ACP Guidelines Committee Member Reviews MDD Treatment Options

In 2016, the American College of Physicians (ACP) issued a clinical practice guideline recommending either cognitive behavioral therapy (CBT) or second-generation antidepressants for the treatment of major depressive disorder (MDD)–a condition with an estimated lifetime prevalence of 16% in the United States.¹

At the ACP Internal Medicine Meeting, Timothy J Wilt, MD, MPH, from the Clinical Guidelines Committee of the ACP, reviewed available pharmacologic and nonpharmacologic treatment for MDD based on the 2016 guideline recommendations.

He pointed out that, although most patients with MDD are treated by their primary care physicians (PCPs), those seen by PCPs are less likely to meet major depressive disorder criteria or adhere to medication than those seen by professionals in mental health fields. “We can do a better job with that,” he said during his talk.

MDD diagnosis begins with proper assessment and screening, Dr Wilt said, naming the Patient Health Questionnaire-9 (PHQ-9) as the most widely used screening tool for MDD. Other screening tools for MDD include the Beck Depression Inventory and Hamilton Depression Rating Scale, among others.

Once MDD is diagnosed, treatment options can be selected after discussing depression severity, treatment effects, adverse effects, cost, accessibility, and preferences with each patient, Dr Wilt said.

Non-pharmacologic treatments include CBT and cognitive therapy, among others, he said. Pharmacologic treatments include various types of second-generation antidepressants, such as selective serotonin reuptake inhibitors (citalopram, escitalopram etc), serotonin and norepinephrine reuptake inhibitors (duloxetine, etc.), and alternatives such as bupropion.

Dr Wilt noted the importance of addressing possible adverse effects of pharmacologic treatments with patients, explaining that adverse effects such as weight gain and sexual adverse effects can impact treatment adherence.

Finally, he emphasized that close monitoring and follow-up are key in ensuring effective treatment for MDD. Treatment response (defined as a 50% improvement in symptoms) and remission (defined as minimal to no symptoms) only occur in about 70% and 40% of patients with MDD, respectively, Dr Wilt said.

—Christina Vogt

References:

1. Qaseem A, Barry MJ, Kansagara D; Clinical guidelines committee of the American College of Physicians. Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;164(5):350-359. doi:10.7326/M15-2570.

2. Wilt TJ. Nonpharmacologic and pharmacologic treatment of adult patients with MDD. Presented at: ACP Internal Medicine Meeting 2019; April 11, 2019; Philadelphia, PA.