Updated guidelines recommend second-generation antidepressants for the treatment of major depressive disorder in adults
The American College of Physicians (ACP) has published updated guidelines outlining clinical recommendations for nonpharmacologic and pharmacologic treatment of adults in the acute phase of major depressive disorder (MDD). In the updated clinical guidelines, ACP recommends the use of cognitive behavioral therapy (CBT) or second-generation antidepressants (SSRIs) as initial treatment for adults with moderate to severe MDD and suggests a combination of both as another initial treatment option. The recommendations and evidence review are published in the Annals of Internal Medicine.
ACP also suggests initiating CBT for adults with mild severe depression; ACP emphasizes the importance of making informed decisions and considering patient preferences when choosing treatment. Overall, the ACP recommends the following:
- Monotherapy with CBT or SGA as initial therapy in patients with moderate to severe acute MDD (strong recommendation; moderate evidence).
- Combination therapy with CBT and SGA as initial therapy in patients in the acute phase of moderate to severe acute MDD (conditional recommendation; low certainty evidence).
- Monotherapy with CBT as initial therapy in patients in the acute phase of mild MDD (conditional recommendation; low certainty evidence).
- One of the following options for patients in the acute phase of moderate to severe MDD who have not responded to initial therapy with SGA at appropriate doses:
- Switching to CBT or supplementing with CBT (conditional recommendation; low certainty evidence),
- Switching to another SGA or supplementing with a second pharmacologic agent (see clinical considerations) (conditional recommendation; low certainty evidence).
An informed selection decision should be individualized based on a discussion of potential treatment effects, harms, side effect profile, cost, feasibility, patient-specific symptoms (e.g., insomnia, hypersomnia, appetite fluctuations), comorbidities, concomitant medication use, and patient preference.
This guideline is based on a systematic review of comparative effectiveness and a network meta-analysis conducted by the ACP Evidence Review Center at the Cochrane University of Continuing Education Austria/Krems (Danube University of Krems), as well as value and preference and cost assessments. Based on two additional rapid reviews on cost-effectiveness analysis.
The ACP Clinical Guidelines Committee will keep this topic as a “living” guideline by regularly updating the literature review, systematic reviews, and clinical guidelines.
The University of Toronto’s accompanying editorial states that the ACP recommendations are a step in the right direction by emphasizing the role of patients in shared decision-making about depression. However, it notes that there are significant gaps in the recommendations regarding treatment approaches other than pharmacotherapy. Clinicians also need more information to ensure that patients can safely discontinue medications without experiencing serious withdrawal symptoms.
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