New Clinical Guidelines for Major Depression

The American Psychiatric Association has released a new clinical practice guideline for the treatment of patients with major depressive disorder.

However, the new guideline is vague and offers little improvement over existing depression treatment guidelines. For instance, it doesn’t help a clinician determine which of the 29 antidepressants to prescribe first.

Controversy has swirled around this latest guideline revision, as every member except one of the committee who began work in 2005 on the new set of depression treatment recommendations has ties to the pharmaceutical industry. A second, independent committee had to review the first committee’s recommendations in 2009, to ensure the recommendations were not industry-biased.

The evidence-based treatment parameters include new recommendations on the use of antidepressant medications, depression-focused psychotherapies, and somatic treatments such as electro-convulsive therapy (ECT).

Suggestions on use of alternative and complementary treatments, the treatment of depression during pregnancy, and strategies for treatment-resistant depression are included in the new review.

“The five-year process of intense review, discussion and thoughtful revision-making has led us to today’s release of new guidelines that we believe will improve patient care,” said Alan J. Gelenberg, M.D., chair of the work group that drafted the guidelines.

“We are hopeful these guidelines will lead to improved lives for many patients.”

The work group led by Dr. Gelenberg was made up of APA members with extensive research and clinical expertise in the assessment and treatment of major depressive disorder. The group reviewed over 13,000 articles published from 1999, when the search from the previous edition ended, to 2006.

Draft versions of the guideline underwent extensive review by more than 100 stakeholders, including experts from the field of psychiatry, allied physician organizations, patient advocacy groups, and members of APA. More than 1,000 comments were submitted.

Each comment was reviewed by the work group and APA’s Steering Committee on Practice Guidelines; substantive revisions were made in response to comments.

In 2009, an independent panel of depression treatment experts without ties to industry specifically reviewed the guideline for potential bias, and the final guideline was approved by the APA Board of Trustees.

One of the key findings of the new guideline is that no antidepressant is more effective than another, according to the research.

A few key changes to the guidelines include:

• Rating scales: The guideline recommends potentially using a clinician- or patient-administered rating scale to assess the type, frequency, and magnitude of psychiatric symptoms in order to tailor the treatment plan to match the needs of the particular patient.
• New strategies for treatment-resistant depression: The guideline explains that electroconvulsive therapy has the strongest data supporting it as a treatment for patients who do not respond to multiple medication trials. Transcranial magnetic stimulation and vagus nerve stimulation have also been added as potential treatments for these patients. Monoamine oxidase inhibitors, known as MAOIs, are also an option.
• Exercise and other healthy behaviors: The guideline cites randomized, controlled trials that demonstrate at least a modest improvement in mood symptoms for patients who engage in aerobic exercise or resistance training. Regular exercise may also reduce the prevalence of depressive symptoms in the general population, with specific benefit found in older adults and individuals with co-occurring medical problems.
• Maintenance treatment recommendation strengthened: The guideline recommends that after the continuation phase, maintenance treatment should be considered, especially for patients with risk factors for recurrence. Maintenance treatment should definitely be provided for patients with more than three prior depressive episodes or chronic illness.

As in the previous depression guideline, this one also emphasizes the importance of psychotherapy in conjunction with antidepressant medications or other treatments.

The American Psychiatric Association is a professional organization with a membership of over 38,000 psychiatrists.

Source: American Psychiatric Association