ACP issues clinical practice guideline on depression treatment in adults

The American College of Physicians issued a new clinical practice guideline this week on nonpharmacologic versus pharmacologic treatment for adult patients with major depressive disorder.

The guideline, which was published online Feb. 9 by Annals of Internal Medicine, is based on a systematic review of randomized, controlled trials published from 1990 through September 2015 that were at least 6 weeks in duration and compared the benefits and harms of multiple nonpharmacologic and pharmacologic treatments for major depressive disorder, including psychotherapy, complementary and alternative medicine (CAM), exercise, and second-generation antidepressants (i.e., newer agents than tricyclics or monoamine oxidase inhibitors). Unpublished studies were also included where appropriate, and nonrandomized studies were eligible for analysis of harms.

The outcomes assessed were benefits in response, remission, speed of response, speed of remission, relapse, quality of life, functional capacity, reduction of suicidality, or reduction of hospitalization. Harms assessed were adverse events overall, withdrawal due to adverse events, serious adverse events, and specific adverse events.

Forty-five trials met the inclusion criteria. The researchers determined that, based on moderate-strength evidence, cognitive behavioral therapy (CBT) and second-generation antidepressants had similar response rates (relative risk, 0.90; 95% CI, 0.76 to 1.07) and remission rates (relative risk, 0.98; 95% CI, 0.73 to 1.32) when used as first-step therapies. Risks for adverse events and medication discontinuation due to adverse events were higher with second-generation antidepressants than with psychological, CAM, or exercise interventions.

In patients for whom treatment with second-generation antidepressants is unsuccessful, low-quality evidence found similar effectiveness of strategies involving switching to or augmenting with another second-generation antidepressant or nonpharmacologic therapy. Low-quality evidence also found that St. John's wort was as effective as second-generation antidepressants in older persons and had similar adverse event rates.

Based on this evidence review, ACP recommends that clinicians choose between CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. This is a strong recommendation based on moderate-quality evidence.

“Although [second-generation antidepressants] are often initially prescribed for patients with depression, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative treatment to [second-generation antidepressants] where available,” the guideline authors wrote. They noted that adverse effects differ among second-generation antidepressants and said that physicians should discuss the adverse effect profiles of different drugs with patients before selecting a treatment. The guideline also noted that the evidence was insufficient in several areas, including the comparative effectiveness of second-generation antidepressants versus third-wave CBT (defined as CBT that targets thought processes to help persons with awareness and acceptance), the applicability of St. John's wort studies to U.S. patients, and the effects of switching versus augmenting therapies.

The authors of an accompanying editorial said that the ACP guideline's emphasis on discussing risks and benefits of treatments with patients is appropriate and follows the principles of shared decision making. “Incorporating these principles and decision aids could address the current mismatch between the treatment desired and the treatment received by patients with depression,” the editorialists wrote.