Key takeaways from ACP’s new Tx guidelines for adults with major depressive disorder

In January 2023, the American College of Physicians (ACP) published updated recommendations on the treatment of adults with major depressive disorder (MDD).¹ The ACP guidelines address initial treatment of patients in the acute phase of mild and moderate-to-severe MDD. Here’s what the ACP recommends, as well as 6 important takeaways.

Recommendations for initial treatment of those with mild or moderate-to-severe MDD center around cognitive behavioral therapy (CBT) and second-generation antidepressants (SGA). For patients in the acute phase of mild MDD, the recommendation is for monotherapy with CBT. However, if CBT is not an option due to cost and/or availability of services, the use of an SGA is acceptable.

For patients in the acute phase of moderate-to-severe MDD, either CBT, an SGA, or a combination of both is recommended.

If initial treatment does not work … Up to 70% of patients with moderate-to-severe MDD will not respond to the initial therapy chosen. If a patient does not respond to initial treatment with an SGA, consider 1 of the following:

• Switching to CBT
• Adding on CBT while continuing the SGA
• Changing to a different SGA
• Adding a second pharmacologic agent.

6 key takeaways. The full guideline should be read for a more complete discussion of the many clinical considerations of these treatment options. However, the most important points include:

• Employ shared clinical decision-making and consider the individual characteristics of each patient when making treatment decisions.

• Consider generic options when using an SGA; generic options appear to be as effective as more expensive brand-name products.

• Start with a low-dose SGA and increase gradually to an approved maximum dose before determining there has been no response.

• Monitor frequently for medication adverse effects.

• Monitor the patient for thoughts about self-harm for the first 2 months.

• Continue treatment for 4 to 9 months once remission is achieved.

A word about strength of evidence. While these recommendations are based on an extensive review of the best available evidence, most are based on low-certainty evidence—illustrating the amount of clinical research still needed on this topic. The exceptions are monotherapy with either CBT or SGA for initial treatment of moderate-to-severe MDD, both of which are based on moderate-strength evidence and received a strong recommendation. The panel felt there was insufficient evidence to assess complementary and alternative interventions including exercise and omega-3 fatty acids.

In January 2023, the American College of Physicians (ACP) published updated recommendations on the treatment of adults with major depressive disorder (MDD).¹ The ACP guidelines address initial treatment of patients in the acute phase of mild and moderate-to-severe MDD. Here’s what the ACP recommends, as well as 6 important takeaways.

Recommendations for initial treatment of those with mild or moderate-to-severe MDD center around cognitive behavioral therapy (CBT) and second-generation antidepressants (SGA). For patients in the acute phase of mild MDD, the recommendation is for monotherapy with CBT. However, if CBT is not an option due to cost and/or availability of services, the use of an SGA is acceptable.

For patients in the acute phase of moderate-to-severe MDD, either CBT, an SGA, or a combination of both is recommended.

If initial treatment does not work … Up to 70% of patients with moderate-to-severe MDD will not respond to the initial therapy chosen. If a patient does not respond to initial treatment with an SGA, consider 1 of the following:

• Switching to CBT
• Adding on CBT while continuing the SGA
• Changing to a different SGA
• Adding a second pharmacologic agent.

6 key takeaways. The full guideline should be read for a more complete discussion of the many clinical considerations of these treatment options. However, the most important points include:

• Employ shared clinical decision-making and consider the individual characteristics of each patient when making treatment decisions.

• Consider generic options when using an SGA; generic options appear to be as effective as more expensive brand-name products.

• Start with a low-dose SGA and increase gradually to an approved maximum dose before determining there has been no response.

• Monitor frequently for medication adverse effects.

• Monitor the patient for thoughts about self-harm for the first 2 months.

• Continue treatment for 4 to 9 months once remission is achieved.

A word about strength of evidence. While these recommendations are based on an extensive review of the best available evidence, most are based on low-certainty evidence—illustrating the amount of clinical research still needed on this topic. The exceptions are monotherapy with either CBT or SGA for initial treatment of moderate-to-severe MDD, both of which are based on moderate-strength evidence and received a strong recommendation. The panel felt there was insufficient evidence to assess complementary and alternative interventions including exercise and omega-3 fatty acids.

In January 2023, the American College of Physicians (ACP) published updated recommendations on the treatment of adults with major depressive disorder (MDD).¹ The ACP guidelines address initial treatment of patients in the acute phase of mild and moderate-to-severe MDD. Here’s what the ACP recommends, as well as 6 important takeaways.

Recommendations for initial treatment of those with mild or moderate-to-severe MDD center around cognitive behavioral therapy (CBT) and second-generation antidepressants (SGA). For patients in the acute phase of mild MDD, the recommendation is for monotherapy with CBT. However, if CBT is not an option due to cost and/or availability of services, the use of an SGA is acceptable.

For patients in the acute phase of moderate-to-severe MDD, either CBT, an SGA, or a combination of both is recommended.

If initial treatment does not work … Up to 70% of patients with moderate-to-severe MDD will not respond to the initial therapy chosen. If a patient does not respond to initial treatment with an SGA, consider 1 of the following:

• Switching to CBT
• Adding on CBT while continuing the SGA
• Changing to a different SGA
• Adding a second pharmacologic agent.

6 key takeaways. The full guideline should be read for a more complete discussion of the many clinical considerations of these treatment options. However, the most important points include:

• Employ shared clinical decision-making and consider the individual characteristics of each patient when making treatment decisions.

• Consider generic options when using an SGA; generic options appear to be as effective as more expensive brand-name products.

• Start with a low-dose SGA and increase gradually to an approved maximum dose before determining there has been no response.

• Monitor frequently for medication adverse effects.

• Monitor the patient for thoughts about self-harm for the first 2 months.

• Continue treatment for 4 to 9 months once remission is achieved.

A word about strength of evidence. While these recommendations are based on an extensive review of the best available evidence, most are based on low-certainty evidence—illustrating the amount of clinical research still needed on this topic. The exceptions are monotherapy with either CBT or SGA for initial treatment of moderate-to-severe MDD, both of which are based on moderate-strength evidence and received a strong recommendation. The panel felt there was insufficient evidence to assess complementary and alternative interventions including exercise and omega-3 fatty acids.