Monotherapy with either CBT or an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (strong recommendation). Combination therapy is given as initial treatment in patients in the acute phase of moderate to severe MDD. Monotherapy with CBT as initial treatment in patients in the acute phase of mild MDD.
For patients in the acute phase of moderate to severe MDD who did not respond to initial treatment with an adequate dose of an SGA, switching to or augmenting with CBT can be considered. Even switching to a different SGA or augmenting with a second pharmacological treatment.
The informed decision on the options should be personalized and based on a discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients’ specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), co-morbidities, concomitant medication use, and patient preferences.
The guideline is based on the accompanying comparative effectiveness living systematic review and network meta-analysis, and on two additional rapid reviews on values and preferences and cost-effectiveness analyses completed by the ACP Center for Evidence Reviews at Cochrane Austria/University for Continuing Education Krems (Danube University Krems).
ACP’s Clinical Guidelines Committee is planning to maintain this topic as a living guideline with literature surveillance and periodic updating of the systematic review and the clinical recommendations.
An accompanying editorial from the University of Toronto, calls ACP’s guideline a step in the right direction with its focus on the patient’s role in shared decision-making around depression.
However, the editorialists point to important gaps in the recommendations concerning non-pharmaceutical approaches to treatment. They also suggest that physicians may need more information about helping patients safely discontinue medications without suffering from potentially severe withdrawal symptoms.