Parker G, Roy K, Wilhelm K, Mitchell P
School of Psychiatry, The University of New South Wales, Randwick, Australia.
J Clin Psychiatry. 2001 Feb;62(2):117-25. doi: 10.4088/jcp.v62n0209.
Although efficacy studies suggest equal potency among antidepressant treatments, their effectiveness in clinical practice appears more variable, particularly in that the newer antidepressants may be less effective in either more severe depression or the melancholic subtype of depression. We pursue some factors that may impact the effectiveness of antidepressant treatments in a clinical sample.
A sample of 182 patients with DSM-IV major depressive disorder was assessed at baseline and 12 months later to establish treatments provided, identify patients who had recovered from the index episode, and quantify likely treatment determinants. Four systems for distinguishing patients with melancholic and non-melancholic depression were examined to assess for differential effects of the antidepressant strategies across those subtypes.
Multimodal therapy (commonly, psychotherapy combined with an antidepressant drug) and patients' frequent attribution of recovery to spontaneous improvement made for difficulty in disentangling recovery determinants. After excluding a spontaneous improvement component, electroconvulsive therapy (ECT) and the irreversible monoamine oxidase inhibitors (MAOIs) appeared to be the most effective therapies across the sample, while the reversible inhibitor of monoamine oxidase-A (RIMA) appeared to be the least effective. The distinct gradient of suggested effectiveness of various strategies appeared to be contributed to principally by the varied effectiveness of alternate treatments across the melancholic subtype, whereby ECT, tricyclic antidepressants, and MAOIs were the most effective, and the selective serotonin reuptake inhibitors (SSRIs), RIMAs, and antipsychotic drugs were much less effective. For the nonmelancholic disorders, the effectiveness of SSRIs appeared to be comparable with that of older antidepressants.
Although most patients received a physical treatment, they commonly judged psychotherapy and spontaneous improvement to be influential in their recovery. Reasons for such attributions are worthy of clarifying studies. Despite patients' concerns about the side effects and stigma of ECT as well as the side effects associated with the older antidepressants, these therapies were rated as more helpful by patients-and were more strongly associated with recovery-than the newer antidepressant drugs. Such overall results are compatible with an earlier study undertaken by us involving an independent sample and retrospective data. The overall gradient is clarified by studying depressive subtypes, allowing an important conclusion. Although the newer and older antidepressant drugs may be of similar effectiveness in nonmelancholic depression, the newer agents appear comparatively inferior for the treatment of melancholia, findings that have clinical implications and perhaps inform us about the pathogenesis of melancholia.
尽管疗效研究表明抗抑郁治疗之间的效力相当，但它们在临床实践中的有效性似乎更具变异性，尤其是新型抗抑郁药在更严重的抑郁症或抑郁症的忧郁亚型中可能效果较差。我们探讨了一些可能影响临床样本中抗抑郁治疗有效性的因素。
对182例符合《精神疾病诊断与统计手册》第四版（DSM-IV）重度抑郁症的患者样本在基线时和12个月后进行评估，以确定所提供的治疗方法，识别已从索引发作中康复的患者，并量化可能的治疗决定因素。研究了四种区分忧郁性抑郁症和非忧郁性抑郁症患者的系统，以评估抗抑郁策略在这些亚型中的不同效果。
多模式治疗（通常是心理治疗与抗抑郁药物联合使用）以及患者频繁将康复归因于自然改善，使得难以理清康复的决定因素。在排除自然改善因素后，电休克治疗（ECT）和不可逆单胺氧化酶抑制剂（MAOIs）似乎是整个样本中最有效的治疗方法，而单胺氧化酶-A可逆抑制剂（RIMA）似乎是最无效的。各种策略建议有效性的明显梯度似乎主要是由忧郁亚型中替代治疗的不同有效性造成的，其中ECT、三环类抗抑郁药和MAOIs最有效，而选择性5-羟色胺再摄取抑制剂（SSRIs）、RIMA和抗精神病药物效果则差得多。对于非忧郁性疾病，SSRIs的有效性似乎与 older antidepressants相当。
尽管大多数患者接受了物理治疗，但他们通常认为心理治疗和自然改善对其康复有影响。这种归因的原因值得进行明确的研究。尽管患者担心ECT的副作用和污名以及与 older antidepressants相关的副作用，但这些治疗方法被患者评为更有帮助，并且与康复的关联比新型抗抑郁药物更强。这些总体结果与我们早期进行的一项涉及独立样本和回顾性数据的研究一致。通过研究抑郁亚型可以明确总体梯度，从而得出一个重要结论。尽管新型和 older antidepressants在非忧郁性抑郁症中可能具有相似的有效性，但新型药物在治疗忧郁症方面似乎相对较差，这些发现具有临床意义，可能会让我们了解忧郁症的发病机制。
