van Calker Dietrich, Zobel Ingo, Dykierek Petra, Deimel Christoph Michael, Kech Sabine, Lieb Klaus, Berger Mathias, Schramm Elisabeth
Department of Psychiatry and Psychotherapy, University Medical Centre Freiburg, Germany.
J Affect Disord. 2009 Apr;114(1-3):243-53. doi: 10.1016/j.jad.2008.07.023. Epub 2008 Oct 11.
The full response to antidepressant pharmacotherapy is evident only after several weeks, but considerable improvements may already be visible within the first two weeks. Little is known about the potential influence of additional psychotherapy on the speed of response to antidepressant treatment. We have analysed in more severely depressed inpatients treated with antidepressants i) the predictive value of early improvement for later response and ii) the impact of additional psychotherapy on the time course of response.
124 patients with a major depression referred for hospitalized care were randomized to 5 weeks of sertraline (or amitriptyline as a second choice) plus either additional Interpersonal Psychotherapy modified for inpatients (IPT) or Clinical Management (CM). "Improvement" was defined as a decrease of > or = 20% on the 17-item Hamilton Rating Scale for Depression (HAMD). "Onset of response" was defined as sustained improvement (without any subsequent increase in the HAMD) culminating in 50% decrease on the HAMD by week 5.
Early improvement within two weeks was highly predictive of later stable response (> or = 50% decrease on the HAMD at weeks 4 and 5) or stable remission (HAMD score of < or = 7 at weeks 4 and 5), irrespective of the type of medication or additional IPT or CM. Survival analysis of the ITT sample revealed that patients of the IPT group had a shorter time to "onset of response" than patients in the CM group (median: 12 vs. 30 days; p=0.041, Log Rank). However, there was no significant difference in the time to onset of response, when more stringent conditions were used.
Due to ethical restrictions a comparison with an untreated placebo group could not be performed.
Early improvement is highly predictive for later stable response or remission in more severely depressed inpatients. In combination therapy, the additional benefit of psychotherapy occurs at least as rapid as the response to antidepressants.
抗抑郁药物治疗的完全疗效要在数周后才明显显现，但在最初两周内可能就已出现显著改善。关于额外的心理治疗对抗抑郁治疗反应速度的潜在影响，人们了解甚少。我们对使用抗抑郁药物治疗的重度抑郁症住院患者进行了分析，一是早期改善对后期反应的预测价值，二是额外的心理治疗对反应时间进程的影响。
124名因重度抑郁症需住院治疗的患者被随机分为两组，一组接受5周的舍曲林治疗（若舍曲林不可用则选用阿米替林），并额外接受针对住院患者的人际心理治疗（IPT）或临床管理（CM）。“改善”定义为在17项汉密尔顿抑郁量表（HAMD）上得分下降≥20%。“反应开始”定义为持续改善（HAMD得分无后续升高），到第5周时HAMD得分下降50%。
无论使用何种药物，以及是否额外接受IPT或CM，两周内的早期改善都高度预测后期的稳定反应（第4周和第5周时HAMD得分下降≥50%）或稳定缓解（第4周和第5周时HAMD得分≤7）。意向性分析样本的生存分析显示，IPT组患者达到“反应开始”的时间比CM组患者短（中位数：12天对30天；p = 0.041，对数秩检验）。然而，当采用更严格的条件时，反应开始时间没有显著差异。
由于伦理限制，无法与未治疗的安慰剂组进行比较。
早期改善对重度抑郁症住院患者后期的稳定反应或缓解具有高度预测性。在联合治疗中，心理治疗的额外益处至少与抗抑郁药物的反应速度一样快。
