Last week, the American College of Physicians (ACP) released a practice guideline in the treatment of depression through the use of medications.

MedPage Today covered some reaction to it from some psychiatrists, who lamented the lack of a comprehensive treatment approach guideline to depression (the ACP guideline focused only on the use of medications).

While I agree, in theory, that any guideline that focuses solely on one treatment method for a common mental disorder such as depression, while completely ignoring other treatment options, is a bad thing, I’m not sure we could’ve expected anything different from this physicians group. After all, physicians treat medical diseases, not mental disorders, and have no training or background in anything other than diseases and medications. Logically, why should a physicians group write a treatment guideline that suggests the use of a treatment that a physician can’t administer (such as psychotherapy)?

The guideline, however, is a short-sighted, simplistic attempt to try and “grade” research on antidepressants and their efficacy, when there is already some much better treatment studies that have already done most of the heavy lifting. For instance, refer any physician to the STAR*D findings, and that’s a nice capsule of what you need to know about modern antidepressant prescriptions. There are also a half-dozen meta-analyses done over the past two decades that already have been published on this or similar topics.

The ACP guideline concluded, in a nutshell, that a physician can feel comfortable prescribing any second-generation antidepressant and not worry about which one, which class of medication, or even what specific type of depression that person may be experiencing.

What a helpful finding that is (sarcasm alert – “Prescribe pretty much any antidepressant, just as you’ve been doing for years!”), but not one without its objectors. The MedPage Today article noted some of the objections from a psychiatrist regarding the ACP guideline:

Dr. Karasu said the ACP guideline committee made “a serious mistake” in suggesting that norepinephrine reuptake inhibitors were interchangeable with SSRIs.

Dr. Karasu also said the ACP guideline failed to distinguish between different types of depressive disorders or stages of depressive episodes.

In making treatment decisions, he suggested, “those are different diseases. … How dysthymia, major depression, subsyndromal depressions are put together with the phases of acute-continuation-maintenance, it’s a bizarre combination. People don’t use SSRIs of any sort for some of these conditions.”

But here’s the kicker for me. The guideline makes the a priori assumption that a general practitioner or family physician is the best health professional equipped to handle and deal with major depressive illness. In fact, that’s probably not true in most cases. Physicians aren’t in the mental health business, and they only prescribe the large amount of antidepressants that they do because so many people turn to them first for such assistance.

There’s nothing wrong with that. But one of the physician’s recommendations should nearly always be, “And I’m going to give you a referral to a [psychiatrist/psychologist/clinical social worker/therapist] to help you further with treatment of this issue. These things are best treated with a combination of medication and psychotherapy and if you only take the medication, research shows it might not work, this may not be the right medication for you, and/or it may be weeks before you start feeling any effect.” How hard is that for a doc to say? And why aren’t more docs making such valuable referrals??

I don’t have the answer, but I do know that guidelines like this one from the ACP may be doing a disservice to the public health by making the assumption (and then publicizing it widely) that physicians are readily equipped and can handle the treatment of severe, major depression in a 15-minute office visit.

Mental health professionals the world over and decades worth of research would beg to differ.

Read the MedPage Today article: Medical News: Psychiatrists Give Mixed Reviews on ACP Antidepressant Guideline

Read the ACP guideline: Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the American College of Physicians

PS – How seriously should I take research that is published without simple fact-checking too? The researchers, for instance, still refer to the PsycINFO database by its old name, and then go on to actually misspell it (the article referred to a database called PsychLit [sic], when it’s old name was actually PsycLIT). I mean, if you can’t even get the name of what you’re searching right, it does make one wonder a little about the accuracy and details found in the rest of the article.

The criteria seemed a bit random as well — “adults 19 years of age or older, human, and English-language articles.” I get the human criteria, but why 19 years of age or older, rather than the traditional adult cutoff of 18? And why not include studies published in a non-English language?

Dr. John Grohol is the CEO and founder of Psych Central. He is an author, researcher and expert in mental health online, and has been writing about online behavior, mental health and psychology issues -- as well as the intersection of technology and human behavior -- since 1992. Dr. Grohol sits on the editorial board of the journal Cyberpsychology, Behavior and Social Networking and is a founding board member and treasurer of the Society for Participatory Medicine.

    Last reviewed: By John M. Grohol, Psy.D. on 26 Nov 2008
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