Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors
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选择性血清素再摄取抑制剂
DOI：
10.1136/bmj.330.7488.420-b
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发表时间：
2005
期刊：
影响因子：
--
通讯作者：
T. Kendrick
中科院分区：
文献类型：
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作者：
R. Peveler;T. Kendrick
编辑Geddes和Cipriani评论说，现有的随机证据并不能提供可靠的估计，在不同严重程度的患者中使用选择性5-羟色胺再摄取抑制剂（SSRIs）治疗的成本和效益，并对非商业基金的下降表示遗憾。英国国民保健服务卫生技术评估计划正在资助一项试验，以解决这个问题。由南安普顿大学牵头，与利物浦大学和精神病学研究所合作，THREAD（抗抑郁药阈值）试验正在比较SSRIs与支持性护理相结合与支持性护理单独在初级保健中的有效性。
由于Paykel说，DSM重度抑郁发作阈值附近的抑郁严重程度是抗抑郁药物比安慰剂更有效的水平，3最近的两项研究表明，SSRI抗抑郁药物可能对抑郁症状较轻的患者有效。NICE指南中所描述的“轻度”抑郁症实际上是ICD-10标准的亚综合征抑郁症。THREAD使用症状严重程度的连续测量，汉密尔顿抑郁量表，作为其主要预测变量，并招募评分≥ 12的患者，可能至少在“中度”范围内。
然而，这项试验的一个发现已经很明显了，那就是病人和医生的偏好使得随机化在这种情况下是一个困难的提议。正如之前在这一人群的咨询和药物治疗试验中所观察到的那样，真正的随机证据可能只能在一组在其他方面不寻常的参与者中获得，我们需要更多地了解随机和偏好设计的优点和缺点，以调查在这种情况下的治疗价值。
Editor—Geddes and Cipriani comment that available randomised evidence does not provide reliable estimates of the costs and benefits of treatment with selective serotonin reuptake inhibitors (SSRIs) in patients with varying degrees of severity and laments the decline in non-commercial funding.1 Recent guidelines from the National Institute for National Excellence (NICE) also lack evidence.2 The NHS health technology assessment programme is funding a trial to tackle this very question. Led by the University of Southampton, in partnership with the University of Liverpool and Institute of Psychiatry, the THREAD (threshold for antidepressants) trial is comparing the effectiveness of SSRIs combined with supportive care with supportive care alone in primary care.
Since Paykel said that severity of depression around the threshold of DSM major depressive episode was the level at which antidepressant drugs were more effective than placebo,3 two recent studies have shown that SSRI antidepressants may be effective in patients with depressive symptoms of lesser severity.4,5 Confusion results from the inexact use of terminology: what is described in NICE guidance as “mild” depression is actually sub-syndromal depression by ICD-10 criteria. THREAD is using a continuous measure of symptom severity, the Hamilton depression rating scale, as its chief predictor variable, and recruiting patients with a score of ≥ 12, likely to lie in at least the “moderate” range.
One finding of the trial already apparent, however, is that patients' and doctors' preferences make randomisation a difficult proposition in this context. As previously observed in trials of counselling and drug treatment in this population, truly randomised evidence may be obtainable only in a group of participants who are unusual in other respects, and we need to learn more about the strengths and weaknesses of randomised and preference designs for investigating the value of treatments in such contexts.