Antidepressants for depression in physically ill people

 

Abstract

Background

There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill’s Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context.

Objectives

To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness.

Search methods

Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009.

Selection criteria

Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria.

Data collection and analysis

The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model.

Main results

Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant.

Authors' conclusions

This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.

 

Plain language summary

Antidepressants for depression in physically ill people

Depression in physical illness is common. Antidepressants have been shown to improve depression in people who are physically healthy, but there has been doubt about whether they are appropriate for people who are physically ill. This review examined clinical trials of antidepressants in physically ill people to determine whether antidepressants help these patients, and in particular if they lessen depression. We used standard methods recommended by Cochrane to identify and select studies and to collect and analyse the information. We extracted information on fifty-one studies in the review. Our results found that antidepressants are better than a placebo (inactive) drug in treating depression in physically ill people. Both the two main classes of antidepressant, tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), were shown to be more effective than a placebo. Antidepressants improved depressive symptoms within 4-5 weeks of treatment, and this benefit persisted after 18 weeks. However, patients taking an antidepressant were more likely to experience sexual dysfunction and dry mouth, and were more likely to stop taking their medication after 6-8 weeks of treatment. There are no grounds to recommend one antidepressant over another on the basis of this review. We conclude that antidepressants appear to be useful in treating depression and should be considered for physically ill patients. The decision to prescribe antidepressants should take account of patients' preferences, symptoms, and possible interactions with other medicines they are taking.

 

摘要

背景

抗憂鬱劑用於身體患病者之憂鬱症

身體的疾病會增加憂鬱症的風險，許多身體的疾病會因為憂鬱症而減少治療的順從性，使預後變差，增加了殘疾和死亡率。抗憂鬱劑能有效地治療身體健康者的憂鬱症，但是對於抗憂鬱劑用於身體患病者的療效就不太清楚了。本篇回顧更新了Gill於2000年所發表的一篇Cochrane review，其中發現抗憂鬱劑對於身體患病者之憂鬱症是有效的。Gill一直有一些較大的試驗評估抗憂鬱劑在這方面療效。 ◆ Translation of physical illness should be 身體的疾病

目標

確認抗憂鬱劑用於治療具有身體疾病患者憂鬱症之療效。

搜尋策略

搜尋Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) 試驗註冊者，同時也搜尋了The Cochrane Central Register of Controlled Trials (CENTRAL) 和標準書目數據庫例如MEDLINE，EMBASE和PsycINFO。審視所納入研究的參考文獻且搜尋試驗註冊者以確認其它未發表的數據。於2009年12月完成最後的搜尋。

選擇標準

隨機對照試驗比較抗憂鬱劑及安慰劑於具生理疾病病患憂鬱症之效果。憂鬱症包括依標準診斷之重鬱症，適應障礙和長期憂鬱症。

資料收集與分析

主要成果是隨機治療 6 – 8週後之效果，此外也由3個額外時間點(4 – 5週，9 – 18週，>18週)提取數據。接受度和耐受度由比較退出試驗和發生不良反應的人數進行評估。使用Odds ratios介於95％信賴區間之數據計算二元資料(對治療的反應)。95％CI 內之標準化平均差異用來計算連續數據(平均憂鬱分數)。使用隨機效應模型匯集數據。

主要結論

本回顧共納入51篇研究，3603位病患。44篇研究共3372位病患的數據用於療效分析。由匯集的療效數據作為主要療效評估，結果顯示OR 2.33，CI 1.80 – 3.00，p<0.00001(25篇研究，1674位病患)有利於抗憂鬱劑。在其它時間點抗憂鬱劑也比安慰劑更有效。在第6 – 8週，接受安慰劑的患者比用抗憂鬱劑的患者較少人退出試驗。口乾和性功能障礙較常發生在抗憂鬱劑治療組。

作者結論

本篇回顧證實抗憂鬱劑治療身體患病者憂鬱症之療效是優於安慰劑。但是此結果有可能因為出版偏差和報告偏差而跨大了已穫得的有效樣本數。更進一步的?究需要確認特定 的抗憂鬱劑對此類患者之療效與接受度的比較。 the meanung of particular is not 不同種類, 不同種類: different kinds of antidepressent.指SSRIs, snri, MAOIs…etc. Particular means only one specified for one disease…Thanks

翻譯人

本摘要由奇美醫院林聖凱翻譯。

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

總結

抗憂鬱劑用於身體患病者之憂鬱症：身體患病者罹患憂鬱症是很常見的。抗憂鬱劑可以改善身體健康者之憂鬱症，但是抗憂鬱劑用於身體患病者之憂鬱症是否是當仍受質疑。本篇回顧檢視抗憂鬱劑用於身體患病者憂鬱症的臨床試驗以確認抗憂鬱劑對這類病患是否有助益，特別是當他們是輕鬱的患者。我們使用Cochrane建議的標準方法確認和選擇研究並收集和分析資料。本篇回顧是從51篇研究中擷取數據。結果發現，治療身體患病者之憂鬱症，抗憂鬱劑效果優於安慰劑(不含活性藥成分)。三環類抗抑鬱藥 (TCA) 及選擇性血清素再攝取抑製劑(SSRIs)這兩類主要的抗憂鬱劑皆被證實比安慰劑更有效。抗憂鬱劑治療4 – 5週內可改善憂鬱症狀且18週後仍可持續。然而，服用抗憂鬱劑的病患較易發生性功能障礙和口乾等副作用，並有可能在治療6 – 8週後停止服藥。本篇回顧無法建議使用何種抗憂鬱劑較好。我們結論是，抗憂鬱劑對憂鬱症有治療效果，對身體患病者之憂鬱症亦然。決定處方抗憂鬱劑時應考慮病患的喜好、症狀及與其它併服藥物之間可能產生的交互作用。