Lustman P J, Griffith L S, Clouse R E, Freedland K E, Eisen S A, Rubin E H, Carney R M, McGill J B
Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA.
Psychosom Med. 1997 May-Jun;59(3):241-50. doi: 10.1097/00006842-199705000-00007.
Depression is a prevalent and chronic condition in diabetes and is associated with poor glucose regulation and poor compliance with diabetes treatment. This investigation evaluated the effects of nortriptyline on depression and glycemic control to see whether depression in diabetes is treatable and whether restoring mental health contributes to improved medical outcome.
Sixty-eight diabetic patients with poor glycemic control, 28 of whom had active major depression (DSM-IIIR), completed a randomized, placebo-controlled, double-blind trial involving 8 weeks of treatment with nortriptyline targeted to therapeutic plasma levels (50-150 ng/ml). Depression improvement was determined with the Beck Depression Inventory; glucose control was measured by glycated hemoglobin levels. Compliance behavior was assessed using medication dispensing devices and glucometers equipped with electronic memory.
The reduction in depression symptoms was significantly greater in depressed patients treated with nortriptyline compared with those receiving placebo (-10.2 vs -5.8, p = .03). Nortriptyline was not statistically superior to placebo in reducing glycated hemoglobin of the depressed subjects (p = .5). However, path analysis indicated that the direct effect of nortriptyline was to worsen glycemic control whereas depression improvement had an independent beneficial effect on glycated hemoglobin. These findings were not explained by the relationships of nortriptyline treatment to weight change (r = -0.21, p = .31) or depression improvement to compliance with the protocol for self-monitoring of blood glucose (r = 0.01, p = .97).
Major depression in diabetic patients can be effectively treated with nortriptyline at the expense of a direct hyperglycemic effect. Path analysis demonstrated a treatment-independent effect of depression improvement on glycemic control, suggesting that a more ideal antidepressant agent may both restore mental health and improve medical outcome.
抑郁症是糖尿病中一种常见的慢性疾病，与血糖调节不佳及糖尿病治疗依从性差相关。本研究评估了去甲替林对抑郁症和血糖控制的影响，以探讨糖尿病中的抑郁症是否可治，以及恢复心理健康是否有助于改善医疗结局。
68例血糖控制不佳的糖尿病患者，其中28例患有活动性重度抑郁症（DSM-IIIR），完成了一项随机、安慰剂对照、双盲试验，接受为期8周的去甲替林治疗，目标血浆水平为（50 - 150 ng/ml）。使用贝克抑郁量表确定抑郁改善情况；通过糖化血红蛋白水平测量血糖控制情况。使用配备电子记忆功能的药物分发装置和血糖仪评估依从行为。
与接受安慰剂的患者相比，接受去甲替林治疗的抑郁症患者抑郁症状的减轻更为显著（-10.2 vs -5.8，p = .03）。在降低抑郁受试者的糖化血红蛋白方面，去甲替林在统计学上并不优于安慰剂（p = .5）。然而，路径分析表明，去甲替林的直接作用是恶化血糖控制，而抑郁改善对糖化血红蛋白有独立的有益作用。这些发现无法通过去甲替林治疗与体重变化的关系（r = -0.21，p = .31）或抑郁改善与血糖自我监测方案依从性的关系（r = 0.01，p = .97）来解释。
糖尿病患者的重度抑郁症可用去甲替林有效治疗，但代价是有直接的高血糖效应。路径分析表明抑郁改善对血糖控制有与治疗无关的作用，提示一种更理想的抗抑郁药可能既能恢复心理健康又能改善医疗结局。
