정신병적 우울증의 치료 전략 = Treatment Strategies for Psychotic Depression

국문 초록 (Abstract)

정신병적 우울증의 심한 정도와 나쁜 예후, 그리고 현재까지의 연구 실적을 고려했을 때, 임상의사들은 정신병적 증상을 동반한 우울증과 정신병적 증상을 동반하지 않는 우울증을 구분하여 치료계획을 수립하는 것이 바람직하다. 저자들은 체계적인 검색을 통해 광범위하게 조사를 하였으나, 정신병적 우울증 환자의 약물치료에 대한 근거는 아직 부족한 것으로 생각한다. 소수의 연구 결과들이지만 현재까지 발표된 근거에 의하면, 항우울제와 항정신병약물의 병합치료와 전기충격요법이 그 효과에 대한 근거 수준이 가장 높아서 정신병적 우울증 환자를 위한 일차적 치료법으로 생각된다. 그러나 최근에 항우울제 단독치료가 항우울제와 항정신병약물의 병합치료에 비해 효과 면에서 떨어지지 않는다는 분석 결과가 발표되면서 항우울제-항정신병약물 병합치료법과 항우울제를 사용하다가 필요시에 항정신병약물을 추가하는 방법 둘 다 권고된 바 있다. 이는 기존 치료 권고 사항과 대조가 되기 때문에, 향후 이러한 관점에서 기존의 치료 전략들이 어떻게 영향을 받을지 주목된다. 그러나 적어도 정신병적 우울증 환자에게 항정신병약물을 단독으로 사용하는 것은 항우울제와 병합하였을 때 보다 덜 효과적이므로 항정신병약물 단독으로 시작하는 것은 바람직하지 않다는 데에는 연구자들 간에 의견이 일치하고 있다. 항우울제 중에서는 삼환계 항우울제에 대한 근거 수준이 가장 높고 선택적 세로토닌 재흡수 차단제의 경우 현재는 근거가 부족하나 앞으로 유망할 것으로 보인다. 항우울제와 항정신병약물 병합 치료에 반응이 없거나 부작용으로 인해 투여할 수가 없을 경우에는 항우울제의 종류를 바꾸거나 lithium을 강화하는 방법을 고려할 수 있다. 실제 임상에서는 환자 개개인의 위험과 이득을 고려하여 약물을 선택하는 것이 중요하다. 또한 선택된 약물을 충분한 양, 그리고 충분한 기간 동안 시도했는지도 중요하다. 이와 함께 부작용의 출현에 대해 잘 모니터링을 해야 하고, 특히 우울증 자체가 악화되는 것과 구분해야 한다. 결론적으로, 임상의사들은 정신병적 증상을 동반하는 우울증 환자의 치료 전략을 현재까지 수행된 연구 근거의 양과 수준을 감안하여 받아들여야 하고, 아직까지 명백한 결론을 이끌어내기에는 부족하기 때문에 향후 이에 대한 많은 체계적 연구들이 필요할 것이다.

다국어 초록 (Multilingual Abstract)

Objectives : Several factors, such as biological markers, clinical correlates, and course of the depressive disorders with psychotic symptoms differ from those without psychotic symptoms. Therefore, specification of a treatment algorithm for depressive disorder with psychotic symptoms is legitimated. This article provides a systematic review of somatic treatments for depressive disorder with psychotic symptoms. Methods : According to the search strategy of the Clinical Research Center for Depression of Korean Health 21 R & D Project, first, PubMed and EMBASE were searched using terms with regard to the treatment of depressive disorders with psychotic symptoms(until July 2006). Reference lists of related reviews and studies were searched. In addition, relevant practice guidelines were searched using PubMed. All identified clinical literatures were reviewed and summarized in a narrative manner. Results : Treatment options, such as a combination of an antidepressant and an antipsychotic versus an antidepressant or an antipsychotic alone are summarized. In addition, issues regarding the electroconvulsive therapy( ECT), combination therapy, and maintenance treatment are discussed. Conclusion : In former times, the combination of an antidepressant and an antipsychotic or ECT were recommended as the first line treatment for depressive disorder with psychotic symptoms. Recently, however, there was a suggestion that there was no conclusive evidence that the combination of an antidepressant and an antipsychotic drug is more effective than an antidepressant alone. More evidence regarding the pharmacological treatment for depressive disorder with psychotic symptoms is needed.

참고문헌 (Reference)

1 Parker G, "a meta-analysis of physical treatments" depression 17-24, jaffectdisord1992;24

2 Bauer M, "World Federation of Societies of Biological Psychiatry Guideline for Biological Treatment of Unipolar Depressive Disorders" 3 (3): 69-86, 2002

3 Zanardi R, "Venlafaxine versus fluvoxamine in the treatment of delusional depression: a pilot double-blind controlled study" 1 : 26-29, 2000

4 Flint AJ, "Two-year outcome of psychotic depression in late life" 155 : 178-183, 1998

5 Brockington IF, "Trials of lithium chlorpromazine and amitriptyline in schizoaffective patients" 162-8, brjpsychiatry1978;133

6 Johnson J, "The validity of major depression with psychotic features based on a community study" 1075-81,

7 Coryell W, "The treatment of psychotic depression" 59 : 22-29, 1998

8 Coryell W, "The time course of nonchronic major depressive disorder Uniformity across episodes and samples National Institute of Mental Health Collaborative Program on the Psychobiology of Depression--Clinical Studies" 405-10,

9 Christodoulou GN, "The prognostic importance of delusions in depression" 233-8, jaffectdisord1994;32

10 Weiss JC, "The pharmacological treatment of delusional depression" 430-6, amjpsychiatry1985;142

11 Greenblatt EN, "The neuropharmacological actions of amoxapine" 107-35,

12 World Health Organization, "The international classification of diseases" 1992

13 Simpson S, "The differentiation of DSM-III-R psychotic depression in later life from nonpsychotic depression comparisons of brain changes measured by multispectral analysis of magnetic resonance brain images, neuropsychological findings, and clinical features" 45 : 193-204, 1999

14 Crismon ML, "The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder" 60 (60): 142-156, 1999

15 Wheeler Vega J, "Somatic treatment of psychotic depression Review and recommendations for practice" 20 (20): 504-519, 2000

16 Staner L, "Shortened REM latency as a psychobiological marker for psychotic depression? An age-, and gender-, and polarity-controlled study" 44 : 1314-1320, 1998

17 Popli AP, "Sertraline and psychotic symptoms: a case series" 9 (9): 15-17, 1997

18 Altshuler LL, "Sertraline and akathisia" 278-9, jclinpsychopharmacol1994;14

19 Schatzberg AF, "Serotonin activity in psychotic" major depression jclinpsychiatry1992;53

20 Ellis P, "Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression Australian and New Zealand clinical practice guidelines for the treatment of depression" 38 (38): 389-407, 2004

21 Muller MJ, "Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome" 18 (18): 111-120, 1998

22 Lane HY, "Risperidone monotherapy for psychotic depression unresponsive to other treatments" 59 (59): 1998

23 Hillert A, "Risperidone in the treatment of disorders with a combined psychotic and depressive syndrome--a functional approach" 213-7, pharmacopsychiatry1992;25

24 Anton RF Jr, "Response of psychotic depression subtypes to pharmacotherapy" 125-31, jaffectdisord1993;28

25 "Relative Efficacy Rates for Therapies of Delusional Depression" 173-182, convulsther1985;1

26 Markowitz J, "Reduced length and cost of hospital stay for major depression in patients treated with ECT" 1025-9, amjpsychiatry1987;144

27 Leyton M, "Psychotic symptoms and vulnerability to recurrent major depression" 33 (33): 107-115, 1995

28 Coryell W, "Psychotic depression" 57 : 27-31, 1996

29 Ohayon MM, "Prevalence of depressive episodes with psychotic features in the general population" 159 (159): 1855-1861, 2002

30 American Psychiatric Association, "Practice guideline for the treatment of patients with major depressive disorder" 157 : 1-45, 2000

31 Spiker DG, "Placebo response rates in psychotic and nonpsychotic depression" 21-3, jaffectdisord1988;14

32 Wijkstra J, "Pharmacological treatment for unipolar psychotic depression: Systematic review and meta-analysis" 188 : 410-415, 2006

33 Rothschild AJ, "Olanzapine response in psychotic depression" 60 (60): 116-118, 1999

34 Nelson JC, "Neuroleptic dose and desipramine concentrations during combined treatment of unipolar depression" 1151-4, amjpsychiatry1986;143

35 Rothschild AJ, "Management of psychotic, treatment-resistant depression" 19 : 237-252, 1996

36 Ebert D, "Lithium-TCA combination treatment of psychotic depression comparison with TCA-neuroleptic treatment" 17 (17): 129-130, 1997

37 Nelson JC, "Lithium augmentation in psychotic depression refractory to combined drug treatment" 363-6, amjpsychiatry1986;143

38 Rothschild AJ, "How long should patients with psychotic depression stay on the antipsychotic medication?" 64 (64): 390-396, 2003

39 Aberg-Wistedt A, "Higher CSF levels of HVA and 5-HIAA in delusional compared to nondelusional depression" 925-6,

40 Gatti F, "Fluvoxamine alone in the treatment of delusional depression" 153 : 414-416, 1996

41 Narayan M, "Fluoxetine-induced delusions in psychotic depression" 56 (56): 1995

42 Zanardi R, "Faster onset of action of fluvoxamine in combination with pindolol in the treatment of delusional depression: a controlled study" 18 : 441-446, 1998

43 Rothschild AJ, "Efficacy of the combination of fluoxetine and perphenazine in the treatment of psychotic depression" 338-42, jclinpsychiatry1993;54

44 Hirschfeld RM, "Efficacy of SSRIs and newer antidepressants in severe depression comparison with TCAs" 60 (60): 326-335, 1999

45 Conte G, "Effectiveness of fluvoxamine and paroxetine in major depressives with psychotic features" 12 : 277-278, 1997

46 Zanardi R, "Double-blind controlled trial of sertraline versus paroxetine in the treatment of delusional depression" 153 : 1631-1633, 1996

47 American Psychiatric Association, "Diagnostic and statistical manual of mental disorders" American Psychiatric Press 1994

48 Nelson JC, "DST studies in psychotic depression: a meta-analysis" 154 : 1497-1503, 1997

49 McElroy SL, "Clozapine in the treatment of psychotic mood disorders, schizoaffective disorder, and schizophrenia." 411-4, jclinpsychiatry1991;52

50 Canadian Psychiatric Association,, "Clinical guidelines for the treatment of depressive disorders" 46 : 5-90, 2001

51 Dubovsky SL, "Challenges in conceptualizing psychotic mood disorders" 197-214

52 Nelson JC, "Augmentation strategies for treatment of unipolar major depression" 25 : 34-55, 1997

53 Anton RF Jr, "Amoxapine versus amitriptyline combined with perphenazine in the treatment of psychotic depression" 1203-8, amjpsychiatry1990;147

54 Ranjan R, "Acute and long-term effectiveness of clozapine in treatment-resistant psychotic depression" 40 : 253-258, 1995

55 Minter RE, "A prospective study of the treatment of psychotic depression" 1470-2, amjpsychiatry1979;136

56 Rothschild AJ, "A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features" 24 (24): 365-373, 2004

57 Bruijn JA, "A double-blind, fixed blood-level study comparing mirtazapine with imipramine in depressed in-patients" 127 (127): 231-237, 1996

58 van den Broek WW, "A double-blind randomized study comparing imipramine with fluvoxamine in depressed inpatients" 175 (175): 481-486, 2004

59 Sweet RA, "A double-blind randomized comparison of nortriptyline plus perphenazine versus nortriptyline plus placebo in the treatment of psychotic depression in late life" 62 (62): 597-604, 2001