Treating Depression After Initial Treatment Failure Directly Comparing Switch and Augmenting Strategies in STAR*D
Treating Depression After Initial Treatment Failure Directly Comparing Switch and Augmenting Strategies in STAR*D
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DOI：
10.1097/jcp.0b013e31823f705d
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发表时间：
2012-02-01
影响因子：
2.9
通讯作者：
Stuermer, Til
中科院分区：
文献类型：
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作者：
Gaynes, Bradley N.;Dusetzina, Stacie B.;Stuermer, Til
目的：对于初始药物治疗失败的抑郁症患者，增加抗抑郁药物和更换抗抑郁药物是两种最常见的后续策略。这些方法尚未被直接比较；因此，我们的目的是在缓解抑郁症的序贯治疗替代方案（STAR*D）临床试验中，比较重度抑郁症患者增加药物治疗与更换药物治疗的结果。
方法：我们对STAR*D临床试验中年龄在18至75岁、患有《精神疾病诊断与统计手册》第四版（DSM - IV）非精神病性抑郁症且初始治疗未缓解的参与者（N = 1292）进行了回顾性分析。我们使用倾向评分匹配来最小化选择偏差，比较了每个研究组参与者的抑郁症状缓解情况、治疗反应和生活质量。
结果：倾向评分匹配后的增加药物组（N = 269）和更换药物组（N = 269）在测量特征上平衡良好。缓解的可能性（风险比，1.14；95%置信区间，0.82 - 1.58）或治疗反应（风险比，1.14；95%置信区间，0.82 - 1.58），以及缓解时间（对数秩检验，P = 0.946）或治疗反应时间（对数秩检验，P = 0.243）在两种治疗策略之间均无差异。同样，生活质量也没有差异。事后分析表明，对于耐受初始治疗12周或更长时间以及初始治疗有部分反应的患者，增加药物治疗可改善结果。
结论：对于接受并耐受积极初始抗抑郁治疗试验的患者，下一步增加药物治疗与更换药物治疗没有明显的优劣之分。研究结果初步表明，那些完成12周或更长时间初始治疗且有部分反应且残留轻度抑郁严重程度的患者，相对于更换药物治疗，可能从增加药物治疗中获益更多。
Objective: Augmenting and switching antidepressant medications are the 2 most common next-step strategies for depressed patients failing initial medication treatment. These approaches have not been directly compared; thus, our objectives are to compare outcomes for medication augmentation versus switching for patients with major depressive disorder in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) clinical trial.Methods: We conducted a retrospective analysis of participants aged 18 to 75 years with DSM-IV nonpsychotic depression who failed to remit with initial treatment in the STAR*D clinical trial (N = 1292). We compared depressive symptom remission, response, and quality of life among participants in each study arm using propensity score matching to minimize selection bias.Results: The propensity-score-matched augment (N = 269) and switch (N = 269) groups were well balanced on measured characteristics. Neither the likelihood of remission (risk ratio, 1.14; 95% confidence level, 0.82-1.58) or response (risk ratio, 1.14; 95% confidence level, 0.82-1.58), nor the time to remission (log-rank test, P = 0.946) or response (log-rank test, P = 0.243) differed by treatment strategy. Similarly, quality of life did not differ. Post hoc analyses suggested that augmentation improved outcomes for patients tolerating 12 or more weeks of initial treatment and those with partial initial treatment response.Conclusions: For patients receiving and tolerating aggressive initial antidepressant trials, there is no clear preference for next-step augmentation versus switching. Findings tentatively suggest that those who complete an initial treatment of 12 weeks or more and have a partial response with residual mild depressive severity may benefit more from augmentation relative to switching.