Rush A John, Trivedi Madhukar H, Wisniewski Stephen R, Stewart Jonathan W, Nierenberg Andrew A, Thase Michael E, Ritz Louise, Biggs Melanie M, Warden Diane, Luther James F, Shores-Wilson Kathy, Niederehe George, Fava Maurizio
Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-9086, USA.
N Engl J Med. 2006 Mar 23;354(12):1231-42. doi: 10.1056/NEJMoa052963.
After unsuccessful treatment for depression with a selective serotonin-reuptake inhibitor (SSRI), it is not known whether switching to one antidepressant is more effective than switching to another.
We randomly assigned 727 adult outpatients with a nonpsychotic major depressive disorder who had no remission of symptoms or could not tolerate the SSRI citalopram to receive one of the following drugs for up to 14 weeks: sustained-release bupropion (239 patients) at a maximal daily dose of 400 mg, sertraline (238 patients) at a maximal daily dose of 200 mg, or extended-release venlafaxine (250 patients) at a maximal daily dose of 375 mg. The study was conducted in 18 primary and 23 psychiatric care settings. The primary outcome was symptom remission, defined by a total score of 7 or less on the 17-item Hamilton Rating Scale for Depression (HRSD-17) at the end of the study. Scores on the Quick Inventory of Depressive Symptomatology - Self Report (QIDS-SR-16), obtained at treatment visits, determined secondary outcomes, including remission (a score of 5 or less at exit) and response (a reduction of 50 percent or more on baseline scores).
Remission rates as assessed by the HRSD-17 and the QIDS-SR-16, respectively, were 21.3 percent and 25.5 percent for sustained-release bupropion, 17.6 percent and 26.6 percent for sertraline, and 24.8 percent and 25.0 percent for extended-release venlafaxine. QIDS-SR-16 response rates were 26.1 percent for sustained-release bupropion, 26.7 percent for sertraline, and 28.2 percent for extended-release venlafaxine. These treatments did not differ significantly with respect to outcomes, tolerability, or adverse events.
After unsuccessful treatment with an SSRI, approximately one in four patients had a remission of symptoms after switching to another antidepressant. Any one of the medications in the study provided a reasonable second-step choice for patients with depression. (ClinicalTrials.gov number, NCT00021528.).
使用选择性5-羟色胺再摄取抑制剂（SSRI）治疗抑郁症失败后，换用一种抗抑郁药是否比换用另一种更有效尚不清楚。
我们将727例患有非精神病性重度抑郁症的成年门诊患者随机分组，这些患者症状未缓解或无法耐受SSRI西酞普兰，让他们接受以下药物之一治疗长达14周：最大日剂量400mg的缓释安非他酮（239例患者）、最大日剂量200mg的舍曲林（238例患者）或最大日剂量375mg的缓释文拉法辛（250例患者）。该研究在18个初级医疗机构和23个精神科护理机构进行。主要结局为症状缓解，定义为研究结束时17项汉密尔顿抑郁评定量表（HRSD-17）总分≤7分。治疗访视时获得的抑郁症状快速自评量表（QIDS-SR-16）评分确定次要结局，包括缓解（出组时评分≤5分）和反应（较基线评分降低50%或更多）。
根据HRSD-17和QIDS-SR-16评估，缓释安非他酮的缓解率分别为21.3%和25.5%，舍曲林分别为17.6%和26.6%，缓释文拉法辛分别为24.8%和25.0%。QIDS-SR-16反应率方面，缓释安非他酮为26.1%，舍曲林为26.7%，缓释文拉法辛为28.2%。这些治疗在结局、耐受性或不良事件方面无显著差异。
使用SSRI治疗失败后，约四分之一的患者换用另一种抗抑郁药后症状缓解。研究中的任何一种药物都为抑郁症患者提供了合理的第二步选择。（ClinicalTrials.gov编号，NCT00021528。）
