Cognitive behavioral therapy (CBT), second-generation antidepressants, or a combination of the two approaches are recommended for the initial treatment of moderate to severe major depressive disorder (MDD) in adults, according to updated clinical recommendations from the American College of Physicians (ACP).
The decision on which treatment to initiate first should be based on a discussion of potential benefits, harms, adverse effect profile, cost, feasibility, patient-specific symptoms, comorbidities, other medications used, and patient preferences, said ACP Clinical Guidelines Committee Chair Timothy J. By Wilt, MD, MPH, written History of Internal Medicine.
For patients who do not respond to initial treatment with adequate doses of second-generation antidepressants, Wilt and team recommend switching to CBT or another antidepressant or augmenting initial therapy with CBT or a second antidepressant.
The guideline recommends the use of CBT as initial monotherapy for patients experiencing an acute phase of mild MDD and also includes new evidence as a second-line treatment since its 2016 publication.
“Our mission is to provide physicians with the best available evidence to provide high-quality care and improve the lives of their patients,” Wilt said MedPage Today.
“Acute major depression is an important and often under-recognized and under-treated condition,” he adds. “Having different options may improve the number of patients who benefit from treatment.”
“General internal medicine physicians are the frontline physicians who diagnose, treat, and refer adults with MDD when needed for additional collaborative mental health care, and this updated Living Clinical Practice Guideline provides general internal medicine physicians and other clinicians with reliable, readable, provides relevant. up-to-date information on treatment options for adults with acute major depressive disorder,” he said.
Wilt also emphasized that the guideline is meant to address the most current evidence for the treatment of MDD, adding that the ACP plans to update their recommendations with the latest evidence as it becomes available.
“Because of the importance of this topic to general internal medicine physicians and mental health clinicians, ACP has designated this topic as a ‘living guideline,’ meaning that ACP will routinely scan the literature for evidence that may influence ACP’s recommendations,” he explained.
In a co-authored editorial, Miriam Schuchman, MD, and Elia Abi-Jaoudeh, MSc, MD, PhD, of the University of Toronto, highlight several shortcomings of the guideline, including a limited list of effective treatment options. Despite the focus on personalized care, “the guideline harms patients by leaving them with a variety of non-pharmacological treatment options that physicians may offer as first- or second-line therapy,” they wrote.
They also noted that the recommendations did not include sufficient guidance on antidepressant withdrawal, although they acknowledged that the guideline is “a step in the right direction to improve primary care for patients with depression, given its focus on patient preferences and its clear view of possible intervention scenarios.”
A key highlight of the guideline was its “focus on the patient’s role in shared decision-making about depression,” they said.
“This effort to respond to patient preferences is critical and may even increase the likelihood that patients will improve with treatment,” they added. “The ACP also increased the credibility of these guidelines and achieved a milestone by spelling out the steps that guideline committee members take when realizing conflicts of interest that may affect their decisions about depression treatment.”
“We hope that, as a living guideline, it will continue to evolve to include the social context underlying emotional struggles and the broader implications of treatment options,” they conclude.
Wilt said MedPage Today that “Physicians should discuss these options with their patients because patient treatment preferences and outcomes may vary, in part due to differences in treatment and adverse effects, cost, and access.”
The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review and network meta-analysis, as well as two rapid reviews completed by the ACP Center for Evidence Review at the Cochrane Austria/University for Continuing Education Krems.
Financial support for the development of this guideline came solely from the ACP operating budget.
Wilt reported no exposure.
Abi-Jaoude reports grants from the University of Toronto Department of Psychiatry Excellence Fund and the CAMH AFP Innovation Fund; Honors from the Jewish General Hospital Child Psychiatry Grand Rounds and the Extension of Community Health Outcomes (ECHO) Ontario; financial support from the Vancouver Central Public Library; and Leadership Roles for Pathological: The Movement, Critical Psychiatry Network and Canadians for Vanessa’s Law. Shuchman reported no disclosures.
History of Internal Medicine
Source reference: Qasim A, et al “Nonpharmacologic and pharmacologic treatment of adults in the acute phase of major depressive disorder: a living clinical guideline from the American College of Physicians” Ann Intern Med 2023; DOI: 10.7326/M22-2056.
History of Internal Medicine
Source Reference: Schuchman M, Abi-Joued E “American College of Physicians Living Guidelines on Depression: A Step Forward, but Gaps Remain” Ann Intern Med 2023; DOI: 10.7326/M22-3701.