Tricyclic drugs for depression in children and adolescents

  • Review
  • Intervention

Authors


Abstract

Background

There is a need to identify effective and safe treatments for depression in children and adolescents. While tricyclic drugs are effective in treating depression in adults, individual studies involving children and adolescents have been equivocal.

Objectives

To assess the effects of oral tricyclic antidepressants compared to placebo in the treatment of child and adolescent depression.

Search methods

CCDANCTR-Studies and CCDANCTR-References were searched on 12/2/2008. The bibliographies of previously published reviews and papers describing original research were cross-checked. We contacted authors of relevant abstracts in conference proceedings of the American Academy of Child and Adolescent Psychiatry, and we hand searched the Journal of the American Academy of Child and Adolescent Psychiatry (1978-1999).

Selection criteria

Randomised controlled trials comparing the efficacy of orally administered tricyclic medication with placebo in depressed people aged 6-18 years.

Data collection and analysis

Most studies reported multiple outcome measures including depression scales and clinical global impression scales. For each study the best available depression measure was taken as the index measure of depression outcome. Predetermined criteria were established to assist in the ranking of measures. Where authors reported categorical outcomes we calculated individual and pooled odds ratios for the odds of improvement in treated compared with control subjects. For continuous outcomes pooled effect sizes were calculated as the number of standard deviations by which the change in depression scores for the treatment group exceeded those for the control groups.

Main results

Thirteen trials (involving 506 participants) were included. No overall improvement with treatment compared to placebo was seen for children or adolescents (odds ratio = 0.84, 95% confidence interval 0.56 to 1.25). A statistically significant but small benefit of treatment over placebo was seen in reducing symptoms (effect size (standardised mean difference) = -0.31, 95% confidence interval -0.62 to -0.01). Subgroup analyses suggest a larger benefit among adolescents (effect size = -0.47, 95% confidence interval -0.92 to -0.02), and no benefit among children (effect size = 0.15, 95% confidence interval -0.34 to 0.64). Treatment with a tricyclic antidepressant caused more vertigo (odds ratio = 4.38, 95% confidence interval 2.33 to 8.25), orthostatic hypotension (odds ratio = 6.78, 95% confidence interval 2.06 to 22.26), tremor (odds ratio 6.29, 95% confidence interval 1.78 to 22.17) and dry mouth (odds ratio = 5.17, 95% confidence interval 2.68 to 29.99) than did placebo, but no statistically significant difference was found for other possible adverse effects.

Authors' conclusions

Data suggest tricyclic antidepressants are not useful in treating depression in pre pubertal children. There is marginal evidence to support the use of tricyclic antidepressants in the treatment of depression in adolescents, although the magnitude of effect is likely to be moderate at best.

摘要

背景

三環藥物治療兒童與青少年憂鬱症

有需要找出有效且安全的兒童與青少年憂鬱症的治療方式. 三環藥物在成人憂鬱症的治療是有效的,但在兒童與青少年相關的研究卻尚無定論.

目標

與安慰劑做比較,評估口服的三環抗憂鬱劑在治療兒童與青少年憂鬱症的效用.

搜尋策略

搜尋CCDANCTRStudies,找出與此文獻回顧相關的研究. 將先前發表的回顧和原著論文的參考書目進行交叉核對. 我們與American Academy of Child and Adolescent Psychiatry 會議紀 錄中有相關摘要的作者接觸, 並手動搜尋Journal of the American Academy of Child and Adolescent Psychiatry (1978 – 1999)

選擇標準

在6 – 18歲的憂鬱症族群,比較口服三環藥物與安慰劑效用的隨機控制的研究.

資料收集與分析

大部分的研究發表了許多結果的量測,包括憂鬱量表和臨床整體印象量表(CGI). 每一個研究的最佳可取得的憂鬱量測被當做是憂鬱結果的指標. 建立先決準則以協助量測的排名. 類別性變項:比較治療組與控制組改善的勝算,我們計算個別及集合的勝算比(odds ratios) 連續變項:藉由治療組的憂鬱分數的變化超過控制組的,以標準差來計算集合效應值(effect sizes)

主要結論

13個試驗被納入(共有506位參加者). 在兒童青少年,相較於安慰劑,無整體改善(odds ratio = 0.84, 95% confidence interval 0.56 to 1.25). 在降低症狀上,相較於安慰劑,有發現達統計學上的顯著意義但小的治療益處, (effect size (standardised mean difference) = −0.31, 95% confidence interval −0.62 to −0.01) 次族群分析,在青春期族群,有更大的治療益處(effect size = −0.47, 95% confidence interval −0.92 to −0.02),在兒童族群則無益處(effect size = 0.15, 95% confidence interval −0.34 to 0.64). 與安慰劑相較, 以三環抗鬱劑治療會造成更多的昡暈(odds ratio = 4.38, 95% confidence interval 2.33 to 8.25),姿勢性低血壓(odds ratio = 6.78, 95% confidence interval 2.06 to 22.26) 顫抖(odds ratio 6.29, 95% confidence interval 1.78 to 22.17),口乾(odds ratio = 5.17, 95% confidence interval 2.68 to 29.99),但在其他可能出現的副作用方面並無統計學上顯著差別.

作者結論

資料顯示三環抗鬱劑在治療青春期前的兒童沒有幫助. 雖然效用的強度至多很可能是中等的,但有些微證據支持三環抗鬱劑在青少年憂鬱症的治療

翻譯人

本摘要由彰化基督教醫院李冠瑩翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

三環藥物似乎在治療青春期前的兒童是沒有幫助的,在青少年至多有中等助益. 雖然三環藥物在治療成人憂鬱症是有效的,但是在兒童與青少年憂鬱症的效用與安全性仍不清楚. 此篇回顧發現在6 – 18歲這個族群,接受三環藥物或安慰劑後,從憂鬱症復原的比率無差異. 與安慰劑相較,以三環藥物治療減低較多憂鬱症狀,但效用是中等的,且臨床重要性仍不確定. 在只有納入青少年族群的研究中發現較大的治療效用. 而在青春期前的兒童並無此差異. 研究方向應朝向較新的抗憂鬱劑和非藥物治療方式來評估.

Plain language summary

Tricyclic drugs for depressed children and adolescents

Tricyclic drugs do not seem useful for treating children before puberty, and are of moderate benefit at most for adolescents. Although tricyclic drugs are effective in treating adults with depression, it is not clear whether they are safe and effective for children and adolescents. This review found no difference in the rates of recovery from depression for people aged 6 to 18 years who took a tricyclic drug or a placebo. Treatment with tricyclic drugs resulted in a greater reduction in depressive symptoms than treatment with a placebo, but the effect was moderate and of questionable clinical importance. The treatment effect was larger in the studies that included only adolescents, while no difference was seen in studies that included only children before the age of puberty. Research should be directed towards evaluation of the newer antidepressant drugs and non-drug therapies.

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