[Counselor_Educ] Treatment Guideline for MDD

[Leinbaugh, Tracy]

>From Medscape Medical News<http://www.medscape.com/news>
APA Releases Updated Treatment Guideline for Major Depression

October 1, 2010 - For the first time in 10 years, the American Psychiatric Association (APA) has updated its practice guideline for the treatment of major depressive disorder (MDD).

The guideline, which took 5 years to update, includes new evidence-based recommendations on a myriad of clinical issues, including the use of antidepressant medications, depression-focused psychotherapies, and somatic treatments - including electroconvulsive therapy (ECT). It also focuses on strategies for treatment-resistant depression and options for treating depression during pregnancy.

"The 5-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, MD, chair of the guidelines work group, in a release. "We are hopeful these guidelines will lead to improved lives for many patients."

This third edition of the APA's practice guideline for MDD is published as a supplement to the October issue of the American Journal of Psychiatry and will post on www.PsychiatryOnline.com<http://www.PsychiatryOnline.com> in November.

Potential Conflicts of Interest Addressed

"It's been 10 years since the old guideline was issued and there's been a huge amount of research published in the interim," Joel Yager, MD, professor of psychiatry at the University of Colorado School of Medicine in Denver and chair of the APA's Steering Committee on Practice Guidelines, told Medscape Medical News.

"It was really obligatory that we did a very serious systematic review of everything that's been published to make certain that we didn't missing anything. It's really an effort to ensure that whatever we're recommending is current," he added.

The work group reviewed more than 13,000 articles published between 1999 (when the search from the previous edition ended) and 2006 and reviewed more than 1000 comments submitted on draft versions of the guideline.

An initial draft of this edition not only underwent extensive review by more than 100 people from the field of psychiatry, allied physician organizations, and patient advocacy groups but was also made available to the entire APA membership.

Although this final version was approved by the assembly in May 2009, it was reviewed specifically for potential bias by an independent panel of depression experts with no current ties to industry before being approved by the APA Board of Trustees.

"Expectations regarding the management of potential conflicts of interest for those involved in medical research, education, and practice-guideline development have changed radically in the past several years," writes APA president Carol A. Bernstein, MD, associate professor of psychiatry and vice chair for education at the New York University School of Medicine in New York City, in her October 1 Psychiatric News column.

"Although the work group endorsed the scientific integrity of the guideline, they were aware that their relationships with industry might result in perceptions of bias," she adds.

"This was actually ready to be published a year ago but because of all of the concerns of potential bias in practice guidelines across American medicine, we took the time to appoint the review group to go over this with a fine-toothed comb," explained Dr. Yager. "They did that and now this thing is as clean as a whistle."

Key Recommendations

Some of the key guideline changes include recommendations for the following:

 *   A clinician- and/or patient-administered rating scale for psychiatric symptoms to help with treatment strategies;
 *   ECT for treatment-resistant depression but also monoamine oxidase inhibitors, transcranial magnetic stimulation, and vagus nerve stimulation as other potential options;
 *   Aerobic exercise or resistance training to improve mood symptoms, especially in older adults with comorbidities; and
 *   Consideration of maintenance treatment after the continuation phase, especially for patients at risk for recurrence.

In addition, "we found that for the initial treatment of mild and moderate depression, psychotherapy and medications are both useful. There's a case to be made for both of them," said Dr. Yager.

He noted that there is evidence-based research to support, especially in the initial phase of depression treatment, the use of cognitive behavioral therapy and interpersonal therapy. "But there's also growing research for psychodynamic, psychotherapy, and problem solving therapy. So clinicians do have options.

As for medications, there's a wide range of antidepressants that can be used, which we've known before and which has been substantiated," added Dr. Yager, who noted that the guideline also reviewed the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, an effectiveness trial that looked at augmentation in switching strategies.

"That very important study showed that there are a lot of different options that clinicians should know about and read about when they're making their treatment decisions," he explained. "There are a number of new antidepressants that have been introduced on the market and we mention what they are. But we make it very clear that the generic medications that have been around for years are really as good as anything else in terms of initial treatment.

"We're sort of reinforcing the value of the selective serotonin reuptake inhibitors, the serotonin-norepinephrine reuptake inhibitors, mirtazapine, and buproprion. All of those are older medications and they are still the ones that should be used," said Dr. Yager.

Although the guideline does not recommend any alternative and complementary treatments as first-line therapy, this area is addressed for the first time with evidence reviews for such things as St. John's wort, omega-3 fatty acids, bright light therapy, and S-adenosyl methionine.

"Also, for women who are pregnant or planning on becoming pregnant or breastfeeding, psychotherapy is certainly a very good first-line approach. This is especially true for the mild to moderate cases of depression that haven't been treated before," Dr. Yager added.

He pointed out that all of the recommendations are for adults only and not for children and do not include bipolar depression. "We're going to be working on a separate guideline for bipolar disorders as well as a revised guideline for psychiatric evaluation and management."

"Pertinent Regardless of How DSM-5 Emerges"

Because of the long development process, the research done for the guideline was keyed to the fourth edition and the fourth edition, text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), reported Dr. Yager. "But everyone on this workgroup is very smart and very current and they were aware of what was going on with DSM-5."

In fact, Dr. Yager is a participant in the DSM-5 Oversight Group. "So I've been keenly aware of the shifts that have been made there. And it looks to us that what this guideline is recommending will be very, very pertinent regardless of how DSM-5 emerges. However, our future tweaks and updates will be geared to changes in the diagnostic criteria."

"It may not be 100% DSM-5, but we think that for most clinicians in practice, what we're saying here is going to be useful for quite a few years," he said.

The APA will also be giving continuing medical education (CME) credit and will make available a CME course to clinicians.

"It's not like this is all brand new stuff. It's really validating what they've been doing," summarized Dr. Yager. "We've been trying to summarize what we know about good practice and good treatment for depression, and I think a lot of psychiatrists already do this. This will just help them to fine tune it and to think about and reconsider some things."

The APA's guideline development process is also currently being renovated. "If we have the resources, we hope to have standing work groups that can have more timely comments and updates. But for the formal guideline process, we'd like to be able to update them every 5 years," said Dr. Yager.

In addition, key changes to the process will include the following:

 *   Using survey data, guideline recommendations will be rated according to both strength of evidence and strength of recommendation; and
 *   Formal surveys of both research and clinical physicians will be used to determine expert opinion.

Overall, "it will take time to implement these innovations, but we anticipate that our practice guidelines will continue to be of the highest professional integrity and offer the best evidence-based recommendations both for the clinician and for our patients," concludes Dr. Bernstein.

The work group members report several financial disclosures. A full list is included in the opening of the guidelines.

Am J Psychiatry. 2010;167(suppl):1-152.

Authors and Disclosures
Journalist
Deborah Brauser is a freelance writer for Medscape.
More on This Topic

 *   Depression and Suicide (Emergency Medicine)<http://emedicine.medscape.com/article/805459-overview>
 *   Physician Suicide (Emergency Medicine)<http://emedicine.medscape.com/article/806779-overview>
 *   Late-Onset Depression (Psychiatry)<http://emedicine.medscape.com/article/1356106-overview>


 *   Depression Resource Center<http://www.medscape.com/resource/depression>
 *   Mental Health and Psychiatric Nursing Resource Center<http://www.medscape.com/resource/psychiatric-nursing>


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Tracy Leinbaugh, PhD, NCC, PCC-S
Associate Professor
Chair, Department of Counseling and Higher Education
205 McCracken Hall
Ohio University
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Phone: 740-593-0846
E-mail: leinbaug at ohio.edu<mailto:leinbaug at ohio.edu>

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