Pharmacological treatment for psychotic depression

 

Abstract

Background

Regarding the pharmacological treatment of psychotic depression there is uncertainty about the effectiveness of an antidepressant alone compared to the combination of an antidepressant and an antipsychotic.

Objectives

To compare the clinical effectiveness of pharmacological treatments for patients with a psychotic depression: antidepressant monotherapy, antipsychotic monotherapy, and the combination of an antidepressant and an antipsychotic, compared with each other and/or with placebo.

Search methods

(1) The Cochrane Central Register of Controlled Trials (CENTRAL) was screened with the terms depressive disorder and drug treatment (April 2004).
(2) MEDLINE (1966 to April 2004) and EMBASE (1980 to April 2004) were searched using terms with regard to treatment of unipolar psychotic depression.
(3) Reference lists of related reviews and reference lists of all identified studies were searched.
(4) Personal communications.

Selection criteria

All randomised controlled trials (RCTs) with patients with major depression with psychotic features as well as RCTs with patients with major depression with or without psychotic features which reported on the subgroup of patients with psychotic features separately.

Data collection and analysis

Two reviewers assessed the methodological quality of the included studies, according to the Cochrane Handbook criteria. Data were entered into RevMan 4.2.5. We used intention-to-treat data. For dichotomous efficacy outcomes, the relative risk with 95% confidence intervals (CI) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary harm outcome, only overall drop-out rates were available for all studies.

Main results

The search identified 3333 abstracts, but only 10 RCTs with a total of 548 patients could be included in the review. Due to clinical heterogeneity, few meta-analyses were possible. We found no conclusive evidence that the combination of an antidepressant and an antipsychotic is more effective than an antidepressant alone (two RCTs; RR 1.44, 95% CI 0.86 to 2.41), but a combination is more effective than an antipsychotic alone (three RCTs; RR 1.92, 95% CI 1.32 to 2.80). There were no statistically significant differences in the overall drop-out rates between any of the treatments, neither in individual studies nor after pooling of studies.

Authors' conclusions

Treatment with an antipsychotic alone is not a good option. Starting with an antidepressant alone and adding an antipsychotic if the patient does not respond or starting with the combination of an antidepressant and an antipsychotic both appear appropriate options for patients with psychotic depression. In clinical practice the balance between risks and benefits suggests that initial antidepressive monotherapy and adding an antipsychotic if there is inadequate response should be the preferred treatment strategy for many patients. The general lack of available data limits confidence in the conclusions drawn.

 

Plain language summary

Pharmacological treatment for psychotic depression

The combination of an antidepressant with an antipsychotic may not be more effective than an antidepressant alone, but combination therapy may be more effective than an antipsychotic alone. Starting with the combination of an antidepressant and an antipsychotic, as well as starting with an antidepressant alone and adding an antipsychotic if the patient does not respond, both appear to be appropriate options for patients with psychotic depression. Clinically, the balance between risks and benefits suggests that initial antidepressant monotherapy should be the preferred option for many patients. Antipsychotic monotherapy is not an appropriate treatment strategy. The general lack of available data limits confidence in the conclusions drawn.

 

摘要

背景

精神病性憂鬱症的藥物治療

針對精神病性憂鬱症的藥物治療，仍未確定單線抗憂鬱劑與合併抗憂鬱劑與抗精神病藥的療效差別

目標

比較對精神病性憂鬱症的藥物臨床效果:單線抗憂鬱劑、單線抗精神病藥物及合併抗憂鬱劑與抗精神病藥物，分別與安慰劑作比較

搜尋策略

(1) 使用depressive disorder及 drug treatment為關鍵字過濾The Cochrane Central Register of Controlled Trials (CENTRAL)資料庫(April 2004))。(2)針對單極性精神病性憂鬱症(unipolar psychotic depression)的字彙搜尋 MEDLINE (1966 to April 2004) and EMBASE (1980 to April 2004)。(3)參考文獻列出相關的回溯文獻及所有可找到的研究。(4)個人溝通的資料

選擇標準

所有隨機控制試驗(randomised controlled trials) ，其患者為重鬱症伴隨精神病或隨機控制試驗其患者為重鬱症，而有或沒有精神病表徵在報告中被分成不同組別

資料收集與分析

兩位回顧者依據the Cochrane Handbook criteria評估所納入研究的方法學品質。數據被鍵入RevMan 4.2.5。我們使用治療意向(intentiontotreat)的資料。對於二分法的療效結果，計算其95%的信賴區間的相對風險(the relative risk with 95% confidence intervals)。對於連續性分布的結果，不可能從隨機控制試驗中抽取數據。針對主要的傷害結果，所有的研究僅有整體的退出率資料

主要結論

搜尋到3333個摘要，但僅有10個隨機控制試驗包含全部548個病患納入這篇回顧文獻。因為臨床的異質性，只有少數能進行後設分析(metaanalysis)。我們發現沒有結論性的證據支持合併抗憂鬱劑與抗精神病藥物比單線抗憂鬱劑有效(two RCTs; RR 1.44, 95% CI 0.86 to 2.41)，但合併抗憂鬱劑與抗精神病藥比單線抗精神病藥物較有療效(three RCTs; RR 1.92, 95% CI 1.32 to 2.80)。，不論是單一研究或集合所有的研究結果，在比較任何治療上的整體退出率，沒有任何顯著差異

作者結論

單線抗精神病藥物治療不是好的選擇。對於精神病性憂鬱症患者，開始就使用抗憂鬱劑而當治療沒反應時加入抗精神病藥物，或者開始就合併使用抗憂鬱劑與抗精神病藥物，兩者都是合適的選擇。在臨床使用上，平衡風險與益處，對於許多患者，開始使用單線抗憂鬱劑而在當治療反應不佳時加上抗精神病藥物是此處建議的治療策略。數據的缺乏限制我們對這個結論的信心

翻譯人

本摘要由彰化基督教醫院李柏賢翻譯

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

總結

合併抗憂鬱劑與抗精神病藥物可能不比單線抗憂鬱劑更有效，然而合併治療可能比單線抗精神病藥物有效。開始就使用合併抗憂鬱劑與抗精神病藥物，如同開始就使用抗憂鬱劑而當治療沒反應時加入抗精神病藥物，兩者對精神病性憂鬱症患者都同樣合適。臨床上平衡風險與益處，建議對許多患者，一開始使用單線抗憂鬱劑。抗精神病藥物不是合適的治療策略。數據的缺乏限制我們對這個結論的信心