Arroll Bruce, Macgillivray Steve, Ogston Simon, Reid Ian, Sullivan Frank, Williams Brian, Crombie Iain
Department of General Practice and Primary Health Care, University of Auckland, NZ.
Ann Fam Med. 2005 Sep-Oct;3(5):449-56. doi: 10.1370/afm.349.
Depression is common in primary care. There are no systematic reviews of depression treatment comparing antidepressants with placebo; hence, we do not know whether these medications are effective in primary care.
We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Group register of controlled trials, MEDLINE, International Pharmaceutical abstracts, PsycINFO, and EMBASE. Abstracts of potential studies were reviewed independently by 2 authors. Studies needed to include randomized controlled trials of either a tricyclic antidepressant (TCA) or selective serotonin reuptake inhibitor (SSRI), or both, and placebo in a primary care setting. The data and quality of the studies were extracted and assessed by 2 authors blind to the other's choice. Disagreements were resolved by discussion. The main outcome measures were the standardized mean difference and weighted mean difference of the final mean depression scores, the relative risk of improvement, and the number withdrawing because of side effects. Pooling of results was done using Review Manager 4.2.2.
There were 10 studies in which TCAs were compared with placebo, 3 in which SSRIs were compared with placebo, and 2 with both compared with placebo. One half of the studies were of low methodological quality, and nearly all studies were of short duration, typically 6 to 8 weeks. Pooled estimates of efficacy data showed a relative risk of 1.26 (95% CI, 1.12-1.42) for improvement with TCAs compared with placebo; For SSRIs, relative risk was 1.37 (95% CI, 1.21-1.55). Most patients, 56% to 60%, responded well to active treatment compared with 42% to 47% for placebo. The number needed to treat for TCAs was about 4, and for SSRIs it was 6. The numbers needed to harm (for withdrawal caused by side effects) ranged from 5 to 11 for TCAs and 21 to 94 for SSRIs. Low-dose (100 mg or 75 mg) as well as high-dose TCAs were effective.
This systematic review is the first comparing antidepressants with placebo for treatment of depression in primary care. Both TCAs and SSRIs are effective. This review is also the first to show that low-dose TCAs are effective in primary care. Prescribing antidepressants in primary care is a more effective clinical activity than prescribing placebo.
抑郁症在初级保健中很常见。目前尚无关于抑郁症治疗的系统评价，比较抗抑郁药与安慰剂的疗效；因此，我们不清楚这些药物在初级保健中是否有效。
我们检索了Cochrane协作网抑郁症、焦虑症和神经症组的对照试验注册库、MEDLINE、国际药学文摘、PsycINFO和EMBASE。两位作者独立审查了潜在研究的摘要。研究需包括在初级保健环境中进行的三环类抗抑郁药（TCA）或选择性5-羟色胺再摄取抑制剂（SSRI），或两者与安慰剂的随机对照试验。由两位对彼此选择不知情的作者提取并评估研究数据和质量。分歧通过讨论解决。主要结局指标为最终平均抑郁评分的标准化均数差和加权均数差、改善的相对风险以及因副作用退出研究的人数。使用Review Manager 4.2.2对结果进行汇总。
有10项研究比较了TCA与安慰剂，3项研究比较了SSRI与安慰剂，2项研究同时比较了TCA和SSRI与安慰剂。一半的研究方法学质量较低，几乎所有研究持续时间较短，通常为6至8周。疗效数据的汇总估计显示，与安慰剂相比，TCA改善的相对风险为1.26（95%CI，1.12 - 1.42）；对于SSRI，相对风险为1.37（95%CI，1.21 - 1.55）。与安慰剂组的42%至47%相比，大多数患者（56%至60%）对积极治疗反应良好。TCA的治疗所需人数约为4，SSRI为6。因副作用导致退出研究的伤害所需人数，TCA为5至11，SSRI为21至94。低剂量（100mg或75mg）以及高剂量的TCA均有效。
本系统评价首次比较了抗抑郁药与安慰剂在初级保健中治疗抑郁症的疗效。TCA和SSRI均有效。本评价也是首次表明低剂量TCA在初级保健中有效。在初级保健中开具抗抑郁药比开具安慰剂是更有效的临床行为。
