ACP Guideline Backs Newer Antidepressants, CBT for Acute Phase of Major Depression

Cognitive behavioral therapy (CBT), second-generation antidepressants, or a combination of the two approaches are recommended for the initial treatment of adults in the acute phase of moderate-to-severe major depressive disorder (MDD), according to updated clinical recommendations from the American College of Physicians (ACP).

The decision on which treatment to start first should be based on a discussion of potential benefits, harms, adverse effect profiles, cost, feasibility, patients’ specific symptoms, comorbidities, other medications being used, and patient preferences, ACP’s Clinical Guidelines Committee, led by Chair Timothy J. Wilt, MD, MPH, wrote in the Annals of Internal Medicine.

For patients who do not respond to initial treatment with an adequate dose of a second-generation antidepressant, Wilt and team recommended transitioning to CBT or a different antidepressant, or augmenting initial therapy with CBT or a second antidepressant.

The guideline also recommends the use of CBT as an initial monotherapy for patients experiencing the acute phase of mild MDD and also includes new evidence on second-line treatments since the 2016 publication.

“Our goal is to provide clinicians with the best available evidence to deliver high-quality care and improve the lives of their patients,” Wilt told MedPage Today.

“Acute major depression is an important and often underrecognized and undertreated condition,” he added. “Having different options can improve the number of patients benefiting from treatment.”

“General internal medicine physicians are frontline doctors who diagnose, treat, and refer, when necessary, adults with MDD for additional collaborative mental health care, and this updated living clinical practice guideline provides general internal medicine physicians and other clinicians with reliable, readable, relevant up-to-date information on treatment options for adults with acute major depressive disorders,” he said.

Wilt also emphasized that this guideline is meant to address the most current evidence for 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 for general internal medicine physicians and mental health clinicians, ACP has designated this topic as a ‘Living Guideline,’ meaning that ACP will regularly scan the literature for evidence that might impact ACP’s recommendations,” he explained.

In an accompanying editorial, Miriam Shuchman, MD, and Elia Abi-Jaoude, MSc, MD, PhD, of the University of Toronto, highlighted several shortcomings of the guideline, including its limited list of effective treatment options. Despite the focus on personalized care, “the guideline does patients a disservice by leaving out several non-medication treatment options that clinicians can offer as first- or second-line therapies,” they wrote.

They also noted that the recommendations do not include enough guidance on antidepressant withdrawal, though they acknowledged that the 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.”

A key highlight of the guideline was its “focus on the patient’s role in shared decision making around depression,” they said.

“This effort to respond to patient preferences is crucial and may even increase the chance that patients will improve with treatment,” they added. “The ACP also increased the trustworthiness of these guidelines and achieved a milestone by spelling out the steps taken when members of the guideline committee acquired conflicts of interest that could affect their judgment about treatments for depression.”

“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,” they concluded.

Wilt told MedPage Today that “clinicians should talk with their patients about these options because patient treatment preferences and outcomes may vary, in part due to differences in treatments 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 Reviews at Cochrane Austria/University for Continuing Education Krems.