Based on findings from a systematic review of clinical evidence, the American College of Physicians (ACP) recently issued updates for the treatment of MDD. The updated nonpharmacologic and pharmacologic recommendations and supporting clinical evidence are published in the Annals of Internal Medicine and emphasize the importance of tailoring therapy to patient needs and the significance of shared decision-making between clinician and patient to improve adherence and clinical outcomes.

As initial therapy in adults with moderate-to-severe MDD, the ACP updated guideline recommends the use of either cognitive behavioral therapy (CBT) or second-generation antidepressants (SGAs) and the combination of both as an alternative initial therapy option.

The ACP noted that the updated guideline is based on an accompanying comparative effectiveness living systematic review and network meta-analysis and on two additional rapid reviews on values and preferences and cost-effectiveness analyses completed by the ACP Center for Evidence Reviews at Cochrane Austria/University for Continuing Education Krems (Danube University Krems). The ACP’s Clinical Guidelines Committee indicates that since this is a living guideline, it will monitor the literature and periodically update the systematic review and the clinical recommendations.

The guideline provides clinicians with updated clinical recommendations on nonpharmacologic and pharmacologic interventions as initial and second-line treatments during the acute phase of a moderate-to-severe MDD episode. The updates are established on the best available evidence of the comparative benefits and harms and consideration of patient values, preferences, and costs. Furthermore, the updates recommend that therapies should be individualized and based on a discussion with patients on the factors mentioned above as well as other factors, such as adverse effect profiles, accessibility, feasibility, patient-specific symptoms (e.g., insomnia, hypersomnia, or changes in appetite), comorbidities, and use of other pharmacologic agents.

The ACP also recommended initiating CBT in adults with mild major depression and emphasizes the significance of informed decision-making in selecting treatment and considering the patient’s preferences. Key recommendations included the following:

• As initial treatment in patients in the acute phase of moderate-to-severe MDD, consider monotherapy with either CBT or an SGA (strong recommendation, moderate-certainty evidence).
• As initial treatment in patients in the acute phase of moderate-to-severe MDD, consider combination therapy with CBT and an SGA (conditional recommendation; low certainty-evidence).
• As initial treatment in patients in the acute phase of mild MDD, consider monotherapy with CBT (conditional recommendation; low-certainty evidence).
• 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, consider one of the following options:
• Shifting to or augmenting with CBT (conditional recommendation; low-certainty evidence)
• Changing to a different SGA or augmenting with a second pharmacologic treatment (conditional recommendation; low-certainty evidence).

The updated guidelines also suggested that when initiating an antidepressant, prescribers should start therapy with a low or minimum dose to decrease the potential of adverse effects and enhance adherence. Clinicians should also monitor patients for exacerbation of symptoms after 1 to 2 weeks of treatment with an SGA.

In a press release on the ACP website, Ryan D. Mire, MD, MACP, ACP president, stated, “Major depressive disorder is a leading cause of disability, resulting in significant costs to individuals, society, and health care systems and is often underrecognized and undertreated. It is critically important for patients to have continuity when being treated and managed to ensure adherence and address adverse effects. Also critical is the need for shared decision making around the best course of treatment based on preferences and including considerations around cost and access to care.”

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