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Next, let’s look at unipolar treatment guidelines. In other words, what are the general guidelines for the treatment of major depressive disorder as we look around the world?
We have a new publication to help here that looked at 12 different guideline-producing organizations and summarized from all those different guidelines. The organizations include British, German, Australian, Spanish, Canadian, Texan (that maybe is a different country), 2 other American sources—the Veterans Administration and American Psychiatric Association—and a smattering of others, including the World Health Organization. Many of them are psychopharmacology guidelines, so they don’t address the role of psychotherapy per se in the treatment of depression, at least not directly. As a result, you may anticipate not all are new here. I guess it’s the nature when you look at 12 different guidelines that you aren’t going to find new stuff. It’s kind of an averaging process that would lead us to the most conservative conclusions. But let’s take a look at some of these guidelines and what was found when they were looked at all together.
For the first-line treatment of major depressive disorder, everyone agrees on serotonin reuptake inhibitors. And nearly all of them include as first-line serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazapine, and bupropion, and a few even included mianserin and newer medications like vortioxetine, agomelatine, and vilazodone. So, SRIs, everybody is in; SNRIs, most are in. Mirtazapine and bupropion, most support. And then the newer stuff, a few support. When you have that many agents that are all regarded as first-line, it strikes me that, well, you haven’t really offered much of a guideline, but good to know that everyone agrees on those.
There was less consistency in the pharmacologic management of depressive diagnoses other than acute major depression. Chronic depression, dysthymia, persistent depressive disorder—not so much of a consensus on how to treat those, and also a lack of consensus on the concept of treatment-resistant depression: How should that be defined, and how should one manage it?
In general, I found this paper useful just to see how much work has gone into formulating guidelines. Large teams from all over the world have worked on these. I found it somewhat sad that all this energy is expended, and then so many agents come out first-line. But the big question for me is, for whom is psychotherapy alone better than medications? That’s the first-line question that we as clinicians face and that is not addressed in this review of unipolar treatment guidelines. Also, a notable absence here is any mention of mixed features, which really complicates how one might approach depression.
So, this study is for pure unipolar major depression. Nonpharmacologic treatments are considered, including device treatments like TMS (transcranial magnetic stimulation), and transcranial direct-current stimulation, vagal nerve stimulation, and deep brain stimulation. Chronotherapies are mostly nondevice treatments, like light therapy or overnight sleep deprivation. Those are mentioned. But across all the guidelines, only ECT (electroconvulsive therapy) has general agreement as a clear and important nonpharmacologic alternative. It’s not first line except in catatonic and psychotic depressions or high suicidality or a previous good response to ECT. In other words, ECT is not a first-line approach, but it is a nonpharmacologic approach that made it into these guidelines very consistently, very near the top for consideration, especially when first-line agents are not working.
In summary, we have a highly conservative way of looking at guidelines here, and there’s nothing particularly controversial. I think the most important finding here is that there are so many guidelines out there, and that they do support our usual pharmacologic approaches. The important question of psychotherapy or medications is not addressed here.
Abstract
Comparison of Guidelines for the Treatment of Unipolar Depression: A Focus on Pharmacotherapy and Neurostimulation
A. J. Bayes, G. B. Parker
Objective: To determine the level of agreement across a set of evidence‐based guidelines for management of the unipolar depressive disorders and with a focus on physical treatments.
Method: A literature search was undertaken using the terms ‘depression’, ‘depressive’ and ‘guidelines’, using PubMed, Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. Twelve national psychiatric or professional guideline‐producing organizations were identified from the period 2007–2017, with guidelines qualitatively reviewed by two assessors.
Results: For major depressive disorder (MDD), there was general consensus to use an antidepressant (AD) in cases of greater severity, although disagreement on AD use in mild to moderate depression. There was some agreement on choice of AD class in first‐line treatment recommendations, though great variability in second‐ and third‐line management particularly in recommended augmentation and combined AD strategies. Electroconvulsive therapy was considered in all but one guideline, with other neurostimulation treatments being less consistently covered and with variable recommendations. Finally, there was low consistency in the management of dysthymia, persistent depressive disorder and treatment resistant depression.
Conclusion: Our review identifies varying levels of consistency in guideline recommendations. Strategies to improve reliability in guideline formulation should also improve their validity.
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Reference
Bayes, A. J., & Parker, G. B. (2018). Comparison of guidelines for the treatment of unipolar depression: A focus on pharmacotherapy and neurostimulation. Acta Psychiatrica Scandinavica, 137(6), 459-471.
