What are the updated guidelines from the American College of Physicians for the treatment of acute depression?
For patients in the acute phase of major depressive disorder, the ACP continues the trend away from drug therapy and toward talk therapy. CBT is recommended as first-line treatment for patients with moderate symptoms (conditional recommendation). Citing evidence that up to 70% of patients with moderate to severe depression will not respond to a second-generation antidepressant, the group recommends offering CBT, medication therapy, or the combination of both to patients with more profound symptoms. (LOE = 5)
Overuse alert: This POEM aligns with the Canadian Psychiatric Association’s Choosing Wisely Canada recommendation: Don’t routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults.
This report updates the guidelines last issued by the American College of Physicians (ACP) in 2016. It is based on a separate systematic review that focused on patient-oriented outcomes; it specifically reviewed patient values and preferences. No guideline development members had conflicts of interest. The evidence was graded. For mild depression, the group recommends cognitive behavioral therapy (CBT) and not medication (conditional recommendation; low-certainty evidence). For moderate to severe symptom scores, the guidelines recommend, based on patient preference, either CBT or a second-generation antidepressant (i.e., not a tricyclic antidepressant) without recommending a specific one (strong recommendation; moderate-certainty evidence). The combination of psychotherapy and medication is also an option for moderate to severe depression (conditional recommendation; low-certainty evidence). Patients who don’t respond to initial drug treatment should be switched to or augmented with CBT (conditional recommendation; low-certainty evidence), switched to a different medication, or treated with an additional antidepressant (conditional recommendation; low-certainty evidence).
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine