Pharmacological treatment for psychotic depression

  • Review
  • Intervention

Authors


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.

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

摘要

药物治疗对精神病性抑郁症的效果

研究背景

在精神病性抑郁症的药物治疗方面,抗抑郁剂单独疗法与抗抑郁剂和抗精神病药联合疗法相比谁更有效尚不能确定。

研究目的

比较精神病性抑郁症患者药物治疗的临床效果: 抗抑郁剂单独疗法、抗精神病药物单独疗法以及这两种药物联用之间相互比较,或分别与安慰剂比较。

检索方法

(1) 采用检索词抑郁症(depressive disorder)及药物疗法(drug treatment)检索Cochrane Central Register of Controlled Trials(CENTRAL)数据库截至2004年4月发表的文献。

(2) 采用与“单相精神病性抑郁症 (unipolar psychotic depression) 的治疗”相关的检索词,检索MEDLINE (1966年–2004年4月) 和EMBASE (1980–2004年4月)数据库。

(3)追溯相关综述及所有纳入研究的参考文献。

(4)通过与作者联系获取资料。

纳入标准

纳入所有研究对象为重度抑郁症伴精神病征象的随机对照试验;以及无论有无精神病征象的重度抑郁症,只要报告了伴精神病征象患者的亚组数据的随机对照试验。

数据收集与分析

两位评价者根据Cochrane手册的标准评估纳入研究的方法学质量。数据录入RevMan 4.2.5软件进行分析。使用意向性分析处理数据。对于二分类变量的疗效指标,计算相对危险度及其95%可信区间。对于连续性变量指标,不可能从随机对照试验中提取数据。对于主要的有害结局指标,本研究只能获得整体的退出率。

主要结果

共检索到3333篇摘要,但本系统评价仅纳入了10个随机对照试验,共计548名患者。由于临床资料的异质性,很难进行Meta-分析。尚无结论性的证据支持抗抑郁剂与抗精神病药物联用比单用抗抑郁剂更有效(2个随机对照试验; RR =1.44, 95% CI: 0.86 ∼ 2.41),但联合用药比单用抗精神病药物更有效(3个随机对照试验; RR =1.92, 95% CI: 1.32 ∼ 2.80)。不论是单个研究结果还是合并的研究结果,各种疗法的整体退出率均无统计学差异。

作者结论

单用抗精神病药物疗效不理想。对精神病性抑郁症患者有效的疗法是,先给予抗抑郁剂,当疗效不佳时联用抗精神病药物;或者一开始就联用抗抑郁剂与抗精神病药物。在临床实践中经权衡利弊,建议对大多数患者先给予抗抑郁剂,只有当疗效不佳时再联用抗精神病药物。不过目前仍缺乏足够的证据来得出可靠的结论。

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.

概要

药物治疗对精神病性抑郁症的效果

药物治疗对精神病性抑郁症的效果

抗抑郁剂与抗精神病药物联用不一定比单用抗抑郁剂更有效,但可能比单用抗精神病药物更为有效。一开始就联用抗抑郁剂与抗精神病药物,或者先用抗抑郁剂,当疗效不佳时再联用抗精神病药物,这两种方案似乎对精神病性抑郁症患者都适用。在临床上权衡利弊后,建议大多数患者选择后一种序贯用药方案。单用抗精神病药物对该病并不适用。目前仍缺乏足够的证据来得出可靠的结论。

翻译注解

本摘要由重庆医科大学中国循证卫生保健协作网(China Effective Health Care Network)翻译。

翻译注解":本摘要由重庆医科大学中国循证卫生保健协作网(China Effective Health Care Network)翻译。: China Effective Health Care Network

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