Wilkinson Philip, Izmeth Zehanah
Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK, OX3 7JX.
Cochrane Database Syst Rev. 2016 Sep 9;9(9):CD006727. doi: 10.1002/14651858.CD006727.pub3.
Depressive illness is common in old age. Prevalence in the community of case level depression is around 15% and milder forms of depression are more common. It causes significant distress and disability. The number of people over the age of 60 years is expected to double by 2050 and so interventions for this often long-term and recurrent condition are increasingly important. The causes of late-life depression differ from depression in younger adults and so it is appropriate to study it separately.This is an update of a Cochrane review first published in 2012.
To examine the efficacy of antidepressants and psychological therapies in preventing the relapse and recurrence of depression in older people.
We performed a search of the Cochrane Common Mental Disorders Group's specialised register (the CCMDCTR) to 13 July 2015. The CCMDCTR includes relevant randomised controlled trials (RCTs) from the following bibliographic databases: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also conducted a cited reference search on 13 July 2015 of the Web of Science for citations of primary reports of included studies.
Both review authors independently selected studies. We included RCTs involving people aged 60 years and over successfully treated for an episode of depression and randomised to receive continuation and maintenance treatment with antidepressants, psychological therapies, or a combination.
Two review authors independently extracted data. The primary outcome for benefit was recurrence rate of depression (reaching a cut-off on any depression rating scale) at 12 months and the primary outcome for harm was drop-outs at 12 months. Secondary outcomes included relapse/recurrence rates at other time points, global impression of change, social functioning, and deaths. We performed meta-analysis using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with 95% confidence intervals (CI).
This update identified no further trials. Seven studies from the previous review met the inclusion criteria (803 participants). Six compared antidepressant medication with placebo; two involved psychological therapies. There was marked heterogeneity between the studies.Comparing antidepressants with placebo on the primary outcome for benefit, there was a statistically significant difference favouring antidepressants in reducing recurrence compared with placebo at 12 months with a GRADE rating of low for quality of evidence (three RCTs, n = 247, RR 0.67, 95% CI 0.54 to 0.82; number needed to treat for an additional beneficial outcome (NNTB) 5). Comparing antidepressants with placebo on the primary outcome for harms, there was no difference in drop-out rates at 12 months' follow-up, with a GRADE rating of low.There was no significant difference between psychological treatment and antidepressant in recurrence rates at 12 months (one RCT, n = 53) or between combination treatment and antidepressant alone at 12 months.
AUTHORS' CONCLUSIONS: This updated Cochrane review supports the findings of the original 2012 review. The long-term benefits and harm of continuing antidepressant medication in the prevention of recurrence of depression in older people are not clear and no firm treatment recommendations can be made on the basis of this review. Continuing antidepressant medication for 12 months appears to be helpful with no increased harms; however, this was based on only three small studies, relatively few participants, use of a range of antidepressant classes, and clinically heterogeneous populations. Comparisons at other time points did not reach statistical significance.Data on psychological therapies and combined treatments were too limited to draw any conclusions on benefits and harms.The quality of the evidence used in reaching these conclusions was low and the review does not, therefore, offer clear guidance to clinicians and patients on best practice and matching interventions to particular patient characteristics.Of note, we identified no new studies that evaluated pharmacological or psychological interventions in the continuation and maintenance treatment of depression in older people. We are aware of studies conducted since the previous review that included both older people and adults under the age of 65 years, but these fall outside of the remit of this review. We believe that there remains a need for studies solely recruiting older people, particularly the 'older old' with comorbid medical problems. However, these studies are likely to be challenging to conduct and may not, so far, have been prioritised by funders.
抑郁症在老年人群中很常见。社区中重度抑郁症的患病率约为15%，轻度抑郁症更为常见。它会导致严重的痛苦和残疾。预计到2050年，60岁以上的人口数量将翻倍，因此针对这种通常为长期且易复发的疾病的干预措施变得越来越重要。老年期抑郁症的病因与年轻人的抑郁症不同，因此单独研究它是合适的。这是对2012年首次发表的Cochrane综述的更新。
探讨抗抑郁药和心理治疗在预防老年人抑郁症复发方面的疗效。
我们检索了Cochrane常见精神障碍小组的专门注册库（CCMDCTR）至2015年7月13日。CCMDCTR包括来自以下文献数据库的相关随机对照试验（RCT）：Cochrane图书馆（所有年份）、MEDLINE（1950年至今）、EMBASE（1974年至今）和PsycINFO（1967年至今）。我们还于2015年7月13日在科学网对纳入研究的主要报告的引用进行了引用文献检索。
两位综述作者独立选择研究。我们纳入了涉及60岁及以上人群的RCT，这些人群因抑郁症发作接受了成功治疗，并被随机分配接受抗抑郁药、心理治疗或联合治疗的延续和维持治疗。
两位综述作者独立提取数据。有益的主要结局是12个月时抑郁症的复发率（在任何抑郁评定量表上达到临界值），有害的主要结局是12个月时的退出率。次要结局包括其他时间点的复发/再发率、总体变化印象、社会功能和死亡情况。我们对二分类结局使用风险比（RR），对连续结局使用均值差（MD）进行荟萃分析，并给出95%置信区间（CI）。
本次更新未发现进一步的试验。上次综述中的七项研究符合纳入标准（803名参与者）。六项研究比较了抗抑郁药与安慰剂；两项涉及心理治疗。各研究之间存在明显的异质性。在有益的主要结局方面，将抗抑郁药与安慰剂进行比较，与安慰剂相比，抗抑郁药在降低12个月时的复发率方面有统计学显著差异，证据质量的GRADE评分为低（三项RCT，n = 247，RR 0.67，95% CI 0.54至0.82；获得额外有益结局所需治疗人数（NNTB）为5）。在有害的主要结局方面，将抗抑郁药与安慰剂进行比较，12个月随访时的退出率没有差异，GRADE评分为低。12个月时心理治疗与抗抑郁药在复发率方面没有显著差异（一项RCT，n = 53），12个月时联合治疗与单独使用抗抑郁药之间也没有显著差异。
本次更新的Cochrane综述支持2012年原始综述的结果。继续使用抗抑郁药预防老年人抑郁症复发的长期益处和危害尚不清楚，基于本次综述无法给出明确的治疗建议。继续使用抗抑郁药12个月似乎有帮助且不会增加危害；然而，这仅基于三项小型研究、相对较少的参与者、使用了多种抗抑郁药类别以及临床异质性人群。其他时间点的比较未达到统计学显著差异。关于心理治疗和联合治疗的数据过于有限，无法就益处和危害得出任何结论。得出这些结论所使用的证据质量较低，因此该综述并未为临床医生和患者提供关于最佳实践以及根据特定患者特征匹配干预措施的明确指导。值得注意的是，我们未发现评估老年人抑郁症延续和维持治疗中药理学或心理干预的新研究。我们知道自上次综述以来进行的研究包括了老年人和65岁以下的成年人，但这些不在本次综述的范围内。我们认为仍然需要专门招募老年人的研究，特别是患有合并症的“高龄老人”。然而，这些研究可能具有挑战性，并且到目前为止可能未被资助者列为优先事项。
