interventions were considered to be adequate if the number of sessions and the amount of time spent with the therapist were the same as in the active treatment. The placebo response rate(PRR) was computed for IBS symptom severity(primary outcome measure) as well as for anxiety, depression and quality of life(secondary outcome measures). RESULTS Six studies, with a total of 555 patients met the inclusion criteria. Four studies used an educational intervention, whereas two studies used a form of supportive therapy as the placebo intervention. The PRR for IBS symptom severity ranged from 25% to 59%, with a pooled mean of 41.4%. The relative PRR for the secondary outcome measures ranged from 0% to 267% for anxiety, 6% to 52% for depression 20% to 125% for quality of life. The PRR associated with pharmacological treatments, treatment with dietary bran and complementary medicine ranged from 37.5% to 47%. Contrary to our expectations, the PRR in studies on psychological interventions was comparable to that in studies on pharmacological, dietary and alternative medical interventions.CONCLUSION The PRR is probably determined to a larger extent by patient-related factors, such as expectations and desire for the treatment to be effective, than the content of the placebo intervention.

强迫症患者、强迫型人格障碍患者和健康对照者之间的认知灵活性和计划能力比较（英文）

背景:强迫症患者(Obsessive Compulsive Disorder,OCD)与强迫型人格障碍患者(Obsessive Compulsive Personality Disorder,OCPD)的认知功能还没有得到充分的研究。目标:验证OCD和OCPD患者的认知灵活性和计划能力。方法:本研究在德黑兰心理咨询门诊选定了25例OCD患者和20例OCPD患者,他们在既往两周都没有服药,并且从大学工作人员和当地社区居民中选定了25名健康对照者。对所有参与者均进行28项一般健康问卷(28-item version of the General Health Questionnaire,GHQ-28)、威斯康星卡片分类测验(Wisconsin Card Sorting Test,WCST)、和伦敦塔试验(Tower of London test,TOL))。本研究运用WCTS的两个测量指标(持续错误数和完成分类数)评估认知灵活性以及TOL的三个测量指标(12个试验总共的移动次数、总应答时和计划时间)评估计划能力。结果:2组患者的当前心理困扰程度显著高于对照组。在控制人口学因素和心理困扰水平后,OCD患者和OCPD患者在WCST测试中比对照组更容易出现持续性错误,而OCD患者(不包括OCPD患者)的完成分类数比对照组显著减少。OCD患者和OCDP患者都比对照组需要更多的移动次数来完成12项TOL任务,并且OCD患者比OCPD患者和对照组需要花更长的时间来完成任务。结论:与健康对照组相比,OCD和OCPD患者的认知灵活性和计划能力都有所受损,并且OCD和OCPD患者之间的认知功能测试也存在一些差异。我们需要对OCD和OCPD患者进行长期随访研究评估在强迫症状严重性加重与减轻时认知功能的改变,从而决定此类认知评估指标对于强迫症是否有诊断或临床关联性。

Cognitive behavioural therapy for auditory hallucinations in schizophrenia:A review

AIM To provide an updated of recent findings about efficacy of cognitive-behavior therapy(CBT) in reduction of command hallucinations.METHODS Pub Med/MEDLINE,Cochrane Library,the Cumulative Index to Nursing and Allied Health Literature,PsycI NFO,Clinical Trial.gov searches were performed using the keywords "hallucinations","behavioural therapy" and " cognitive therapy" in order to identify relevant articles published during the years of 2011 to 2016.No language limits were used.Studies conducted within control group,reviews,editorials,were excluded.Data on efficacy,acceptability and tolerability were extracted by three authors independently.Disagreements were resolved in a consensus meeting or by another reviewer.RESULTS A total of eight articles were eligible for inclusion.Two are randomized clinical trials(RCTs) and six are observational studies.The two RCTs included showed a greater efficacy of CBT compared to standard care on auditory hallucinations(AHs).Nevertheless,they considered different CBT models,particularly Treatment of Resistant Command Hallucinations and Cognitive Therapy for Command Hallucinations.As regards non RCT-studies,all papers included showed reduction on frequency and severity of AHs and distress related to them.However,the lack of content details within non-RCTs studies decreased their comparability.In terms of predictive variables,our findings show that negative symptoms at baseline appeared to be the strongest predictor of the treatment efficacy.Indeed,negative symptoms showed a significant negative correlation on outcome.CONCLUSION Although more conclusive studies are still needed,we found some preliminary evidence for the efficacy of CBT in the treatment of command hallucinations.

Restless legs syndrome following the use of ziprasidone: a case report

Restless legs syndrome(RLS)is a common sleep-related movement disorder characterised by an uncomfortable urge to move the legs that occurs during periods of inactivity.Although there have been many case reports on antipsychotic-induced RLS,ziprasidone has never been reported as a cause of RLS.We present a case of a female patient with schizophrenia who presented with symptoms of RLS following the administration of high doses of ziprasidone added to quetiapine and valproate.The patient’s symptoms of RLS occurred following the administration and titration of ziprasidone to 160 mg,and were relieved upon reducing the dose to 120 mg/day.Other potential causative medications and differential diagnoses that could have caused similar symptoms were excluded.Clinicians should be aware of the potential for ziprasidone-induced RLS.Dopamine and serotonin interaction could be the mechanism underlying ziprasidone-induced RLS.

Key psychosocial challenges in vascularized composite allotransplantation

Psychosocial factors are important elements in the assessment and follow-up care for vascularized composite allotransplantation(VCA) and require multidisciplinary evaluation protocols. This review will highlight differences between VCA with solid organ transplantation(SOT), provide information on the psychosocial selection of VCA candidates, ethical issues, psychological outcomes, and on the need for multicenter research. VCA is primarily a life-enhancing procedure to improve recipients' quality of life and psychological well-being and it represents a potential option to provide reproduction in case of penile or uterine transplantation. The risk benefit ratio is distinctly different than SOT with candidates desiring life enhancing outcomes including improved body image, return to occupations, restored touch, and for uterine transplant, pregnancy. The Chauvet Workgroup has been convened with membership from a number of transplant centers to address these issues and to call for multicenter research. A multicenter research network would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about factors that increase risk of non-adherence and other adverse psychosocial and medical outcomes.

Olfactory function in psychotic disorders: Insights from neuroimaging studies

Olfactory deficits on measures of identification, familiarity,and memory are consistently noted in patients with psychotic disorders relative to age-matched controls. Olfactory intensity ratings, however, appear to remain intact while the data on hedonics and detection threshold are inconsistent. Despite the behavioral abnormalities noted, no specific regional brain hypoactivity has been identified in psychosis patients, for any of the olfactory domains. However, an intriguing finding emerged from this review in that the amygdala and pirifom cortices were not noted to be abnormal in hedonic processing(nor was the amygdala identified abnormal in any study) in psychotic disorders. This finding is in contrast to the literature in healthy individuals, in that this brain region is strongly implicated in olfactory processing(particularly for unpleasant odorants). Secondary olfactory cortex(orbitofrontal cortices, thalamus, and insula) was abnormally activated in the studies examined, particularly for hedonic processing. Further research, using consistent methodology, is required for better understanding the neurobiology of olfactory deficits. The authors suggest taking age and sex differences into consideration and further contrasting olfactory subgroups(impaired vs intact) to better our understanding of the heterogeneity of psychotic disorders.

一个参与者眼中的行为遗传学史上的里程碑(英文)

行为遗传学的历史,从横切面看,就好似一个由心理学、遗传学、生物学、进化论、人类学、人口学、生物统计、社会学以及法哲学等学科组合成的万花筒。任何一对学科的演进都呈正相关。虽然任何一对学科都不至于相互否定,但是,他们各自独特的历史和人物,又使得每一对学科并不完全相似。

Brain-derived neurotrophic factor as a potential biomarker of cognitive recovery in schizophrenia

Brain-derived neurotrophic factor(BDNF) has been proposed as a biomarker of schizophrenia and, more specifically, as a biomarker of cognitive recovery. Evidence collected in this review indicates that BDNF is relevant in the pathophysiology of schizophrenia and could play a role as a marker of clinical response. BDNF has been shown to play a positive role as a marker in antipsychotic treatment, and it has been demonstrated that typical antipsychotics decrease BDNF levels while atypical antipsychotics maintain or increase serum BDNF levels. Furthermore, BDNF levels have been associated with severe cognitive impairments in patients with schizophrenia. Consequently, BDNF has been proposed as a candidate target of strategies to aid the cognitive recovery process. There is some evidence suggesting that BDNF could be mediating neurobiological processes underlying cognitive recovery. Thus, serum BDNF levels seem to be involved in some synaptic plasticity and neurotransmission processes. Additionally, serum BDNF levels significantly increased in schizophrenia subjects after neuroplasticity-based cognitive training. If positive replications of those findings are published in the future then serum BDNF levels could be definitely postulated as a peripheral biomarker for the effects of intensive cognitive training or any sort of cognitive recovery in schizophrenia. All in all, the current consideration of BDNF as a biomarker of cognitive recovery in schizophrenia is promising but still premature.

Using machine learning to identify factors related to nitrous oxide(laughing gas)relapse among adolescents

Introduction Nitrous oxide(N2O/laughing gas)has been used in medical practice as an inhalational anaesthetic and analgesic for more than 150 years.1 In the past decades,N2O exhibited increasing popularity among recreational drug users for its euphoric effects,potentially through its interaction with the endogenous opioid system.2 Recreational use of N2O emerged as the seventh most used drug globally in the past decade.3 The use of N2O can cause myelopathy,myocardial injury,anaemia,severe mood disorders,sensory and motor neuropathy,and psychotic symptoms.45 Prolonged N2O intake results in vitamin B12 deficiency and inhibits methionine synthetase,folate and DNA production,leading to plasma homocysteine(HCY)level elevation and bone marrow haematopoietic dysfunction.6 This study aimed to investigate the neurological symptoms of nitrous oxide use and then explore the relapse trajectory and risk factors for relapse.

Woman diagnosed with obsessive-compulsive disorder became delusional after childbirth:A case report

BACKGROUND Obsessive-compulsive disorder(OCD)is a common mental disorder that varies greatly in manifestation and causes much distress to individuals.We describe a case in which a Chinese woman with OCD became delusional after childbirth,and discuss the possible phenomenological and psychological alterations.CASE SUMMARY A 27-year-old woman presented to the Psychiatry Department of our hospital with obsessions and compulsions.After taking medication,her symptoms were alleviated.Three years later,during her pregnancy,the obsessions returned and even progressed into paranoid delusions after childbirth.After multiple adjustments of treatment along with several fluctuations,she finally achieved remission and gained reasonable insight.CONCLUSION This case suggests that the patient with OCD appeared to move along a continuum of beliefs,and highlights the importance of effective intervention during pregnancy,which would exert a significant impact on postpartum exacerbation outcomes.

No Effects of Meteorological Factors on the SARS-CoV-2 Infection Fatality Rate

Objective Previous studies have shown that meteorological factors may increase COVID-19 mortality,likely due to the increased transmission of the virus.However,this could also be related to an increased infection fatality rate(IFR).We investigated the association between meteorological factors(temperature,humidity,solar irradiance,pressure,wind,precipitation,cloud coverage)and IFR across Spanish provinces(n=52)during the first wave of the pandemic(weeks 10–16 of 2020).Methods We estimated IFR as excess deaths(the gap between observed and expected deaths,considering COVID-19-unrelated deaths prevented by lockdown measures)divided by the number of infections(SARS-CoV-2 seropositive individuals plus excess deaths)and conducted Spearman correlations between meteorological factors and IFR across the provinces.Results We estimated 2,418,250 infections and 43,237 deaths.The IFR was 0.03%in<50-year-old,0.22%in 50–59-year-old,0.9%in 60–69-year-old,3.3%in 70–79-year-old,12.6%in 80–89-year-old,and26.5%in≥90-year-old.We did not find statistically significant relationships between meteorological factors and adjusted IFR.However,we found strong relationships between low temperature and unadjusted IFR,likely due to Spain’s colder provinces’aging population.Conclusion The association between meteorological factors and adjusted COVID-19 IFR is unclear.Neglecting age differences or ignoring COVID-19-unrelated deaths may severely bias COVID-19 epidemiological analyses.

Forgiveness education in fibromyalgia: A qualitative inquiry

The purpose of this qualitative study was to assess perspectives on the acceptability and the potential applicability of a forgiveness education in patients with fibromyalgia. The concept and tools of forgiveness were presented to thirteen women (age: 40 - 54 years) with a previous diagnosis of fibromyalgia. Subjects participated in 1 of 2 focus groups following a 90-minute education session in which forgiveness was presented as an emotion-focused coping strategy to deal with interpersonal stressors. Qualitative assessment of focus group discussions reveals 3 themes: 1) forgiveness is healthy and reduces pain, 2) forgiveness is within a patient’s personal control, and 3) forgiveness education is similar to other types of patient education and is well received. Our results suggest that forgiveness education is acceptable and feasible in patients with fibromyalgia. This justifies further exploration of forgiveness as an emotion-focused self- management strategy to decrease psychological distress.

Noninvasive ultrasound deep brain stimulation of nucleus accumbens induces behavioral avoidance

Ultrasound stimulation is an emerging noninvasive option in treating neuropsychiatric disorders. The present study investigates the behavioral alterations resulting from ultrasound stimulation on the nucleus accumbens(NAc) in freely moving mice. Our results show that an acute ultrasound stimulation on the NAc, rather than the visual cortex or auditory cortex, led to a pronounced avoidance behavior, while repeated NAc ultrasound stimulation resulted in an obvious conditioned place aversion with changes in synaptic protein(Glu A1/2 subunit) expression. Notably, NAc ultrasound stimulation suppressed the morphine-induced conditioned place preference. The results provide evidence that NAc ultrasound stimulation can be applied as a potential noninvasive therapeutic option in treating psychiatric disorders.

抑郁症的非药物治疗：系统性综述与证据图

背景抑郁症非药物治疗的疗效比较目前仍然不清楚。方法我们对一些系统性综述作了概述，回顾了随机对照试验（RCT），比较抑郁症非药物治疗的有效性和认知行为治疗（CBT）。对多个电子数据库在2016年2月之前发表的所有文献进行了检索，不限制语言。成对的评阅人进行资料纳入、数据提炼并评估偏倚的风险。在适用的时候进行了荟萃分析。结果我们收录了367项RCT，纳入了约2000名患者，进行了11种治疗，导出17项独立的头对头比较。通过标准化的量表评估，发现CBT、自然疗法、行为干预与躯体活动干预可以降低抑郁的严重程度。然而，这些非药物干预的相对疗效仍然缺乏。这些干预对临床缓解和复发的效果不清楚。CBT的发生率比抗抑郁药物更低。局限性由于证据缺乏一致性、证据不清或偏倚风险高，导致证据的质量只是低到中等，限制了我们研究结果的可信度。结论抑郁症的非药物治疗能减少抑郁症状，在轻度到重度抑郁症患者中，应当合并抗抑郁药物治疗，一同进行。对于非药物治疗的选择，应当根据患者的价值观、偏好、临床和社会因素来与患者共同作出决定。