A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation Bipolar Network.
A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation Bipolar Network.
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抗抑郁药在双相抑郁治疗中作用的重新评估：来自斯坦利基金会双相网络的数据。
DOI：
10.1046/j.1399-5618.2003.00065.x
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发表时间：
2003
影响因子：
5.4
通讯作者：
StanleyFoundationBipolarNetwork
中科院分区：
文献类型：
--
作者：
Post,RobertM;Leverich,GabrieleS;Nolen,WillemA;Kupka,RalphW;Altshuler,LoriL;Frye,MarkA;Suppes,Trisha;McElroy,Susan;Keck,Paul;Grunze,Heinze;Walden,Jorg;StanleyFoundationBipolarNetwork
目的：使用单峰抗抑郁药（AD）作为情绪稳定剂辅助剂的风险效益比仍然是该领域专家争论和分歧的领域。本文回顾了以下方面的新数据：(1) 双相情感障碍患者的抑郁症，(2) AD 的转换率，以及 (3) AD 终止的风险，这些都与正在进行的讨论和建议相关。方法：在第一项回顾的研究中，使用美国国家心理健康研究所生命图表法 (NIMH-LCM) 对 258 名双相情感障碍门诊患者进行为期 1 年的前瞻性评估。在第二项研究中，127 名双相抑郁患者被随机接受 10 周的舍曲林、安非他酮或文拉法辛治疗，作为情绪稳定剂的辅助治疗。无反应者被重新随机分组，而反应者则接受一年的持续治疗。在最终研究中，Altshuler 等人。回顾性和前瞻性地评估了在正常状态 2 个月后继续使用 AD 的患者与停止 AD 的患者相比，抑郁症复发的风险。结果：尽管进行了强化自然主义治疗，但前瞻性随访 1 年的 258 名双相情感障碍门诊患者的抑郁天数是躁狂天数的三倍，这再次强调了尽管有多种治疗选择，双相情感障碍中仍然存在相当大的抑郁发病率。在对随机接受三种 AD 之一的双相抑郁患者进行的研究中，经过 175 项使用情绪稳定剂增强 AD 治疗的试验，发现了一系列从轻躁狂到躁狂转变的严重程度和持续时间。在为期 10 周的急性试验中，9.1% 的患者转为轻躁狂或躁狂，另外 9.1% 的患者仅出现一周或更长时间的轻躁狂（无或轻微功能障碍）。在 73 项持续期 AD 试验中，分别有 16.4% 和 19.2% 的人与轻躁狂到躁狂以及轻躁狂转换相关。在 Altshuler 等人中。研究显示，那些在任何 AD 治疗中保持良好状态超过 2 个月的患者（仅占最初治疗患者的 15-20%）以及继续接受 AD 治疗的患者在 1 年以上抑郁症复发率较低（第一项和第二项研究中分别为 35% 和 36%），而与停止 AD 治疗的患者（复发抑郁症分别为 68% 和 70%）相比。令人惊讶的是，与停止 AD 的患者相比，继续 AD 并没有增加转为躁狂的几率。结论：这些数据表明，抑郁症和抑郁循环仍然是约三分之二接受强化治疗的双相情感障碍门诊患者的一个重大问题。急性 AD 增强与适度的缓解率相关，18.2% 的患者转为轻躁狂发作，35.6% 的持续试验显示这两种类型的转变。两项独立的研究表明，在 AD 治疗至少 2 个月后仍保持良好状态的极小亚组中，应考虑继续这种 AD 增强治疗，因为停用 AD 似乎与随后一年抑郁症复发风险大幅增加相关，而转为躁狂症的风险并没有降低。
Objectives:The risk‐to‐benefit ratio of the use of unimodal antidepressants (ADs) as adjuncts to mood stabilizers continues to be an area of controversy and disagreement among experts in the field. This paper reviews new data on: (1) depression in bipolar illness, (2) switch rates on ADs and (3) risks of AD discontinuation that are pertinent to the ongoing discussion and recommendations.Methods:In the first study reviewed, 258 outpatients with bipolar illness were assessed prospectively on a daily basis using the National Institute of Mental Health‐Life Chart MethodTM(NIMH‐LCM) for 1 year. In the second study, 127 bipolar depressed patients were randomized to 10 weeks of sertraline, bupropion, or venlafaxine, as adjuncts to mood stabilizers; non‐responders were re‐randomized and responders were offered a year of continuation treatment. In the final study, Altshuler et al. retrospectively and prospectively assessed the risk of depressive relapses in patients who remained on ADs after 2 months of euthymia compared with those who discontinued ADs.Results:Despite intensive naturalistic treatment, the 258 outpatients with bipolar illness followed prospectively for 1 year showed three times as many days depressed as days manic, re‐emphasizing the considerable depressive morbidity that remains in bipolar disorder despite the number of treatment options available. In the study of bipolar depressed patients randomized to one of three ADs, a range of severities and durations of hypomanic to manic switches were discerned following 175 trials of AD augmentation of treatment with a mood stabilizer. Of the acute 10‐week trials, 9.1% were associated with switches into hypomania or mania and another 9.1% with a week or more of hypomania alone (with no to minimal dysfunction). In 73 continuation phase AD trials, 16.4 and 19.2% were similarly associated with hypomanic to manic and hypomanic switches, respectively. In the Altshuler et al. studies, those who remained well on any AD for more than 2 months (only 15–20% of those initially treated) and who continued on ADs showed a lesser rate of relapse into depression over 1 year (35 and 36% in the first and second study, respectively) compared with those who discontinued their ADs (68 and 70% relapsing into depression). Surprisingly, this continuation of ADs was associated with no increase in the rate of switching into mania compared with those stopping ADs.Conclusions:These data reveal that depression and depressive cycling remain a substantial problem in some two‐thirds of intensively treated bipolar outpatients. Acute AD augmentation was associated with a modest response rate and 18.2% switched into a hypomanic to manic episode, and 35.6% of the continuation trials showed these two types of switches. Two separate studies suggest that in the very small subgroup who remain well on ADs for at least 2 months, one should consider continuation of this AD augmentation treatment, because AD discontinuation appears associated with a substantially increased risk of depression relapse over the subsequent year with no reduced risk of switching into mania.