难治性躁狂症的定义、评估及管理

Keck P E, McElroy S L

Department of Psychiatry, University of Cincinnati College of Medicine, 231 Albert Sabin Way, P.O. Box 670559, Cincinnati, OH 45267-0559, USA.

Psychopharmacol Bull. 2001 Autumn;35(4):130-48.

Treatment refractory mania is a common clinical problem. Unfortunately, the treatment of acute mania refractory to standard antimanic and mood-stabilizing medications has not been well studied. This review will discuss the definition, evaluation, and differential diagnosis of treatment refractory mania; the definition of an adequate treatment trial for acute mania; the identification of predictors of treatment response; and clinical trials in treatment refractory mania. Computerized searches of the medical literature regarding treatment refractory mania were undertaken using Paperchase (1966-2001), and bibliographies of all articles identified were reviewed to identify all relevant case reports, case series, clinical trials, and methodologic and phenomenologic reports. Operational definitions of treatment refractory mania were proposed based on sequential nonresponse to adequate trials of antimanic agents. The average time of onset of antimanic agents studied in randomized trials was 1 to 2 weeks. Clinical tools for assessing treatment response retrospectively and prospectively appear to have an important role in managing medication treatment in patients with bipolar disorder. Relatively few reliable predictors of treatment response to established antimanic agents have been identified. However, these predictors represent important factors in treatment selection to minimize the probability of nonresponse. Very few randomized, controlled trials of antimanic agents have been conducted in patients with treatment refractory mania. Field testing of treatment algorithms and systematic collection of data from naturalistic treatment studies should provide much-needed data regarding the efficacy of antimanic agents in treatment refractory mania.

难治性躁狂是一个常见的临床问题。遗憾的是，对于标准抗躁狂和心境稳定剂治疗无效的急性躁狂症的治疗，尚未得到充分研究。本综述将讨论难治性躁狂的定义、评估和鉴别诊断；急性躁狂充分治疗试验的定义；治疗反应预测因素的识别；以及难治性躁狂的临床试验。使用Paperchase（1966 - 2001年）对关于难治性躁狂的医学文献进行了计算机检索，并对所有已识别文章的参考文献进行了审查，以识别所有相关的病例报告、病例系列、临床试验以及方法学和现象学报告。基于对抗躁狂药物充分试验的连续无反应，提出了难治性躁狂的操作性定义。随机试验中研究的抗躁狂药物的平均起效时间为1至2周。回顾性和前瞻性评估治疗反应的临床工具似乎在双相情感障碍患者的药物治疗管理中具有重要作用。已确定的对既定抗躁狂药物治疗反应的可靠预测因素相对较少。然而，这些预测因素是治疗选择中的重要因素，可将无反应的可能性降至最低。针对难治性躁狂患者进行的抗躁狂药物随机对照试验非常少。治疗算法的现场测试以及来自自然主义治疗研究的数据系统收集，应能提供关于抗躁狂药物在难治性躁狂中疗效的急需数据。