重复经颅磁刺激联合帕罗西汀治疗抑郁症的Meta分析
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摘要
目的:评价重复经颅磁刺激联合帕罗西汀治疗抑郁症的临床疗效,为抑郁症的临床治疗提供参考。方法:检索中国期刊全文数据库、万方数据知识服务平台、维普中文期刊全文数据库、PubMed、EMbase、Cochrane Library,搜集重复经颅磁刺激联合帕罗西汀治疗抑郁症的随机对照试验(RCTs)。检索时限设定为建库至2017年8月31日,由2位评价者独立进行文献筛选、基本资料提取和偏倚风险评估后,采用RevMan 5.3软件进行Meta分析。结果:最终纳入16个RCTs,共1150例患者。治疗首发抑郁症的Meta分析:5篇文献以有效率为主要结局指标,显示联合治疗组与对照组比较,合并后RR=1.35,95%CI(1.11,1.65),总体效应量Z=3.00,P<0.01,两者在治疗首发抑郁症的有效率方面,差异有统计学意义;5篇文献以不良反应率为主要结局指标,显示联合治疗组与对照组比较,合并后RR=0.83,95%CI(0.56,1.24),总体效应量Z=0.92,P>0.05,两者在治疗首发抑郁症后的不良反应率方面,差异无统计学意义;3篇文献以汉密尔顿抑郁量表(HAMD)评分为次要结局指标,显示联合治疗组与对照组比较,合并后MD=-1.71,95%CI(-4.82,1.40),总体效应量Z=1.08,P>0.05,两者在改善抑郁症的HAMD评分方面,差异无统计学意义。治疗抑郁症的Meta分析:5篇文献以有效率为主要结局指标,显示联合治疗组与对照组比较,合并后RR=1.20,95%CI(0.96,1.52),总体效应量Z=1.58,P>0.05,两者在治疗抑郁症的有效率方面,差异无统计学意义;4篇文献以不良反应率为主要结局指标,显示联合治疗组与对照组比较,合并后RR=0.96,95%CI(0.68,1.34),总体效应量Z=0.26,P>0.05,两者在治疗抑郁症后的不良反应率方面,差异无统计学意义;8篇文献以HAMD评分为次要结局指标,显示联合治疗组与对照组比较,合并后MD=-3.26,95%CI(-3.83,-2.69),总体效应量Z=11.20,P<0.01,两者在改善首发抑郁症的HAMD评分方面,差异有统计学意义。结论:重复经颅磁刺激结合帕罗西汀治疗首发抑郁症和抑郁症的疗效优于帕罗西汀和伪刺激结合帕罗西汀,但在不良反应方面差异却无统计学意义。因此治疗首发抑郁症和抑郁症,重复经颅磁刺激联合帕罗西汀更适合应用于临床。因纳入文献数量有限且部分质量较低,上述结论仍需大样本、高质量的RCTs进一步验证。
Objective: To evaluate the therapeutic effect of repetitive transcranial magnetic stimulation(TMS) combined with paroxetine in the treatment of depression, provide reference for the clinical treatment and related research of depression. Methods: We electronically searched databases, including CNKI Chinese Journal Full-text Database, Wanfang Database, VIP Database, PubMed, the Cochrane Library and EMbase, to collect randomized controlled trials(RCTs) about depression treated by repetitive TMS combined with paroxetine. The time limitation was from the establishment of each database to 31 st August 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of the included studies. Then, Meta-analysis was performed by using RevMan 5.3 software. Results: A total of sixteen related articles and 1 150 patients were retrieved. The effective rate was selected as primary outcome measure in five articles, and Meta analysis showed that compared with control group, pooled RR was 1.35 with 95%CI [1.11, 1.65], Z=3.00, P<0.01, in the test for overall effect, implying the significant effective rate difference between the two groups was in the treatment of first-episode depressive. The adverse reaction rate was selected as primary outcome measure in five articles.Meta analysis showed that compared with control groups, pooled RR was 0.83 with 95%CI [0.56, 1.24], Z=0.92, P>0.05, in the test for overall effect, implying that the adverse reaction rate difference of two groups was not significant. The HAMD scores was selected as secondary outcome measure in three articles, and Meta analysis showed that compared with control groups, pooled MD was-1.71 with 95%CI [-4.82, 1.40], Z=1.08, P>0.05, in the test for overall effect, implying that the HAMD scores difference of two groups was not significant. The effective rate was selected as primary outcome measure in five articles. Meta-analysis showed that compared with control groups, pooled RR was 1.20 with 95%CI [0.96, 1.52], Z=1.58, P>0.05, in the test for overall effect, implying the effective rate difference of two groups was not significant in the treatment of depressive. The adverse reaction rate was selected as primary outcome measure in four articles, and Meta-analysis showed that compared with control groups, pooled RR was 0.96 with 95%CI [0.68,1.34], Z=0.26, P>0.05, in the test for overall effect, implying the adverse reaction rate difference of two groups was not significant in the treatment of depressive. The HAMD scores were selected as secondary outcome measure in eight articles, and Meta analysis showed that compared with the control group, pooled MD was-3.26 with 95%CI [-3.83,-2.69], Z=11.20, P<0.01, in the test for overall effect, implying that the HAMD scores difference of two groups was significant in the treatment of depressive. Conclusion:The effect of repeated TMS combined Paroxetine in the treatment of first-episode depressive disorder and depression is better than Paroxetine with and without pseudo stimulus, but there is no difference in side effects. Therefore, repeated TMS combined paroxetine may be more suitable for clinical use in the treatment of first-episode depression and depression. However, the above conclusion still needs to be verified by large sample and high quality RCTs.
Objective: To evaluate the therapeutic effect of repetitive transcranial magnetic stimulation(TMS) combined with paroxetine in the treatment of depression, provide reference for the clinical treatment and related research of depression. Methods: We electronically searched databases, including CNKI Chinese Journal Full-text Database, Wanfang Database, VIP Database, PubMed, the Cochrane Library and EMbase, to collect randomized controlled trials(RCTs) about depression treated by repetitive TMS combined with paroxetine. The time limitation was from the establishment of each database to 31 st August 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of the included studies. Then, Meta-analysis was performed by using RevMan 5.3 software. Results: A total of sixteen related articles and 1 150 patients were retrieved. The effective rate was selected as primary outcome measure in five articles, and Meta analysis showed that compared with control group, pooled RR was 1.35 with 95%CI [1.11, 1.65], Z=3.00, P<0.01, in the test for overall effect, implying the significant effective rate difference between the two groups was in the treatment of first-episode depressive. The adverse reaction rate was selected as primary outcome measure in five articles.Meta analysis showed that compared with control groups, pooled RR was 0.83 with 95%CI [0.56, 1.24], Z=0.92, P>0.05, in the test for overall effect, implying that the adverse reaction rate difference of two groups was not significant. The HAMD scores was selected as secondary outcome measure in three articles, and Meta analysis showed that compared with control groups, pooled MD was-1.71 with 95%CI [-4.82, 1.40], Z=1.08, P>0.05, in the test for overall effect, implying that the HAMD scores difference of two groups was not significant. The effective rate was selected as primary outcome measure in five articles. Meta-analysis showed that compared with control groups, pooled RR was 1.20 with 95%CI [0.96, 1.52], Z=1.58, P>0.05, in the test for overall effect, implying the effective rate difference of two groups was not significant in the treatment of depressive. The adverse reaction rate was selected as primary outcome measure in four articles, and Meta-analysis showed that compared with control groups, pooled RR was 0.96 with 95%CI [0.68,1.34], Z=0.26, P>0.05, in the test for overall effect, implying the adverse reaction rate difference of two groups was not significant in the treatment of depressive. The HAMD scores were selected as secondary outcome measure in eight articles, and Meta analysis showed that compared with the control group, pooled MD was-3.26 with 95%CI [-3.83,-2.69], Z=11.20, P<0.01, in the test for overall effect, implying that the HAMD scores difference of two groups was significant in the treatment of depressive. Conclusion:The effect of repeated TMS combined Paroxetine in the treatment of first-episode depressive disorder and depression is better than Paroxetine with and without pseudo stimulus, but there is no difference in side effects. Therefore, repeated TMS combined paroxetine may be more suitable for clinical use in the treatment of first-episode depression and depression. However, the above conclusion still needs to be verified by large sample and high quality RCTs.
引文
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[2] MURRAY C J,LOPEZ A D. Alternative projections of mortality and disability by cause 1990-2020:global burden of disease study[J]. Lancet,1997,349(9064):1498-1504.
[3] HACKETT M L,ANDERSON C S,HOUSE A O. Management of depression after stroke a systematic review of pharmacological therapies[J]. Stroke,2005,36(5):1098-1103.
[4] BERLIM M T,VAN DEN EYNDE F,DASKALAKIS Z J. Efficacy and acceptability of high frequency repetitive transcranial magnetic stimulation(rTMS)versus electroconvulsive therapy(ECT)for major depression:a systematic review and metaanalysis of randomized trials[J]. Depress Anxiety,2013,30(7):614-623.
[5] LEFAUCHEUR J P,ANDRE-OBADIA N,ANTAL A,et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation(rTMS)[J]. Clin Neurophysiol,2014,125(11):2150-2206.
[6] WANG Y M,LI N,YANG L L,et al. Randomized controlled trial of repetitive transcranial magnetic stimulation combined with paroxetine for the treatment of patients with first-episode major depressive disorder[J]. Psychiatry Res,2017,254(4):18-23.
[7]金建烽,王志伟,严清章,等.重复经颅磁刺激治疗对抑郁症患者时间知觉的作用效应[J].中国健康心理学杂志,2016,24(12):1770-1774.
[8]李凝,王学义,宋美,等.重复经颅磁刺激联合帕罗西汀治疗抑郁症首次发病患者的起效时间及对执行功能的影响[J].中华精神科杂志,2012,45(3):137-140.
[9]汪正华,阚博,阳中明.帕罗西汀联合低频重复经颅磁刺激治疗抑郁症的对照研究[J].临床精神医学杂志,2017,27(3):203-205.
[10]高慧,吴悦娟.重复经颅磁刺激治疗抑郁症的疗效分析及相关机制[J].中国健康心理学杂志,2017,25(5):641-644.
[11]谢蓓芳,余海民,顾群英,等.重复经颅磁刺激联合帕罗西汀治疗首发抑郁症疗效及与血清脑源性神经营养因子的关系[J].中国基层医药,2015,22(17):2683-2685.
[12]王丹,文红,黄国平.超低频经颅磁刺激对抑郁症的疗效[J].四川精神卫生,2013,26(4):297-299.
[13]张烨.超低频经颅磁刺激联合帕罗西汀对首发抑郁症患者的早期效果分析[D].南充:川北医学院,2013.
[14]李军,孙忠国,李玉芳.重复低频经颅磁刺激联合药物治疗老年抑郁症的疗效观察[J].引文版:医药卫生,2015,7(8):4-5.
[15]刘鲜华. rTMS联合抗抑郁剂对抑郁症患者早期疗效、认知功能及血浆MBP和NSE浓度的影响[D].新乡:新乡医学院,2014.
[16]张宁.重复经颅磁刺激联合帕罗西汀治疗首发抑郁症患者疗效分析[J].中国现代药物应用,2016,10(21):79-80.
[17]冀伟.高频重复经颅磁刺激结合帕罗西汀在抑郁症首次发病患者中的应用[J].社区医学杂志,2015,13(7):48-50.
[18]李海涛.超低频经颅磁刺激联合帕罗西汀对首发抑郁症患者的早期疗效分析[J].世界最新医学信息文摘,2013,13(34):26-27.
[19]王润泽,焦金,马元业,等.低频重复经颅磁刺激联合帕罗西汀治疗抑郁症的疗效及安全性分析[J].中国初级卫生保健,2017,31(3):92-94.
[20]栾晓英.重复超低频经颅磁刺激联合抗抑郁药物对抑郁症患者早期疗效的影响[J].精神医学杂志,2016,29(6):434-436.
[21]李艳艳,刘治港,陈力,等.帕罗西汀配合高频重复经颅磁刺激对老年难治性抑郁症患者认知功能及MBP和NSE的影响[J].国际精神病学杂志,2017,44(1):12-15.
[22]但昭君,李海峰,何晓阔,等.醒脑开窍针法配合重复经颅磁刺激治疗脑卒中后言语功能障碍临床研究[J].康复学报,2017,27(6):15-18.
[23]李益民,吕华,刘其香,等.高频重复经颅磁刺激治疗精神分裂症强迫症状对照研究[J].中国神经精神疾病杂志,2017,43(1):39-42.
[24]陈静,张长国,张红波,等.高频与低频重复经颅磁刺激治疗帕金森病的临床观察[J].中国康复医学杂志,2014,29(5):464-467.
[25]李成,李小爱,梁晖,等.重复经颅磁刺激联合氟西汀治疗肝气郁滞型卒中后抑郁33例疗效观察[J].康复学报,2016,26(6):14-18.
[26] RUMI D O,GATTAZ W F,RIGONATTTI S P,et al. Transcrainial magnetic stimulation accelerates the antidepressant effect of amitriptyline in severe depression:a double-blind placebo-controlled study[J]. Biol Psychiatry,2005,57(2):162-166.
[27] ROSSINI D,MAGRI L,LUCCA A,et al. Does rTMS hasten the response to escitalopram,sertraline,or venlafaxine in patients with major depressive disorder? a double-blind,randomized,sham-controlled trial[J]. J Clin Psychiatry,2005,66(12):1569-1575.
[2] MURRAY C J,LOPEZ A D. Alternative projections of mortality and disability by cause 1990-2020:global burden of disease study[J]. Lancet,1997,349(9064):1498-1504.
[3] HACKETT M L,ANDERSON C S,HOUSE A O. Management of depression after stroke a systematic review of pharmacological therapies[J]. Stroke,2005,36(5):1098-1103.
[4] BERLIM M T,VAN DEN EYNDE F,DASKALAKIS Z J. Efficacy and acceptability of high frequency repetitive transcranial magnetic stimulation(rTMS)versus electroconvulsive therapy(ECT)for major depression:a systematic review and metaanalysis of randomized trials[J]. Depress Anxiety,2013,30(7):614-623.
[5] LEFAUCHEUR J P,ANDRE-OBADIA N,ANTAL A,et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation(rTMS)[J]. Clin Neurophysiol,2014,125(11):2150-2206.
[6] WANG Y M,LI N,YANG L L,et al. Randomized controlled trial of repetitive transcranial magnetic stimulation combined with paroxetine for the treatment of patients with first-episode major depressive disorder[J]. Psychiatry Res,2017,254(4):18-23.
[7]金建烽,王志伟,严清章,等.重复经颅磁刺激治疗对抑郁症患者时间知觉的作用效应[J].中国健康心理学杂志,2016,24(12):1770-1774.
[8]李凝,王学义,宋美,等.重复经颅磁刺激联合帕罗西汀治疗抑郁症首次发病患者的起效时间及对执行功能的影响[J].中华精神科杂志,2012,45(3):137-140.
[9]汪正华,阚博,阳中明.帕罗西汀联合低频重复经颅磁刺激治疗抑郁症的对照研究[J].临床精神医学杂志,2017,27(3):203-205.
[10]高慧,吴悦娟.重复经颅磁刺激治疗抑郁症的疗效分析及相关机制[J].中国健康心理学杂志,2017,25(5):641-644.
[11]谢蓓芳,余海民,顾群英,等.重复经颅磁刺激联合帕罗西汀治疗首发抑郁症疗效及与血清脑源性神经营养因子的关系[J].中国基层医药,2015,22(17):2683-2685.
[12]王丹,文红,黄国平.超低频经颅磁刺激对抑郁症的疗效[J].四川精神卫生,2013,26(4):297-299.
[13]张烨.超低频经颅磁刺激联合帕罗西汀对首发抑郁症患者的早期效果分析[D].南充:川北医学院,2013.
[14]李军,孙忠国,李玉芳.重复低频经颅磁刺激联合药物治疗老年抑郁症的疗效观察[J].引文版:医药卫生,2015,7(8):4-5.
[15]刘鲜华. rTMS联合抗抑郁剂对抑郁症患者早期疗效、认知功能及血浆MBP和NSE浓度的影响[D].新乡:新乡医学院,2014.
[16]张宁.重复经颅磁刺激联合帕罗西汀治疗首发抑郁症患者疗效分析[J].中国现代药物应用,2016,10(21):79-80.
[17]冀伟.高频重复经颅磁刺激结合帕罗西汀在抑郁症首次发病患者中的应用[J].社区医学杂志,2015,13(7):48-50.
[18]李海涛.超低频经颅磁刺激联合帕罗西汀对首发抑郁症患者的早期疗效分析[J].世界最新医学信息文摘,2013,13(34):26-27.
[19]王润泽,焦金,马元业,等.低频重复经颅磁刺激联合帕罗西汀治疗抑郁症的疗效及安全性分析[J].中国初级卫生保健,2017,31(3):92-94.
[20]栾晓英.重复超低频经颅磁刺激联合抗抑郁药物对抑郁症患者早期疗效的影响[J].精神医学杂志,2016,29(6):434-436.
[21]李艳艳,刘治港,陈力,等.帕罗西汀配合高频重复经颅磁刺激对老年难治性抑郁症患者认知功能及MBP和NSE的影响[J].国际精神病学杂志,2017,44(1):12-15.
[22]但昭君,李海峰,何晓阔,等.醒脑开窍针法配合重复经颅磁刺激治疗脑卒中后言语功能障碍临床研究[J].康复学报,2017,27(6):15-18.
[23]李益民,吕华,刘其香,等.高频重复经颅磁刺激治疗精神分裂症强迫症状对照研究[J].中国神经精神疾病杂志,2017,43(1):39-42.
[24]陈静,张长国,张红波,等.高频与低频重复经颅磁刺激治疗帕金森病的临床观察[J].中国康复医学杂志,2014,29(5):464-467.
[25]李成,李小爱,梁晖,等.重复经颅磁刺激联合氟西汀治疗肝气郁滞型卒中后抑郁33例疗效观察[J].康复学报,2016,26(6):14-18.
[26] RUMI D O,GATTAZ W F,RIGONATTTI S P,et al. Transcrainial magnetic stimulation accelerates the antidepressant effect of amitriptyline in severe depression:a double-blind placebo-controlled study[J]. Biol Psychiatry,2005,57(2):162-166.
[27] ROSSINI D,MAGRI L,LUCCA A,et al. Does rTMS hasten the response to escitalopram,sertraline,or venlafaxine in patients with major depressive disorder? a double-blind,randomized,sham-controlled trial[J]. J Clin Psychiatry,2005,66(12):1569-1575.
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