Thase Michael E, Friedman Edward S, Biggs Melanie M, Wisniewski Stephen R, Trivedi Madhukar H, Luther James F, Fava Maurizio, Nierenberg Andrew A, McGrath Patrick J, Warden Diane, Niederehe George, Hollon Steven D, Rush A John
Department of Psychiatry, University of Pittsburgh Medical Center, 3811 OHara St., Pittsburgh, PA 15213-2593, and Massachusetts General Hospital, USA.
Am J Psychiatry. 2007 May;164(5):739-52. doi: 10.1176/ajp.2007.164.5.739.
The authors compared the effectiveness of cognitive therapy and pharmacotherapy as second-step strategies for outpatients with major depressive disorder who had received inadequate benefit from an initial trial of citalopram. Cognitive therapy was compared with medication augmentation and switch strategies.
An equipoise-stratified randomization strategy was used to assign participants to either augmentation of citalopram with cognitive therapy (N=65) or medication (N=117; either sustained-release bupropion [N=56] or buspirone [N=61]) or switch to cognitive therapy (N=36) or another antidepressant (N=86; sertraline [N=27], sustained-release bupropion [N=28], or extended-release venlafaxine [N=31]). Treatment outcomes and the frequency of adverse events were compared.
Less than one-third of participants consented to randomization strata that permitted comparison of cognitive therapy and pharmacotherapy. Among participants who were assigned to second-step treatment, those who received cognitive therapy (either alone or in combination with citalopram) had similar response and remission rates to those assigned to medication strategies. For those who continued on citalopram, medication augmentation resulted in significantly more rapid remission than augmentation with cognitive therapy. Among those who discontinued citalopram, there were no significant differences in outcome, although those who switched to a different antidepressant reported significantly more side effects than those who received cognitive therapy alone.
After an unsatisfactory response to citalopram, patients who consented to random assignment to either cognitive therapy or alternative pharmacologic strategies had generally comparable outcomes. Pharmacologic augmentation was more rapidly effective than cognitive therapy augmentation of citalopram, whereas switching to cognitive therapy was better tolerated than switching to a different antidepressant.
作者比较了认知疗法与药物疗法作为第二步治疗策略对接受西酞普兰初始治疗疗效欠佳的重度抑郁症门诊患者的有效性。将认知疗法与药物增效及换药策略进行了比较。
采用均衡分层随机化策略，将参与者分配至以下组：西酞普兰联合认知疗法增效组（N = 65）、药物组（N = 117；缓释安非他酮 [N = 56] 或丁螺环酮 [N = 61]）、转为认知疗法组（N = 36）或换用另一种抗抑郁药组（N = 86；舍曲林 [N = 27]、缓释安非他酮 [N = 28] 或缓释文拉法辛 [N = 31]）。比较治疗结果及不良事件发生频率。
不到三分之一的参与者同意进入允许比较认知疗法和药物疗法的随机化分层。在被分配接受第二步治疗的参与者中，接受认知疗法（单独或与西酞普兰联合）的参与者与接受药物策略的参与者的缓解率和应答率相似。对于继续使用西酞普兰的患者而言，药物增效比认知疗法增效能显著更快地实现缓解。在停用西酞普兰的患者中，结局无显著差异，尽管换用另一种抗抑郁药的患者报告的副作用明显多于仅接受认知疗法的患者。
对西酞普兰反应不佳后，同意随机分配至认知疗法或替代药物策略的患者，其总体结局大致相当。药物增效比西酞普兰联合认知疗法增效起效更快，而转为认知疗法比换用另一种抗抑郁药耐受性更好。
