Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7160, USA.
Depress Anxiety. 2011 Nov;28(11):989-98. doi: 10.1002/da.20898. Epub 2011 Sep 2.
We explored whether clinical outcomes differ by treatment strategy following initial antidepressant treatment failure among patients with and without clinically relevant symptom clusters.
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial was used to examine depression remission and response in patients with coexisting anxiety, atypical features, insomnia, and low energy. We applied propensity scoring to control for selection bias that precluded comparisons between augmentation and switch strategies in the original trial. Binomial regressions compared the likelihood of remission or response among patients with and without symptom clusters for switch versus augmentation strategies (n = 269 per arm); augmentation strategy type (n = 565); and switch strategy type (n = 727).
We found no statistically significant difference in remission or response rates between augmentation or switch strategies. However, symptom clusters did distinguish among augmentation and switch strategies, respectively. For patients with low energy, augmentation with buspirone was less likely to produce remission than augmentation with bupropion (remission Risk Ratio (RR): 0.54, 95% CI: 0.35-0.85, response RR: 0.67, 95% CI: 0.43, 1.03). Also, for patients with low energy, switching to venlafaxine or bupropion was less likely to produce remission than switching to sertraline (RR: 0.59, 95% CI: 0.36-0.97; RR: 0.63, 95% CI: 0.38-1.06, respectively).
Remission and response rates following initial antidepressant treatment failure did not differ by treatment strategy for patients with coexisting atypical symptoms or insomnia. However, some second-step treatments for depression may be more effective than others in the presence of coexisting low energy. Subsequent prospective testing is necessary to confirm these initial findings.
本研究旨在探讨在伴有或不伴有临床相关症状群的患者中，初始抗抑郁治疗失败后，不同治疗策略的临床结局是否存在差异。
本研究采用序列治疗选择缓解抑郁（STAR*D）试验，以评估同时存在焦虑、非典型特征、失眠和乏力的患者在接受增效治疗和转换治疗后的抑郁缓解和反应情况。我们应用倾向评分来控制原始试验中增效和转换策略之间选择偏倚，从而无法进行比较。二项式回归比较了伴有和不伴有症状群的患者在增效与转换策略（每组 269 例）、增效策略类型（565 例）和转换策略类型（727 例）之间的缓解或反应可能性。
我们未发现增效或转换策略之间的缓解或反应率存在统计学显著差异。然而，症状群确实可以区分增效和转换策略。对于乏力患者，与使用安非他酮增效相比，使用丁螺环酮增效不太可能产生缓解（缓解风险比（RR）：0.54，95%置信区间（CI）：0.35-0.85，反应 RR：0.67，95% CI：0.43-1.03）。同样，对于乏力患者，与转换为舍曲林相比，转换为文拉法辛或安非他酮不太可能产生缓解（RR：0.59，95% CI：0.36-0.97；RR：0.63，95% CI：0.38-1.06）。
对于同时存在非典型症状或失眠的患者，初始抗抑郁治疗失败后，治疗策略的缓解和反应率没有差异。然而，在存在共存的低能量情况下，某些抑郁症的二线治疗可能比其他治疗更有效。需要进一步的前瞻性研究来证实这些初步发现。
