January 23, 2023
3 min read
Abi-Jaoude reports receiving grants or contracts from CAMH AFP innovation funds and the University of Toronto Department of Psychiatry Excellence Funds; receiving honoraria from the Extension of Community Health Outcomes in Ontario and the Jewish General Hospital Child Psychiatry Grand Rounds; being an advisory board member of Pathological: The Movement; being a steering group member for the Critical Psychiatry Network; being the founding co-director of Canadians for Vanesa’s Law; and receiving travel support from the Vancouver Central Public Library. Gartlehner reports the manuscript was funded by the ACP. Shuchman reports no relevant financial disclosures.
In an update to its guidance on depression, ACP now recommends cognitive behavioral therapy or second-generation antidepressants as an initial treatment for patients in the acute phase of moderate to severe major depressive disorder.
The recommendation is strong based on moderate-certainty evidence, according to ACP.
The organization also recommends using a combination of the two as an alternate initial treatment option. This is a conditional recommendation with low-certainty evidence.
ACP’s other recommendations include:
- using only cognitive behavioral therapy as an initial treatment in patients in the acute phase of mild major depressive disorder (MDD; conditional recommendation with low-certainty evidence); and
- for patients in the acute phase of moderate to severe MDD who did not respond to initial treatment with an adequate second-generation antidepressant dose, switching to a different second-generation antidepressant or augmenting with a second pharmacologic treatment (conditional recommendation with low-certainty evidence) or augmenting with or switching to cognitive behavioral therapy (conditional recommendation with low-certainty evidence).
The recommendations are living guidance. According to a press release, ACP’s Clinical Guidelines Committee will continue to monitor the literature and periodically update its systematic review and clinical recommendations.
“MDD is a leading cause of disability, resulting in great costs to individuals, society and health care systems,” Amir Qaseem, MD, PhD, vice president of clinical policy and the Center for Evidence Reviews at ACP, and colleagues wrote in the guideline document, published in Annals of Internal Medicine. “In the United States, more than 20% of adults experience MDD in their lifetime, with around 10% experiencing it in a given year.”
The guidance was based on an updated systematic review and network meta-analysis of evidence from Gerald Gartlehner, MD, MPH, head of the department for evidence-based medicine and evaluation at the University for Continuing Education Krems in Austria, and colleagues, as well as two separate rapid reviews on the cost-effectiveness of treatment strategies and patients’ values and preferences.
Upon analyzing 65 randomized trials, Gartlehner and colleagues found that most nonpharmacologic treatments and antidepressants had similar benefits as first-step treatments, although antidepressants were associated with higher risks for discontinuation. They additionally noted that, as second-step therapies, various augmentation and switching strategies offered similar symptomatic relief.
“Our confidence in these findings is mixed,” Gartlehner and colleagues wrote. “The evidence was strongest for the comparisons of antidepressants with CBT or St. John’s wort as first-step treatments, and for pharmacologic switch and augmentation strategies as second-step treatments. For other comparisons, the evidence had substantial weaknesses, such as methodological shortcomings, small sample sizes, or restrictions of dosing ranges of antidepressants.”
They additionally noted that choosing the initial treatment for MDD should be individualized and based on discussions with patients about their experiences with past treatments, their preferences and the pros and cons of each option.
“Although most studies report similar efficacy between nonpharmacologic treatments and antidepressants, clinicians need to inform patients that for most comparisons, these results are uncertain and need to be interpreted cautiously,” they wrote.
In an accompanying editorial, Miriam Shuchman, MD, an associate professor in the department of psychiatry at the University of Toronto, and Elia Abi-Jaoude, MSc, MD, PhD, an assistant professor in the same department, wrote that, considering the prevalence of depression, “this guideline is a welcome contribution, with its systematic discussion and delineation of evidence-based treatment options.”
“Although it has some gaps, it is more valuable in several ways than other widely consulted practice guidelines for depression,” they wrote.
These gaps include a “limited menu of effective treatments” and “the issue of antidepressant withdrawal,” according to Shuchman and Abi-Jaoude.
They wrote that “the guideline does patients a disservice” by omitting nonmedication treatment options that could be offered as a first- or second-line therapy: behavioral activation, guided self-help, interpersonal therapy and psychodynamic therapy.
Additionally, they noted that providers frequently underestimate the adverse effects of antidepressants, like withdrawal. Though the guidance does advise providers to decrease the dose gradually when a patient opts to stop using antidepressants, “it misses the chance to let clinicians know how difficult this can be,” Shuchman and Abi-Jaoude wrote.
“Despite such gaps, the ACP’s depression guideline is a step in the right direction to improving primary care for patients with depression, due to its focus on patient preferences and its clear-eyed view of possible interventions,” they concluded. “We hope that, as a living guideline, it will continue to evolve to incorporate the social contexts underlying mental struggles and the broader effects of treatment options.”