Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
J Affect Disord. 2020 Apr 1;266:626-632. doi: 10.1016/j.jad.2020.01.149. Epub 2020 Jan 28.
Clinically relevant issues in the real-world treatment of depression have not always been captured by conventional treatment guidelines.
Certified psychiatrists of the Japanese Society of Clinical Neuropsychopharmacology were asked to evaluate treatment options regarding 23 clinical situations in the treatment of depression using a 9-point Likert scale (1="disagree" and 9="agree"). According to the responses of 114 experts, the options were categorized into first-, second-, and third-line treatments.
First-line antidepressants varied depending on predominant symptoms: escitalopram (mean ± standard deviation score, 7.8 ± 1.7) and sertraline (7.3 ± 1.7) were likely selected for anxiety; duloxetine (7.6 ± 1.9) and venlafaxine (7.2 ± 2.1) for loss of interest; mirtazapine for insomnia (8.2 ± 1.6), loss of appetite (7.9 ± 1.9), agitation and severe irritation (7.4 ± 2.0), and suicidal ideation (7.5 ± 1.9). While first-line treatment was switched to either an SNRI (7.7 ± 1.9) or mirtazapine (7.4 ± 2.0) in the case of non-response to an SSRI, switching to mirtazapine (7.1 ± 2.2) was recommended in the case of non-response to an SNRI, and vice versa (switching to an SNRI (7.0 ± 2.0) in the case of non-response to mirtazapine). Augmentation with aripiprazole was considered the first-line treatment for partial response to an SSRI (7.1 ± 2.3) or SNRI (7.0 ± 2.5).
The evidence level of expert consensus is considered low. All included experts were Japanese.
Recommendations made by experts in the field are useful and can supplement guidelines and informed decision making in real-world clinical practice. We suggest that pharmacological strategies for depression be flexible and that each patient's situational needs as well as the pharmacotherapeutic profile of medications be considered.
常规治疗指南并未充分涵盖抑郁症实际治疗中的相关临床问题。
日本临床神经精神药理学学会的认证精神科医生被要求使用 9 分 Likert 量表（1=不同意，9=同意）对 23 种抑郁症治疗情况下的治疗选择进行评估。根据 114 名专家的回复，这些选择被分为一线、二线和三线治疗。
根据主要症状，一线抗抑郁药有所不同：艾司西酞普兰（均数±标准差评分，7.8±1.7）和舍曲林（7.3±1.7）可能用于焦虑；度洛西汀（7.6±1.9）和文拉法辛（7.2±2.1）用于兴趣丧失；米氮平用于失眠（8.2±1.6）、食欲减退（7.9±1.9）、激越和严重烦躁（7.4±2.0）以及自杀意念（7.5±1.9）。如果 SSRI 治疗无反应，则将一线治疗转换为 SNRI（7.7±1.9）或米氮平（7.4±2.0）；如果 SNRI 治疗无反应，则建议换用米氮平（7.1±2.2），反之亦然（如果米氮平治疗无反应，则换用 SNRI（7.0±2.0））。阿立哌唑增效被认为是 SSRI（7.1±2.3）或 SNRI（7.0±2.5）部分反应的一线治疗。
专家共识的证据水平被认为较低。所有纳入的专家均为日本人。
该领域专家的建议是有用的，可以补充指南和知情决策，以适应实际临床实践。我们建议，抑郁症的药物治疗策略应具有灵活性，并考虑到每位患者的具体情况需求以及药物的治疗谱。
