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Treating the Acute Phase of Major Depressive Disorder: ACP Updates Living Guideline

Cognitive-behavioral therapy (CBT) and/or second-generation antidepressants (SGAs) can be used for initial therapy of adults in the acute phase of moderate-to-severe major depressive disorder (MDD), the American College of Physicians (ACP) recommends in an update of its guideline on nonpharmacologic and pharmacologic options. ACP recommends using combination therapy with CBT and SGAs as an alternate initial treatment option. The guideline and supporting evidence are available on the Annals of Internal Medicine website.

ACP also suggests initiating CBT in adults with mild MDD. ACP stresses the importance of informed decision-making when selecting treatment and taking patient preferences into account. In summary, the College recommends the following: 

  • 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).
  • One of the following options for patients in the acute phase of moderate-to-severe MDD who did not respond to initial treatment with an adequate dose of an SGA:
    • switching to or augmenting with CBT (conditional recommendation; low-certainty evidence)
    • switching to a different SGA or augmenting with a second pharmacologic treatment (conditional recommendation; low-certainty evidence)

A systematic review and meta-analysis provides the evidence basis for these recommendations. Other articles discuss the cost-effectiveness of pharmacologic and nonpharmacologic interventions as first- and second-step treatments in patients with MDD and patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder.

Editorial: “The need for clinicians to consider a broader array of nondrug treatments [for MDD] is underscored by the current body of evidence about second-generation antidepressants: They can be helpful, but effect sizes are small and many patients who respond initially do not maintain benefit,” editorialists write. “As a result, patients often go from one drug to the next in the hopes of landing on one that ‘works.’ This narrow clinical approach of pursuing medication-based treatments ignores the ways difficulties in a person’s work or relationships may contribute to their struggles with depression. At a time when the COVID-19 pandemic has underscored the importance of the social context of mental health, clinicians may need to consider other forms of support and tailor prescribing to what is most relevant and accessible for a particular patient. For example, the 2022 depression guideline from the National Institute for Health and Care Excellence, a public advisory body in the United Kingdom, lists 10 effective first-line treatments for severe depression. In addition to antidepressants and CBT, these include interpersonal therapy and psychodynamic therapy, as well as problem solving, behavioral activation, and guided self-help.”

Source: Annals of Internal Medicine