难治性抑郁症:定义、患病率、检测、管理和研究干预。

IF 73.3 1区 医学 Q1 Medicine World Psychiatry Pub Date : 2023-10-01 DOI:10.1002/wps.21120
Roger S McIntyre, Mohammad Alsuwaidan, Bernhard T Baune, Michael Berk, Koen Demyttenaere, Joseph F Goldberg, Philip Gorwood, Roger Ho, Siegfried Kasper, Sidney H Kennedy, Josefina Ly-Uson, Rodrigo B Mansur, R Hamish McAllister-Williams, James W Murrough, Charles B Nemeroff, Andrew A Nierenberg, Joshua D Rosenblat, Gerard Sanacora, Alan F Schatzberg, Richard Shelton, Stephen M Stahl, Madhukar H Trivedi, Eduard Vieta, Maj Vinberg, Nolan Williams, Allan H Young, Mario Maj
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引用次数: 0

摘要

难治性抑郁症(TRD)是常见的,并与多种严重的公共卫生影响有关。目前还不存在对TRD的一致定义,该定义在临床决策和健康结果方面具有显著的预测效用。相反,人们提出了大量的定义,这些定义在概念框架上差异很大。缺乏一致的定义阻碍了对TRD患病率的精确估计,也掩盖了识别风险因素、预防机会和有效干预措施的努力。此外,它还导致临床实践决策的异质性,对护理质量产生不利影响。美国食品药品监督管理局(FDA)和欧洲药品管理局(EMA)采用了最常用的TRD定义(即,尽管治疗试验充分且坚持治疗,但对至少两种抗抑郁药的反应不足)。目前估计,至少有30%的抑郁症患者符合这一定义。相当大比例的TRD患者实际上具有伪耐药性(例如,由于治疗试验不足或不坚持治疗)。尽管已知多种社会人口学、临床、治疗和环境因素会对抑郁症患者的反应产生负面影响,但很少有因素能预测多种治疗方式的无反应。静脉注射氯胺酮和鼻内注射氯胺酮(与抗抑郁药联合给药)被证明对TRD有效。一些第二代抗精神病药物(如阿立哌唑、布瑞哌唑、卡哌嗪、喹硫平XR)被证明是部分应答者抗抑郁药的辅助治疗药物,但只有奥氮平-氟西汀联合用药在美国食品药品监督管理局定义的TRD中进行了研究。重复性经颅磁刺激(TMS)被认为是有效的,并被美国食品药品监督管理局批准用于TRD患者,加速θ脉冲TMS最近也显示出疗效。电休克治疗被认为是TRD的一种有效的急性和维持性干预措施,初步证据表明其对急性静脉注射氯胺酮没有劣效性。延长抗抑郁药试验、药物转换和联合抗抑郁药的证据喜忧参半。基于手动的心理治疗师在TRD中并没有被证明是有效的,但当添加到传统的抗抑郁药中时,可以显著缓解症状。数字疗法正在研究中,代表了这一人群未来潜在的临床前景。
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Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions.

Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.

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来源期刊
World Psychiatry
World Psychiatry Nursing-Psychiatric Mental Health
CiteScore
64.10
自引率
7.40%
发文量
124
期刊介绍: World Psychiatry is the official journal of the World Psychiatric Association. It aims to disseminate information on significant clinical, service, and research developments in the mental health field. World Psychiatry is published three times per year and is sent free of charge to psychiatrists.The recipient psychiatrists' names and addresses are provided by WPA member societies and sections.The language used in the journal is designed to be understandable by the majority of mental health professionals worldwide.
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