ACP's updated depression guideline recommends CBT, second-generation antidepressants

ACP updated its guideline for major depressive disorder (MDD) to recommend either cognitive behavioral therapy (CBT) or second-generation antidepressants (SGAs) as initial treatment in adults with moderate to severe cases and suggests the combination of both as an alternative initial treatment option.

The living clinical guideline and supporting evidence reviews, on nonpharmaceutical and pharmaceutical treatments, cost-effectiveness, and values and preferences of patients, were published Jan. 24 by Annals of Internal Medicine.

The guideline stresses the importance of informed decision making in selection of a treatment and inclusion of patient preferences. ACP recommends:

• monotherapy with either CBT or an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (strong recommendation, moderate-certainty evidence),
• combination therapy with CBT and an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (conditional recommendation; low-certainty evidence),
• monotherapy with CBT as initial treatment in patients in the acute phase of mild MDD (conditional recommendation; low-certainty evidence), and
• one of two options for patients in the acute phase of moderate to severe MDD who have not responded to initial treatment with an adequate dose of an SGA: switching to or augmenting with CBT (conditional recommendation; low-certainty evidence), or switching to a different SGA or augmenting with a second pharmacological treatment (conditional recommendation; low-certainty evidence).

To enable informed decisions, physicians should discuss with patients potential treatment benefits, harms, adverse effect profiles, cost, feasibility, specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), comorbidities, concomitant medication use, and preferences.

An accompanying editorial noted important gaps in the recommendations, such as the limited menu of effective treatments. “The guideline does patients a disservice by leaving out several nonmedication treatment options that clinicians can offer as first- or second-line therapies,” the editorialists wrote. The editorial also suggested that physicians may need more information about helping patients safely discontinue medications without experiencing potentially severe withdrawal symptoms.

“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,” the editorialists wrote. “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.”