Nolen W A, Bloemkolk D
University Medical Centre Utrecht, The Netherlands.
Neuropsychobiology. 2000;42 Suppl 1:11-7. doi: 10.1159/000054845.
A review of the methodology and results of 9 controlled studies on the acute treatment of bipolar depression and the risk of switches into (hypo)mania is presented. There are indications but no proof for efficacy of mood stabilizers such as lithium, carbamazepine and valproate. Only lamotrigine has been shown to be effective, with a relative low risk of switching. Several antidepressants appear effective as well, but again there is no (placebo-controlled) proof of their efficacy. The only exception is tranylcypromine which has been found to be more effective than imipramine. The switch ratio into (hypo)mania by tricyclic antidepressants seems to be higher than by several other antidepressants, especially the selective serotonin reuptake inhibitors. In the acute treatment of bipolar depression, it is recommended to start with a mood stabilizer, and to add an antidepressant after 4-6 weeks in case of nonresponse. In severer cases, one might consider to start earlier with the combination of a mood stabilizer and an antidepressant, and in refractory patients, there is a place for tranylcypromine. In the maintenance treatment, there are indications that the combined treatment of a mood stabilizer (mostly lithium) and an antidepressant (TCA) is associated with an increased risk of switches into (hypo)mania, when compared to a mood stabilizer alone. Therefore, it is recommended to try whether a monotherapy with a mood stabilizer is effective, before combining it with an antidepressant.
本文综述了9项关于双相抑郁急性治疗及转躁（轻躁）风险的对照研究的方法和结果。有迹象表明锂盐、卡马西平和丙戊酸盐等心境稳定剂有效，但尚无确凿证据。仅拉莫三嗪被证明有效，且转躁风险相对较低。几种抗抑郁药似乎也有效，但同样没有（安慰剂对照）证据证明其疗效。唯一的例外是反苯环丙胺，它被发现比丙咪嗪更有效。三环类抗抑郁药导致转躁（轻躁）的比例似乎高于其他几种抗抑郁药，尤其是选择性5-羟色胺再摄取抑制剂。在双相抑郁的急性治疗中，建议先使用心境稳定剂，若4-6周无反应则加用抗抑郁药。在病情较重的情况下，可考虑更早联合使用心境稳定剂和抗抑郁药，对于难治性患者，反苯环丙胺有应用价值。在维持治疗中，有迹象表明与单独使用心境稳定剂相比，心境稳定剂（主要是锂盐）和抗抑郁药（三环类抗抑郁药）联合治疗会增加转躁（轻躁）风险。因此，建议在将心境稳定剂与抗抑郁药联合使用之前，先尝试心境稳定剂单药治疗是否有效。
