Whittington Craig J, Kendall Tim, Pilling Steve
CORE, Sub-department of Clinical Health Psychology, University College London, London, UK.
Curr Opin Psychiatry. 2005 Jan;18(1):21-5.
This article summarizes recent developments in the use of selective serotonin reuptake inhibitors and atypical antidepressants to treat children and adolescents with depression at a time when their use in this context has generated considerable controversy and confusion for clinicians, patients and their families. Recent reports and recommendations from drug regulators in the UK and the US are discussed, alongside other reviews and recently published randomized controlled trials.
It is now widely accepted that these drugs increase the risk of suicide-related behaviours and although recently published trials have been more positive, a meta-analysis of published and unpublished trials has cast doubt about efficacy. The evidence for publication bias in the studies considered is also raised and the implications discussed. There is some evidence, however, that the combination of psychological treatment with fluoxetine may be both effective and protective against the increased risk of suicide-related behaviours, although problems over blinding suggest further research is needed to clarify this potentially positive combination treatment.
Current evidence supports the conclusions of the UK drug regulator in warning against the use of all the newer antidepressants except fluoxetine in this age group, and alternative therapies should be sought in the first instance. Caution is needed in interpreting drug company sponsored trials given the evidence of selective reporting and publication bias. Combining fluoxetine with a psychological treatment such as cognitive-behavioural therapy is also worth considering.
本文总结了选择性5-羟色胺再摄取抑制剂和非典型抗抑郁药在治疗儿童及青少年抑郁症方面的最新进展，目前这类药物在该领域的应用已给临床医生、患者及其家属带来了相当大的争议和困惑。文章讨论了英国和美国药品监管机构的近期报告及建议，同时也提及了其他综述以及最近发表的随机对照试验。
目前已广泛认可这些药物会增加自杀相关行为的风险，尽管近期发表的试验结果较为乐观，但一项对已发表和未发表试验的荟萃分析对其疗效提出了质疑。文中还指出了所考虑研究中存在发表偏倚的证据并讨论了其影响。不过，有证据表明心理治疗与氟西汀联合使用可能既有效又能降低自杀相关行为增加的风险，尽管盲法方面存在问题，这表明需要进一步研究来阐明这种潜在的积极联合治疗方法。
当前证据支持英国药品监管机构的结论，即警告除氟西汀外的所有新型抗抑郁药在该年龄组中的使用，应首先寻求替代疗法。鉴于存在选择性报告和发表偏倚的证据，在解读制药公司赞助的试验时需谨慎。将氟西汀与认知行为疗法等心理治疗方法联合使用也值得考虑。
