2023+意大利全国共识:难治性抑郁症的临床管理(英文版.pdf
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1、Mainaetal.Annals of General Psychiatry (2023)22:48 https:/doi.org/10.1186/s12991-023-00478-7RESEARCHOpen Access The Author(s)2023.Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use,sharing,adaptation,distribution and reproduction in
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5、atryNationwide consensus ontheclinical management oftreatment-resistant depression inItaly:aDelphi panelGiuseppe Maina1,2,Marina Adami3,Giuseppe Ascione3,Emi Bondi4,Domenico De Berardis5,Dario Delmonte3,Silvia Maffezzoli3,Giovanni Martinotti6,Alessandra Nivoli7,Elena Ottavianelli8*,the Delphi Panel
6、Collaboration Group and Andrea Fagiolini9 Abstract Background Treatment-resistant depression(TRD)is defined by the European Medicines Agency as a lack of clini-cally meaningful improvement after treatment,with at least two different antidepressants.Individual,familiar,and socio-economic burden of TR
7、D is huge.Given the lack of clear guidelines,the large variability of TRD approaches across different countries and the availability of new medications to meet the need of effective and rapid acting therapeutic strategies,it is important to understand the consensus regarding the clinical characteris
8、tics and treatment pathways of patients with TRD in Italian routine clinical practice,particularly in view of the recent availability of esketa-mine nasal spray.Methods A Delphi questionnaire with 17 statements(with a 7 points Likert scale for agreement)was administered via a customized web-based pl
9、atform to Italian psychiatrists with at least 5 years of experience and specific expertise in the field of depression.In the second-round physicians were asked to answer the same statements considering the interquartile range of each question as an index of their colleagues responses.Stata 16.1 soft
10、ware was used for the analyses.Results Sixty panellists,representative of the Italian territory,answered the questionnaire at the first round.For 8/17 statements more than 75%of panellists reached agreement and a high consensus as they assigned similar scores;for 4 statements the panellists assigned
11、 similar scores but in the middle of the Likert scale showing a moderate agreement with the statement,while for 5 statements there was indecision in the agreement and low consensus with the statement.Conclusions This Delphi Panel showed that there is a wide heterogeneity in Italy in the management o
12、f TRD patients,and a compelling need of standardised strategies and treatments specifically approved for TRD.A high level of consensus and agreement was obtained about the importance of adding lithium and/or antipsychotics as aug-mentation therapies and in the meantime about the need for long-term m
13、aintenance therapy.A high level of con-sensus and agreement was equally reached for the identification of esketamine nasal spray as the best option for TRD patients and for the possibility to administrate without difficulties esketamine in a community outpatient setting,highlighting the benefit of a
14、n appropriate educational support for patients.*Correspondence:Elena Ottavianellielena.ottavianellifullcro.orgFull list of author information is available at the end of the articlePage 2 of 11Mainaetal.Annals of General Psychiatry (2023)22:48 Keywords Treatment-resistant depression,Major depressive
15、disorder,Antidepressants,Consensus statement,Customized treatment,EsketamineBackgroundThe primary goal of treating depression is to achieve complete resolution of symptoms,but approximately 30%of patients with major depressive disorder(MDD)do not respond adequately to treatment 1,2.Non-response to m
16、edication is common and can persist after multi-ple attempts with different medications 2.The suc-cess rate of treatment decreases with each subsequent trial,as shown in the Sequenced Treatment Alternatives to Relieve Depression(STAR-D)trial 1.Treatment-resistant depression(TRD)is defined by the Eur
17、opean Medicines Agency(EMA)as a lack of clinically mean-ingful improvement after treatment with at least two different antidepressants 3.TRD is a complex condi-tion influenced by genetic,clinical and environmental factors,as well as comorbidities and psychosocial fac-tors 4.Patients with TRD experie
18、nce a higher burden of illness compared to responders,including more severe symptoms,greater disability,and reduced quality of life 2,5.The economic burden of TRD is also significant,with higher direct and indirect costs compared to non-treatment-resistant depression 6.Current management of TRD is c
19、hallenging due to the lack of evidence-based guidelines or a consensus strategy in Europe,leading to variation in treatment choices 7.Pharmacological options,that include selective serotonin reuptake inhibi-tors(SSRI),serotoninnorepinephrine reuptake inhibi-tors(SNRI),tricyclic antidepressants(TCA),
20、monoamine oxidase inhibitors(MAOIs),and atypical antidepressants and non-pharmacological treatments(neurostimulation,psychotherapeutic interventions)could be used,alone or in combination,with different strategies,such as dose escalation,medication switching,combination therapy,and augmentation/addit
21、ional therapy.The everyday Ital-ian clinical practice is not different from the European context;in Italy it can be documented,on the one hand the frequent use of SSRI,SNRI and augmentation strate-gies,and on the other hand the rare utilization of psycho-social approaches 5.However,in real-world pra
22、ctice,treatment response rates are low.A recent observational study on TRD in Europe confirmed that TRD patients have a poor chance of achieving remission at both 6 and 12months;more-over,the study found that patients who had achieved remission at 6months were then unable to maintain it for a long t
23、ime 7.Despite low remission rate,TRD patients often remain on the same pharmacological treatment for extended periods of time 7,8.There is a need for additional therapeutic strategies for TRD that are rapid acting and have proven efficacy in this population 4,9,10.Ketamine and its S-enantiomer,esket
24、amine,have shown promise in targeting the glutamate pathway and restoring synaptic connections in the brain to improve mood symptoms 11,12.Esketamine nasal spray,devel-oped and approved specifically for TRD,provides an additional treatment option with rapid onset of action and demonstrated efficacy
25、compared with other well-established pharmacological strategy such as augmen-tation with quetiapine XR 13.Few adverse events are reported with esketamine(the most common are tran-sient dissociative symptoms,nausea,dizziness)14 and the safety concerns can be managed by administering esketamine under
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- 关 键 词:
- 意大利 全国 共识 共鸣 难治 抑郁症 临床 管理
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