每天一篇经济学人 | Drugs and depression 药物与抑郁...

Almost 35 years ago American drug regulators approved Prozac, the first in a series of blockbuster antidepressants known as selective serotonin re-uptake inhibitors (ssris). Prozac and its cousins were lauded by patients and doctors as miracle drugs. They lifted low moods quickly and seemed to have no drawbacks. Divorce, bereavement, problems at work—a daily pill was there to help with that, and anything else which made you sad. Many people have stayed on these drugs for life. In Western countries today between one person in seven and one in ten takes antidepressants.

大约35年前，美国药品监管机构批准了百忧解(一种抗抑郁药)，这是选择性血清素再吸收抑制剂(SSRIs)系列重磅抗抑郁药中的第一种。百忧解和它的“近亲”被病人和医生誉为神奇的药物。它们很快就摆脱了低落的情绪，似乎没有任何缺点。离婚、丧亲之痛、工作上的问题，每天吃一颗药就能解决这些问题，还有其他任何让你悲伤的事情。许多人终生服用这些药物。今天在西方国家，七分之一到十分之一的人服用抗抑郁药。

The shine of ssris has worn off. A growing number of studies show that they are less effective than thought. Drug companies often publish the results of clinical trials selectively, withholding those in which the drugs turn out not to work well. When the results of all trials submitted to America’s medicines regulator between 1979 and 2016 were scrutinised by independent scientists, it turned out that antidepressants had a substantial benefit beyond a placebo effect in only 15% of patients.

SSRIs的光芒已经褪去。越来越多的研究表明，它们并没有想象的那么有效。制药公司经常选择性地公布临床试验结果，而不公布那些最终证明药效不佳的结果。1979年至2016年期间，独立科学家对提交给美国药品监管机构的所有试验结果进行了仔细检查，结果发现，只有15% 的患者服用抗抑郁药物后，获得了比安慰剂效果更大的益处。

Clinical guidelines have been revised accordingly in recent years. No longer are drugs the recommended first line of treatment for less severe cases of depression. For these, self-help guidance, behavioural therapy and recommendations for things like exercise and sleep are preferable. For work burnout, a sick note for time off may suffice. The drugs are to be reserved only for more severe depression, where they can be truly life-saving. 

近年来，临床指南进行了相应的修订。药物不再是治疗轻度抑郁症的首选治疗方法。对于这些患有轻度抑郁症的人来说，自助指导、行为疗法和关于锻炼和睡眠等方面的建议是更好的选择。对于工作精疲力竭的人来说，病假条可能就足够了。这些药物只用于更严重的抑郁症，在这种情况下，它们可以真正拯救生命。

The problem is that lots of people who do not need antidepressants are already on them, refilling prescriptions written years or even decades ago. They should be helped to get off the drugs. The side-effects are often life-limiting and, as people age, become life-threatening. They include sexual dysfunction (which sufferers describe as “genital anaesthesia”), lethargy, emotional numbness, increased risk of birth defects when taken during pregnancy, and, in older people, strokes, falls, seizures, heart problems and bleeding after surgery. This is a threat to health-care systems as long-term users age.

问题是，很多不需要抗抑郁药的人已经在服用抗抑郁药了，他们的处方是几年前甚至几十年前开出的。应该帮助他们戒掉这些药物。副作用往往会折寿，随着年龄的增长，甚至会危及生命。这些副作用包括性功能障碍(患者将其描述为“生殖器感觉丧失”)、没精打采、情感钝化、怀孕期间服用，出生缺陷风险增加，以及老年人会中风、摔倒、癫痫、心脏病以及手术后出血。随着长期使用者年龄的增长，这对医疗保健系统是一种威胁。

Doctors rarely talk to patients about stopping the drugs because they fear this could lead to a return of depressive symptoms. But for many people it may be safe to stop. Even among long-term users with several past episodes of depression, a recent trial in Britain showed that 44% of patients could stop taking pills safely. For milder cases, the success rate is probably higher still.

医生很少和病人谈论停药，因为他们担心这可能会导致抑郁症状复发。但对许多人来说，停药可能是安全的。英国最近的一项试验表明，即使是那些有过几次抑郁症经历的长期使用者，其中44%的患者可以安全地停药。对于病情较轻的病例，成功率可能更高。

Several things are needed for change to happen. Doctors need guidelines on how to de-prescribe the drugs. Health-care insurers and providers such as Britain’s various national health services should start paying for ways of delivering the drugs that help those who wish to stop taking them but who need to taper off them in order to avoid severe withdrawal effects. These include liquid formulations, tapering strips which contain pills with progressively smaller drug concentrations, and the services of compounding pharmacies, which prepare bespoke doses. In the Netherlands, 70% of people using tapering strips have managed to quit successfully.

改变需要做几件事。医生需要指导如何去取消这些药物的处方。医疗保险公司和英国各种国家医疗服务机构等提供方应该开始为提供药物的方式付费，以帮助那些希望停药但需要逐渐减少用药以避免严重的戒断效应的人。这些包括液体制剂、含有药物浓度逐渐减小的药片的锥形条，以及配制定制剂量的复合药房服务。在荷兰，70%的使用锥形条的人都成功地戒掉了药物。

All this could cost more than refilling prescriptions today. But with so many people on the drugs, the costs of side-effects will soon pile up. Add to that the misery of the millions whose lives have been robbed of their common joys by useless prescriptions, and the case for change is unanswerable.

这一切的花费可能比现在重新开处方还要高。但是有这么多人在使用这种药物，副作用的成本很快就会增加。再加上那些被无用的处方剥夺了共同快乐的数百万人的痛苦，改变的理由是无可辩驳的。