APA Issues New Depression Treatment Guidelines

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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.

APA Strived for Guidelines Free From Industry Bias

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.

Even when such data were available, Gelenberg and colleagues often found fault with them.

For example, they noted that transcranial magnetic stimulation had been compared in several trials with electroconvulsive therapy, a mainstay of treatment for severe depression for decades, but some of the results set off alarm bells.

"TMS has been found in randomized studies to be either less effective than ECT or comparable in efficacy to ECT," Gelenberg and colleagues wrote, "but in the latter studies TMS was more effective and ECT was less effective than is typically seen in clinical trials" -- apparently a hint that physicians should take those results with a grain of salt.

New Guidelines Stress Tailored Psychological Treatment

Among nonpharmacologic therapies, ECT still has by far the largest evidence base for its efficacy, the guideline authors indicated.

As in the last version of the guideline, the update is careful to stress the importance of psychotherapy in conjunction with drug and device-based treatments, as well as the many individual patient factors that may affect treatment choices.

Bernstein indicated in her statement that the APA is still grappling with how to manage conflicts of interest. "Early this year, the Council of Medical Specialty Societies issued principles for preventing undue influence of industry in the activities of its member societies," she said.

"One of the principles states that chairs of work groups and the majority of work group members that develop practice guidelines should have no conflicts of interest. How 'conflict of interest' is defined and monitored remains an issue in all of medicine," Bernstein added.

She said the APA would probably adopt "congruent policies" including specific rules for guideline authors.