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<h2>From <a href="http://www.medscape.com/news">Medscape Medical News</a> <o:p></o:p></h2>
<h1>APA Releases Updated Treatment Guideline for Major Depression<o:p></o:p></h1>
<p id=authors>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).<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>"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."<o:p></o:p></p>
<p>This third edition of the APA's practice guideline for MDD is published as a
supplement to the October issue of <i>the American Journal of Psychiatry </i>and
will post on <a href="http://www.PsychiatryOnline.com" target="_blank">www.PsychiatryOnline.com</a>
in November.<o:p></o:p></p>
<p><b>Potential Conflicts of Interest Addressed</b> <o:p></o:p></p>
<p>"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 <i>Medscape
Medical News.</i> <o:p></o:p></p>
<p>"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.<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>"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 <i>Psychiatric News</i> column.<o:p></o:p></p>
<p>"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.<o:p></o:p></p>
<p>"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."<o:p></o:p></p>
<p><b>Key Recommendations</b> <o:p></o:p></p>
<p>Some of the key guideline changes include recommendations for the following:<o:p></o:p></p>
<ul type=disc>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;
mso-list:l0 level1 lfo2'>A clinician- and/or patient-administered rating
scale for psychiatric symptoms to help with treatment strategies;<o:p></o:p></li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;
mso-list:l0 level1 lfo2'>ECT for treatment-resistant depression but also
monoamine oxidase inhibitors, transcranial magnetic stimulation, and vagus
nerve stimulation as other potential options;<o:p></o:p></li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;
mso-list:l0 level1 lfo2'>Aerobic exercise or resistance training to
improve mood symptoms, especially in older adults with comorbidities; and<o:p></o:p></li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;
mso-list:l0 level1 lfo2'>Consideration of maintenance treatment after the
continuation phase, especially for patients at risk for recurrence.<o:p></o:p></li>
</ul>
<p>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.<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>"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.<o:p></o:p></p>
<p>"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.<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>"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.<o:p></o:p></p>
<p>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."<o:p></o:p></p>
<p><b>"Pertinent Regardless of How <i>DSM-5</i> Emerges"</b> <o:p></o:p></p>
<p>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 <i>Diagnostic
and Statistical Manual of Mental Disorders </i>(<i>DSM</i>), reported Dr.
Yager. "But everyone on this workgroup is very smart and very current and
they were aware of what was going on with <i>DSM-5</i>."<o:p></o:p></p>
<p>In fact, Dr. Yager is a participant in the <i>DSM-5</i> 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 <i>DSM-5</i> emerges. However, our future tweaks
and updates will be geared to changes in the diagnostic criteria."<o:p></o:p></p>
<p>"It may not be 100% <i>DSM-5</i>, 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.<o:p></o:p></p>
<p>The APA will also be giving continuing medical education (CME) credit and
will make available a CME course to clinicians.<o:p></o:p></p>
<p>"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."<o:p></o:p></p>
<p>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.<o:p></o:p></p>
<p>In addition, key changes to the process will include the following:<o:p></o:p></p>
<ul type=disc>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;
mso-list:l3 level1 lfo3'>Using survey data, guideline recommendations will
be rated according to both strength of evidence and strength of
recommendation; and<o:p></o:p></li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;
mso-list:l3 level1 lfo3'>Formal surveys of both research and clinical
physicians will be used to determine expert opinion.<o:p></o:p></li>
</ul>
<p>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.<o:p></o:p></p>
<p><i>The work group members report several financial disclosures. A full list
is included in the opening of the guidelines. </i><o:p></o:p></p>
<p><i>Am J Psychiatry</i>. 2010;167(suppl):1-152.<o:p></o:p></p>
<h2>Authors and Disclosures<o:p></o:p></h2>
<h3>Journalist<o:p></o:p></h3>
<h4>Deborah Brauser is a freelance writer for Medscape.<o:p></o:p></h4>
<p class=MsoNormal>More on This Topic<o:p></o:p></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="100%"
style='width:100.0%'>
<tr>
<td valign=top style='padding:0in 0in 0in 0in'>
<ul type=disc>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:
auto;mso-list:l1 level1 lfo5'><a
href="http://emedicine.medscape.com/article/805459-overview">Depression
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<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:
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<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:
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</ul>
</td>
<td valign=top style='padding:0in 0in 0in 0in'>
<ul type=disc>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:
auto;mso-list:l4 level1 lfo6'><a
href="http://www.medscape.com/resource/depression">Depression Resource
Center</a> <o:p></o:p></li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:
auto;mso-list:l4 level1 lfo6'><a
href="http://www.medscape.com/resource/psychiatric-nursing">Mental
Health and Psychiatric Nursing Resource Center</a> <span
style='font-size:12.0pt'><o:p></o:p></span></li>
</ul>
</td>
</tr>
</table>
<p>Medscape Medical News © 2010 WebMD, LLC<br>
Send press releases and comments to <a href="mailto:news@medscape.net">news@medscape.net</a>.<o:p></o:p></p>
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