From the Department of Health Psychology (Doyle), Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Psychiatry (Freedland, Carney), Washington University School of Medicine, St Louis, Missouri; Developmental Psychology (de Jonge), University of Groningen, Groningen, the Netherlands; College of Medicine and Health (Dickens), University of Exeter, Exeter, United Kingdom; Department of Psychology (Pedersen), University of Southern Denmark, Odense, Denmark; Health Outcomes Research Centre (Sorensen), Royal College of Surgeons in Ireland, Dublin, Ireland; and School of Psychology (Dempster), Queen's University Belfast, Belfast, United Kingdom.
Psychosom Med. 2021 Jun 1;83(5):423-431. doi: 10.1097/PSY.0000000000000944.
Depression is common in patients with coronary artery disease (CAD) and is associated with poor outcomes. Although different treatments are available, it is unclear which are best or most acceptable to patients, so we conducted a network meta-analysis of evidence from randomized controlled trials (RCTs) of different depression treatments to ascertain relative efficacy.
We searched for systematic reviews of RCTs of depression treatments in CAD and updated these with a comprehensive search for recent individual RCTs. RCTs comparing depression treatments (pharmacological, psychotherapeutic, combined pharmacological/psychotherapeutic, exercise, collaborative care) were included. Primary outcomes were acceptability (dropout rate) and change in depressive symptoms 8 week after treatment commencement. Change in 26-week depression and mortality were secondary outcomes. Frequentist, random-effects network meta-analysis was used to synthesize the evidence, and evidence quality was evaluated following Grading of Recommendations, Assessment, Development and Evaluations recommendations.
Thirty-three RCTs (7240 participants) provided analyzable data. All treatments were equally acceptable. At 8 weeks, combination therapy (1 study), exercise (1 study), and antidepressants (10 studies) yielded the strongest effects versus comparators. At 26 weeks, antidepressants were consistently effective, but psychotherapy was only effective versus usual care. There were no differences in treatment groups for mortality. Grading of Recommendations, Assessment, Development and Evaluations ratings ranged from very low to low.
Overall, the evidence was limited and biased. Although all treatments for post-CAD depression were equally acceptable, antidepressants have the most robust evidence base and should be the first-line treatment. Combinations of antidepressants and psychotherapy, along with exercise, could be more effective than antidepressants alone but require further rigorous, multiarm intervention trials.Systematic Review Registration: CRD42018108293 (International Prospective Register of Systematic Reviews).
抑郁症在冠心病（CAD）患者中很常见，与不良结局相关。虽然有不同的治疗方法，但尚不清楚哪种方法对患者最好或最可接受，因此我们进行了一项针对不同抑郁症治疗方法的随机对照试验（RCT）的网络荟萃分析，以确定相对疗效。
我们搜索了 CAD 抑郁症治疗的系统评价 RCT，并通过全面搜索最新的单个 RCT 更新了这些评价。纳入了比较抑郁症治疗（药物治疗、心理治疗、药物联合心理治疗、运动、协作护理）的 RCT。主要结局是治疗开始后 8 周时的可接受性（退出率）和抑郁症状的变化。26 周时的抑郁和死亡率是次要结局。使用固定效应网络荟萃分析对证据进行综合，并按照推荐、评估、发展和评估建议对证据质量进行评估。
33 项 RCT（7240 名参与者）提供了可分析的数据。所有治疗方法的可接受性都相同。在 8 周时，联合治疗（1 项研究）、运动（1 项研究）和抗抑郁药（10 项研究）与对照相比效果最强。在 26 周时，抗抑郁药始终有效，但心理治疗仅对常规护理有效。治疗组之间的死亡率没有差异。推荐、评估、发展和评估的分级范围从极低到低。
总的来说，证据有限且存在偏倚。尽管 CAD 后抑郁症的所有治疗方法都同样可接受，但抗抑郁药的证据基础最有力，应作为一线治疗方法。抗抑郁药联合心理治疗和运动可能比单独使用抗抑郁药更有效，但需要进一步进行严格的、多臂干预试验。
CRD42018108293（国际前瞻性系统评价注册）。
