Samenvatting
Met nadruk op methodologische problemen wordt de effectiviteit besproken van a antipsychotica bij schizofrene psychosen, b antidepressiva bij unipolaire depressies en c anxiolytica, antidepressiva en antipsychotica bij angststoornissen. Achtereenvolgens komen aan de orde: de korte-termijneffectiviteit van acute behandelingen in vergelijking met die van een placebo; de effectiviteit op langere termijn, wanneer de behandeling voortgezet of gestaakt wordt; vergelijkingen met de effectiviteit van cognitieve gedragstherapieën (CGT). De strekking luidt als volgt: ad a Het nut bij acute behandelingen kan nauwelijks betwijfeld worden. De waarde van jarenlang gebruik is moeilijker te taxeren. De effectiviteit is afhankelijk van psychosociale karakteristieken van de omgeving van de patiënt. Over de algemene en blijvende effectiviteit van CGT valt nog niets te zeggen. Ad b en c Het gemiddelde verschil in effectiviteit tussen medicijnen en placebo bij acute behandelingen is klein; uitgedrukt in effectgroottes kleiner dan 0,5 bij depressies, gegeneraliseerde angststoornissen en paniekstoornissen, en misschien iets groter bij dwangstoornissen en sociale fobieën; met enkele amenderingen lijken, waar onderzocht, benzodiazepinen, antidepressiva en antipsychotica even effectief bij angststoornissen. Gezien de nadelen van de alternatieven, is een SSRI altijd een goede eerste keuze, ongeacht de diagnose. De waarde van zeer langdurige medicamenteuze behandelingen is onduidelijk. De gemiddelde effectiviteit van CGT is minstens zo groot als van medicatie en de verbeteringen beklijven minstens zo goed. Bij een ‘modale’ patiënt met een depressie of angststoornis valt er vooralsnog veel voor te zeggen medicatie als een optie van tweede keuze te beschouwen, mede gezien de bijwerkingen die een enkele keer zeer ernstig kunnen zijn. Meer onderzoek naar de mogelijke meerwaarde van een combinatie van psychologische en medicamenteuze behandelingen is geboden.
Abstract
Emphasizing methodological problems in its assessment, effectiveness is reviewed of a antipsychotics in schizophrenic psychosis, b antidepressants in unipolar depression, and c anxiolytics, antidepressants and antipsychotics in anxiety disorders. Discussed are: drug-placebo differences in acute treatment, long-term effectiveness when treatment is continued or discontinued, and comparisons with cognitive behavioural therapy (CBT). The purport is as follows. As to a, usefulness in acute treatment can hardly be doubted. The benefit of continuing treatment for years is more difficult to assess. Effectiveness is dependent on psychosocial characteristics of the patient's environment. As yet nothing can be said on the general and lasting effectiveness of CBT. As to b and c, in acute treatment, mean drug-placebo differences in effectiveness are small; expressed in effect sizes smaller than 0.5 in depression, generalized anxiety disorder and panic disorder, and perhaps somewhat larger in obsessive-compulsive disorder and social phobia; as far as investigated, benzodiazepines, antidepressants and antipsychotics seem to be, with some amendments, equally effective in anxiety disorders. In view of the disadvantages of the alternatives, an SSRI is always a good pick, irrespective of the diagnosis. The benefit of very prolonged drug treatments is unclear. Mean effectiveness of CBT is at least as great as that of medication, and improvements take root at least as well. For a ‘modal’ patient with a depression or anxiety disorder, there is a case for considering the use of medication as an option of second choice, also in view of the side-effects which occasionally can be very serious. More research is needed into possibilities of an extra benefit of combinations of psychological and drug treatments.
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dr. W. van den Burg is werkzaam als universitair docent en onderzoeker bij de Afdeling Neuropsychologie van de Rijksuniversiteit Groningen. Zijn onderwijs en onderzoek betreffen neuropsychologie, methodologie/statistiek, en biologische psychiatrie, momenteel in het bijzonder de werkzaamheid van psychofarmaca.
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van den Burg, W. De (in)effectiviteit van psychofarmaca. DITH 18, 1–30 (1998). https://doi.org/10.1007/BF03060189
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DOI: https://doi.org/10.1007/BF03060189