Wisniewski Stephen R, Fava Maurizio, Trivedi Madhukar H, Thase Michael E, Warden Diane, Niederehe George, Friedman Edward S, Biggs Melanie M, Sackeim Harold A, Shores-Wilson Kathy, McGrath Patrick J, Lavori Philip W, Miyahara Sachiko, Rush A John
Department of Psychiatry, Epidemiology Data Center, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, and Clinical Psychopharmacology Unit, Massachusetts General Hospital, Boston, USA.
Am J Psychiatry. 2007 May;164(5):753-60. doi: 10.1176/ajp.2007.164.5.753.
Treatment of major depressive disorder typically entails implementing treatments in a stepwise fashion until a satisfactory outcome is achieved. This study sought to identify factors that affect patients' willingness to accept different second-step treatment approaches.
Participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial who had unsatisfactory outcomes after initial treatment with citalopram were eligible for a randomized second-step treatment trial. An equipoise-stratified design allowed participants to exclude or include specific treatment strategies. Analyses were conducted to identify factors associated with the acceptability of the following second-step treatments: cognitive therapy versus no cognitive therapy, any switch strategy versus any augmentation strategy (including cognitive therapy), and a medication switch strategy only versus a medication augmentation strategy only.
Of the 1,439 participants who entered second-step treatment, 1% accepted all treatment strategies, 3% accepted only cognitive therapy, and 26% accepted cognitive therapy (thus, 71% did not accept cognitive therapy). Those with higher educational levels or a family history of a mood disorder were more likely to accept cognitive therapy. Participants in primary care settings and those who experienced a greater side effect burden or a lower reduction in symptom severity with citalopram were more likely to accept a switch strategy as compared with an augmentation strategy. Those with concurrent drug abuse and recurrent major depressive disorder were less likely to accept a switch strategy.
Few participants accepted all treatments. Acceptance of cognitive therapy was primarily associated with sociodemographic characteristics, while acceptance of a treatment switch was associated with the results of the initial treatment.
重度抑郁症的治疗通常需要逐步实施治疗方法，直至取得满意的疗效。本研究旨在确定影响患者接受不同第二步治疗方法意愿的因素。
在缓解抑郁症的序贯治疗替代方案（STAR*D）试验中，接受西酞普兰初始治疗后疗效不佳的参与者有资格参加随机第二步治疗试验。一种平衡分层设计允许参与者排除或纳入特定的治疗策略。进行分析以确定与以下第二步治疗的可接受性相关的因素：认知疗法与非认知疗法、任何换药策略与任何增效策略（包括认知疗法）、仅药物换药策略与仅药物增效策略。
在进入第二步治疗的1439名参与者中，1%接受了所有治疗策略，3%仅接受认知疗法，26%接受了认知疗法（因此，71%不接受认知疗法）。教育水平较高或有情绪障碍家族史的人更有可能接受认知疗法。与增效策略相比，初级保健机构的参与者以及那些使用西酞普兰时副作用负担更大或症状严重程度降低较少的人更有可能接受换药策略。同时患有药物滥用和复发性重度抑郁症的人接受换药策略的可能性较小。
很少有参与者接受所有治疗。对认知疗法的接受主要与社会人口学特征相关，而对治疗换药的接受与初始治疗的结果相关。
