Ghaemi S Nassir, Hsu Douglas J, Soldani Federico, Goodwin Frederick K
Bipolar Disorder Research Program, Cambridge Hospital, Cambridge, MA and Harvard Medical School, Boston, MA 02139, USA.
Bipolar Disord. 2003 Dec;5(6):421-33. doi: 10.1046/j.1399-5618.2003.00074.x.
The 2002 American Psychiatric Association (APA) guidelines for the treatment of bipolar disorder recommended more conservative use of antidepressants. This change in comparison with previous APA guidelines has been criticized, especially from some groups in Europe. The Munich group in particular has published a critique of assumptions underlying the conservative recommendations of the recent APA treatment guidelines. In this paper, we re-examine the argument put forward by the Munich group, and we demonstrate that indeed, conceptually and empirically, there is a strong rationale for a cautious approach to antidepressant use in bipolar disorder, consistent with, and perhaps even more strongly than, the APA guidelines. This rationale is based on support for the following four propositions: (i) The risk of antidepressant induced mood-cycling is high, (ii) Antidepressants have not been shown to definitively prevent completed suicides and reduce mortality, whereas lithium has, (iii) Antidepressants have not been shown to be more effective than mood stabilizers in acute bipolar depression and have been shown to be less effective than mood stabilizers in preventing depressive relapse in bipolar disorder and (iv) Mood stabilizers, especially lithium and lamotrigine, have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes. We therefore draw three conclusions from this interpretation of the evidence: (i) There are significant risks of mania and long-term worsening of bipolar illness with antidepressants, (ii) Antidepressants should generally be reserved for severe cases of acute bipolar depression and not routinely used in mild to moderate cases and (iii) Antidepressants should be discontinued after recovery from the depressive episode, and maintained only in those who repeatedly relapse after antidepressant discontinuation (a minority we judge to represent only about 15-20% of bipolar depressed patients).
2002年美国精神病学协会（APA）双相情感障碍治疗指南建议更谨慎地使用抗抑郁药。与之前的APA指南相比，这一变化受到了批评，尤其是来自欧洲的一些团体。特别是慕尼黑小组发表了对近期APA治疗指南保守建议背后假设的批评。在本文中，我们重新审视了慕尼黑小组提出的论点，并证明事实上，从概念和实证角度来看，对于双相情感障碍使用抗抑郁药采取谨慎态度有充分的理由，这与APA指南一致，甚至可能更有力。这一理由基于对以下四个命题的支持：（i）抗抑郁药诱发情绪循环的风险很高；（ii）抗抑郁药尚未被证明能明确预防自杀完成和降低死亡率，而锂盐已被证明有此作用；（iii）在急性双相抑郁中，抗抑郁药未被证明比心境稳定剂更有效，且在预防双相情感障碍抑郁复发方面已被证明比心境稳定剂效果更差；（iv）心境稳定剂，尤其是锂盐和拉莫三嗪，已被证明在双相抑郁发作的急性和预防性治疗中有效。因此，我们从对证据的这种解读中得出三个结论：（i）使用抗抑郁药存在双相情感障碍躁狂和长期病情恶化的重大风险；（ii）抗抑郁药通常应保留用于急性双相抑郁的严重病例，而不应在轻至中度病例中常规使用；（iii）抑郁发作恢复后应停用抗抑郁药，仅在停用抗抑郁药后反复复发的患者中维持使用（我们判断这一小部分患者仅占双相抑郁患者的约15 - 20%）。
