Major depression is often a relapsing disorder. It is therefore important to start its treatment with therapies that maximize the chance of not only getting the patients well but also keeping them well. We examined the associations between initial treatments and sustained response by conducting a network meta-analysis of randomized controlled trials (RCTs) in which adult patients with major depression were randomized to acute treatment with a psychotherapy (PSY), a protocolized antidepressant pharmacotherapy (PHA), their combination (COM), standard treatment in primary or secondary care (STD), or pill placebo, and were then followed up through a maintenance phase. By design, acute phase treatment could be continued into the maintenance phase, switched to another treatment or followed by discretionary treatment. We included 81 RCTs, with 13,722 participants. Sustained response was defined as responding to the acute treatment and subsequently having no depressive relapse through the maintenance phase (mean duration: 42.2±16.2 weeks, range 24-104 weeks). We extracted the data reported at the time point closest to 12 months. COM resulted in more sustained response than PHA, both when these treatments were continued into the maintenance phase (OR=2.52, 95% CI: 1.66-3.85) and when they were followed by discretionary treatment (OR=1.80, 95% CI: 1.21-2.67). The same applied to COM in comparison with STD (OR=2.90, 95% CI: 1.68-5.01 when COM was continued into the maintenance phase; OR=1.97, 95% CI: 1.51-2.58 when COM was followed by discretionary treatment). PSY also kept the patients well more often than PHA, both when these treatments were continued into the maintenance phase (OR=1.53, 95% CI: 1.00-2.35) and when they were followed by discretionary treatment (OR=1.66, 95% CI: 1.13-2.44). The same applied to PSY compared with STD (OR=1.76, 95% CI: 0.97-3.21 when PSY was continued into the maintenance phase; OR=1.83, 95% CI: 1.20-2.78 when PSY was followed by discretionary treatment). Given the average sustained response rate of 29% on STD, the advantages of PSY or COM over PHA or STD translated into risk differences ranging from 12 to 16 percentage points. We conclude that PSY and COM have more enduring effects than PHA. Clinical guidelines on the initial treatment choice for depression may need to be updated accordingly.

中文翻译：

---

实现重度抑郁症持续缓解的初始治疗选择：系统评价和网络荟萃分析


重度抑郁症通常是一种复发性疾病。因此，重要的是，在开始治疗时，必须最大限度地提高患者康复和保持健康的机会。我们通过对随机对照试验 (RCT) 进行网络荟萃分析，研究了初始治疗与持续缓解之间的关联，其中成年重度抑郁症患者被随机分配接受心理治疗 (PSY) 的急性治疗，这是一种协议化的抗抑郁药物疗法 (PHA) 、它们的组合（COM）、初级或二级护理（STD）的标准治疗或药丸安慰剂，然后通过维持阶段进行随访。根据设计，急性期治疗可以继续进入维持期，转换为另一种治疗或随后进行酌情治疗。我们纳入了 81 项随机对照试验，共有 13,722 名参与者。持续反应定义为对急性治疗有反应，随后在维持阶段没有抑郁复发（平均持续时间：42.2±16.2周，范围24-104周）。我们提取了最接近 12 个月的时间点报告的数据。当这些治疗继续进入维持阶段时（OR=2.52，95% CI：1.66-3.85）以及随后进行酌情治疗时（OR=1.80，95% CI：1.21），COM 比 PHA 产生更持续的反应。 -2.67）。与 STD 相比，这同样适用于 COM（当 COM 继续进入维持阶段时，OR=2.90，95% CI：1.68-5.01；当 COM 随后进行酌情治疗时，OR=1.97，95% CI：1.51-2.58）。 PSY 也比 PHA 更常使患者保持良好状态，无论是当这些治疗继续进入维持阶段时（OR=1.53，95% CI：1.00-2.35）还是随后进行酌情治疗时（OR=1.53，95% CI：1.00-2.35）。66，95% CI：1.13-2.44）。与 STD 相比，PSY 也同样如此（当 PSY 继续进入维持期时，OR=1.76，95% CI：0.97-3.21；当 PSY 之后进行酌情治疗时，OR=1.83，95% CI：1.20-2.78）。鉴于 STD 的平均持续缓解率为 29%，PSY 或 COM 相对于 PHA 或 STD 的优势转化为 12 至 16 个百分点的风险差异。我们得出结论，PSY 和 COM 比 PHA 具有更持久的影响。关于抑郁症初始治疗选择的临床指南可能需要相应更新。