The American Psychiatric Association has issued an update to its 10-year-old treatment guidelines for major depression following a yearlong delay during which the group sought to defuse conflict-of-interest problems involving guideline committee members.
The new recommendations cover use of antidepressant medications and psychotherapies, as well as treatments such as electroconvulsive therapy and alternative treatments. The guidelines also address depression during pregnancy and strategies for treatment-resistant depression.
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Among the changes made to the previous set of guidelines is a recommendation to add the use of rating scales to assess type, frequency, and extent of psychiatric symptoms to better tailor the treatments to the needs of the patient. Therapies based on exercise and other healthy behaviors as methods for providing modest improvement of depression symptoms and the strengthening of previous recommendation that maintenance treatment be considered in patients at high risk for recurrence of major depression are other new features of the revised guidelines.
The committee began work in 2005 when the APA and many other medical societies did not forbid guideline authors from serving as consultants to pharmaceutical companies.
Indeed, most of the depression guideline authors, including chairman Dr. Alan Gelenberg of Penn State University in Hershey, Pa., reported extensive relationships with industry. But, following heavy criticism that guideline authors across medicine were too cozy with drug and device companies, the ethics landscape has changed dramatically in recent years.
Gelenberg disclosed consulting relationships with 17 companies; another consulted or served on speakers bureaus for 25. Only one of the panel's seven members reported no industry ties.
"Both the [APA] board and the work group realized that previous policies that emphasized disclosure were not as rigorous as the current climate warranted," according to APA President Dr. Carol Bernstein in a statement.
So when the committee completed its work in 2009, the APA's leadership decided to have another panel free of current industry ties review the final product for evidence of bias.
That group, chaired by Dr. Victor Reus of the University of California San Francisco, gave the guideline its blessing -- noting, according to Bernstein, "that in accordance with available evidence, no particular antidepressant medication is identified by the guideline as more effective or preferred over other antidepressants."
Although that may protect the committee against charges of industry-oriented bias, it may also disappoint physicians hoping for an evidence-based system to help them decide which of 29 individual antidepressant medications in seven classes might be best for a given patient.
The APA last updated its depression treatment guideline in 2000, before the introduction of new drugs such as desvenlafaxine (Pristiq) and duloxetine (Cymbalta) as well as extended-release versions of several others.
The past decade has also seen approvals of nonpharmacologic therapies such as transcranial magnetic stimulation and vagus nerve stimulation.
The guideline summarizes the available data on efficacy and adverse effects for the available therapies. In a few cases, that includes head-to-head studies of drugs within or between classes, but those are the exception.