Vittengl Jeffrey R, Jarrett Robin B, Weitz Erica, Hollon Steven D, Twisk Jos, Cristea Ioana, David Daniel, DeRubeis Robert J, Dimidjian Sona, Dunlop Boadie W, Faramarzi Mahbobeh, Hegerl Ulrich, Kennedy Sidney H, Kheirkhah Farzan, Mergl Roland, Miranda Jeanne, Mohr David C, Rush A John, Segal Zindel V, Siddique Juned, Simons Anne D, Cuijpers Pim
From the Department of Psychology, Truman State University, Kirksville, Mo.; the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas; the Department of Clinical Psychology and the EMGO Institute for Health and Care Research, VU University Amsterdam, the Netherlands; the Department of Psychology, Vanderbilt University, Nashville, Tenn.; the Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj, Romania; the Department of Psychology, University of Pennsylvania, Philadelphia; the Department of Psychology and Neuroscience, University of Colorado, Boulder; the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta; the Fatemeh Zahra Infertility and Reproductive Health Research Center and the Department of Psychiatry, Babol University of Medical Sciences, Babol, Iran; the Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany; the Department of Psychiatry, Faculty of Medicine, University of Toronto; the Department of Psychology, University of Toronto-Scarborough; the Health Services Research Center, Neuropsychiatric Institute, University of California, Los Angeles; the Department of Preventive Medicine and the Center for Behavioral Intervention Technologies, Feinberg School of Medicine, Northwestern University, Chicago; the Duke-National University of Singapore Graduate Medical School, Singapore; and the Department of Psychology, University of Notre Dame, Notre Dame, Ind.
Am J Psychiatry. 2016 May 1;173(5):481-90. doi: 10.1176/appi.ajp.2015.15040492. Epub 2016 Feb 12.
Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes.
Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models.
About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels.
Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.
尽管一般的抑郁症患者从认知行为疗法（CBT）或药物治疗中能获得一定程度的改善，但仍有一些患者出现不同的治疗结果。作者对负面及异常积极结果的发生率、预测因素和调节因素进行了测试。
16项比较CBT和药物治疗单相抑郁症的随机临床试验，纳入了1700名患者，提供了汉密尔顿抑郁量表（HAM-D）和/或贝克抑郁量表（BDI）的个体治疗前和治疗后评分。作者使用多水平模型检查了人口统计学和临床预测因素以及任何病情恶化（HAM-D或BDI得分增加≥1分）、可靠恶化（HAM-D得分增加≥8分或BDI得分增加≥9分）、极端无反应（治疗后HAM-D得分≥21分或BDI得分≥31分）、显著改善（HAM-D或BDI得分降低≥95%）和显著反应（治疗后HAM-D或BDI得分为0）的治疗调节因素。
约5%-7%的患者出现任何病情恶化，1%出现可靠恶化，4%-5%出现极端无反应，6%-10%出现显著改善，4%-5%出现显著反应。仅在HAM-D上显著改善（优势比=1.67）和脱落（优势比=1.67）在药物治疗中比在CBT中更常见。病情恶化或显著反应的患者治疗前症状水平较低，而极端无反应或显著改善的患者症状水平较高。
在比较CBT和药物治疗抑郁症的随机临床试验中，病情恶化和极端无反应，以及类似地，显著改善和显著反应，都很少发生。治疗前症状水平有助于预测负面和异常积极的结果，但不能指导CBT与药物治疗的选择。与CBT相比，药物治疗可能更频繁地产生临床医生评定的显著改善和脱落。
