Mulrow C D, Williams J W, Chiquette E, Aguilar C, Hitchcock-Noel P, Lee S, Cornell J, Stamm K
Evidence-based Practice Center, Department of Medicine, the University of Texas Health Science Center at San Antonio, USA.
Am J Med. 2000 Jan;108(1):54-64. doi: 10.1016/s0002-9343(99)00316-2.
Several medications have recently been introduced for the treatment of depression. We reviewed the literature to summarize their efficacy in the treatment of depression in adult patients in primary care settings.
We searched the literature published from 1980 to January 1998 using the Cochrane Collaboration Depression Anxiety and Neurosis Group's specialized registry of 8,451 clinical trials, references from trials and 46 pertinent meta-analyses, and consultation with experts. We included randomized controlled trials of at least 6 weeks' duration that measured clinical outcomes and compared one of 32 newer medications with another newer antidepressant, an older antidepressant, a placebo, or a psychosocial intervention for the treatment of depressed patients in primary care settings. The primary outcome was response rate, defined as the proportion of patients experiencing a 50% or greater improvement in depressive symptoms.
There were 28 randomized controlled trials involving 5,940 adult primary care patients with major depression, depression requiring treatment, dysthymia, or mixed anxiety depression. Newer agents, including selective serotonin re-uptake inhibitors, serotonin norepinephrine inhibitors, reversible inhibitors of monoamine oxidase, and dopamine antagonists, were usually compared with tricyclic agents. Average response rates were 63% for newer agents, 35% for placebo, and 60% for tricyclic agents. Newer agents were significantly more effective than placebo [risk ratio = 1.6; 95% confidence interval (CI), 1.2 to 2.1), but similar to tricyclic agents (risk ratio = 1.0; 95% CI, 0.9 to 1.1). Response rates were similar in the different types of depressive disorders, except that two small trials in frail older patients showed no significant effects of newer agents compared with placebo. Dropout rates as a result of adverse effects were 8% with newer agents and 13% with tricyclic agents (P <0.05).
In primary care settings, newer antidepressants are more effective than placebo and have similar efficacy compared with tricyclic agents in the acute treatment of depression. Dropout rates as a result of adverse effects are lower with newer compared with tricyclic agents. Future studies should compare the effectiveness of different therapies among primary care patients with less severe depression and greater medical and psychiatric comorbidity.
近期有多种药物被用于治疗抑郁症。我们回顾了相关文献，以总结它们在基层医疗环境中治疗成年抑郁症患者的疗效。
我们利用Cochrane协作网抑郁、焦虑与神经症小组的8451项临床试验专门登记库、试验参考文献以及46项相关的荟萃分析，并咨询专家，检索了1980年至1998年1月发表的文献。我们纳入了至少为期6周的随机对照试验，这些试验测量了临床结局，并将32种新型药物之一与另一种新型抗抑郁药、一种老式抗抑郁药、安慰剂或心理社会干预措施进行比较，以治疗基层医疗环境中的抑郁症患者。主要结局是缓解率，定义为抑郁症状改善50%或更多的患者比例。
有28项随机对照试验，涉及5940名患有重度抑郁症、需要治疗的抑郁症、心境恶劣或混合性焦虑抑郁的成年基层医疗患者。新型药物，包括选择性5-羟色胺再摄取抑制剂、5-羟色胺去甲肾上腺素抑制剂、单胺氧化酶可逆抑制剂和多巴胺拮抗剂，通常与三环类药物进行比较。新型药物的平均缓解率为63%，安慰剂为35%，三环类药物为60%。新型药物比安慰剂显著更有效[风险比=1.6；95%置信区间（CI），1.2至2.1]，但与三环类药物相似（风险比=1.0；95%CI，0.9至1.1）。不同类型的抑郁症缓解率相似，不过两项针对体弱老年患者的小型试验显示，与安慰剂相比，新型药物没有显著效果。因不良反应导致的脱落率，新型药物为8%，三环类药物为13%（P<0.05）。
在基层医疗环境中，新型抗抑郁药在抑郁症的急性治疗中比安慰剂更有效，且与三环类药物疗效相似。与三环类药物相比，新型药物因不良反应导致的脱落率更低。未来的研究应比较不同治疗方法对抑郁症较轻、合并更多内科和精神疾病的基层医疗患者的有效性。
