Antidepressants for anorexia nervosa

  • Review
  • Intervention

Authors


Abstract

Background

Anorexia Nervosa (AN) is an illness characterised by extreme concern about body weight and shape, severe self-imposed weight loss, and endocrine dysfunction. In spite of its high mortality, morbidity and chronicity, there are few intervention studies on the subject.

Objectives

The aim of this review was to evaluate the efficacy and acceptability of antidepressant drugs in the treatment of acute AN.

Search methods

The strategy comprised of database searches of the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register, MEDLINE (1966 to April 28th, 2005), EMBASE (1980 to week 36, 2004), PsycINFO (1969 to August week 5, 2004), handsearching the International Journal of Eating Disorders and searching the reference lists of all papers selected. Personal letters were sent to researchers in the field requesting information on unpublished or in-progress trials.

Selection criteria

All randomised controlled trials of antidepressant treatment for AN patients, as defined by the Diagnostic and Statistical Manual, fourth edition (DSM-IV) or similar international criteria, were selected.

Data collection and analysis

Quality ratings were made giving consideration to the strong relationship between allocation concealment and potential for bias in the results; studies meeting criteria A and B were included. Trials were excluded if non-completion rates were above 50%. The standardised mean difference and relative risk were used for continuous data and dichotomous data comparisons, respectively. Whenever possible, analyses were performed according to intention-to-treat principles. Heterogeneity was tested with the I-squared statistic. Weight change was the primary outcome. Secondary outcomes were severity of eating disorder, depression and anxiety symptoms, and global clinical state. Acceptability of treatment was evaluated by considering non-completion rates.

Main results

Only seven studies were included. Major methodological limitations such as small trial size and large confidence intervals decreased the power of the studies to detect differences between treatments, and meta-analysis of data was not possible for the majority of outcomes. Four placebo-controlled trials did not find evidence that antidepressants improved weight gain, eating disorder or associated psychopathology. Isolated findings, favouring amineptine and nortriptyline, emerged from the antidepressant versus antidepressant comparisons, but cannot be conceived as evidence of efficacy of a specific drug or class of antidepressant in light of the findings from the placebo comparisons. Non-completion rates were similar between the compared groups.

Authors' conclusions

A lack of quality information precludes us from drawing definite conclusions or recommendations on the use of antidepressants in acute AN. Future studies testing safer and more tolerable antidepressants in larger, well designed trials are needed to provide guidance for clinical practice.

摘要

背景

抗憂鬱劑使用在神經性厭食症(anorexia nervosa)

神經性厭食症是一種疾病,其特徵在極度在意體重及身材,自我導致的嚴重體重減輕,及有內分泌功能異常。雖然有高致死率致病率及慢性化,仍少有介入的研究在這樣的主題。

目標

這篇回顧文獻的目的在評估抗憂鬱劑治療神經性厭食症的療效及可接受度。

搜尋策略

策略是搜尋資料庫the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register, MEDLINE (1966 to April 28th, 2005), EMBASE (1980 to week 36, 2004), PsycINFO (1969 to August week 5, 2004),及手動搜尋the International Journal of Eating Disorders 及尋找所有挑 選文獻的引用文獻。以信件連絡這個領域的研究者以求得未發表技進行中的試驗資料。

選擇標準

挑選所有隨機控制試驗(randomised controlled trials),其在研究以抗憂鬱劑治療神經性厭食症患者,診斷定義依照Diagnostic and Statistical Manual, fourth edition (DSMIV) 或相似的國際條件。

資料收集與分析

品質的評量在考量分配的保密及結果有誤差可能性之間的關聯強度;研究須符合條件A及B才納入。試驗的未完成率高於50則被排除。對連續性數據及二分法的數據各自以標準平均差及相對風險來比較。當可行性夠時,以治療意向(intentiontotreat)為分析原則。異質性的測試使用the Isquared statistic。體重變化是主要的結果。第二結果是厭食症的嚴重度、憂鬱及焦慮症狀、整體臨床狀態。治療接受度已考量未完成率來評估。

主要結論

只有7個研究被納入。主要的方法學限制如試驗規模太小及信賴區間太大而減少研究的效度去分辨治療間的差異,而後設性的分析無法使用在大部分的結果。四個安慰劑控制的試驗發現沒有證據支持抗憂鬱劑可以改善體重增加、厭食症或相關的精神病理。單獨的發現是在抗憂鬱劑之間的比較, amineptine及nortriptyline較佳,但缺乏安慰劑的比較,不能被認為是某種或某類抗憂鬱劑有療效上的證據。未完成率在各組間都類似。

作者結論

缺乏有品質的資訊無法讓我們得到抗憂鬱劑使用在急性神經性厭食症的確定結論或建議。要提出臨床使用的指引需要未來更大型、完整規劃的試驗研究來測試抗憂鬱劑的安全性及耐受性。

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

神經性厭食症是高致死率及慢性化的疾病。目前處理神經性厭食症沒有最好的治療方式,經常是多種介入同時使用。藥物治療有時被附加在其他治療上。這篇回顧文獻的目的在從隨機控制試驗的證據中評估抗憂鬱劑治療神經性厭食症的療效及可接受度。四個安慰劑控制的試驗沒有發現證據支持抗憂鬱劑在改善體重增加、飲食疾病或相關症狀,及試驗完成率的差異上有療效。對於多數的結果無法使用後設分析。然而這些研究中主要的方法學限制(譬如缺乏偵測差異的效力)無法讓我們得到抗憂鬱劑使用在急性神經性厭食症的確定結論或建議。要提出臨床使用的指引需要未來更大型、完整規劃的試驗研究來測試抗憂鬱劑的安全性及耐受性。

Plain language summary

Antidepressants for anorexia nervosa

The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy and acceptability of antidepressant treatment in acute AN. Seven small studies were identified; four placebo-controlled trials did not find evidence of efficacy of antidepressants in improving weight gain, eating disorder or associated symptoms, as well as differences in completion rates. Meta-analysis of data was not possible for most outcomes. However, major methodological limitations of these studies (e.g. insufficient power to detect differences) prevent from drawing definite conclusions or recommendations for antidepressant use in acute AN. Further studies testing safer antidepressants in larger and well designed trials are needed to guide clinical practice.

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