Amir Qaseem, MD, PhD, MHA; Michael J. Barry, MD; Devan Kansagara, MD, MCR; for the Clinical Guidelines Committee of the American College of Physicians
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: All financial and intellectual disclosures of interest were declared and potential conflicts were discussed and managed. Dr. Forciea was recused from voting on this guideline and from chairing during the discussion of the guideline for an active indirect financial conflict. Dr. Manaker was recused from voting on the guideline for an active indirect financial conflict. Dr. Vijan was recused from voting on the guideline for an active direct intellectual conflict. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2570. A record of disclosures of interest and management of conflicts of is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Kansagara: Portland Veterans Affairs Medical Center, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR 97239.
Dr. Barry: Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114.
Author Contributions: Conception and design: M.J. Barry, R.P. Harris, A. Qaseem.
Analysis and interpretation of the data: C. Boyd, N. Fitterman, R.P. Harris, L.L. Humphrey, D. Kansagara, A. Qaseem, T.J. Wilt.
Drafting of the article: T.D. Denberg, D. Kansagara, A. Qaseem.
Critical revision of the article for important intellectual content: M.J. Barry, C. Boyd, R.D. Chow, T.D. Denberg, R.P. Harris, L.L. Humphrey, D. Kansagara, A. Qaseem, T.J. Wilt.
Final approval of the article: M.J. Barry, C. Boyd, R.D. Chow, T.D. Denberg, N. Fitterman, R.P. Harris, L.L. Humphrey, D. Kansagara, R. McLean, A. Qaseem, T.J. Wilt.
Statistical expertise: A. Qaseem, T.J. Wilt.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem
Qaseem A, Barry MJ, Kansagara D, for the 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;164:350-359. doi: 10.7326/M15-2570
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Published: Ann Intern Med. 2016;164(5):350-359.
Published at www.annals.org on 9 February 2016
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness of treatment with second-generation antidepressants versus nonpharmacologic treatments for major depressive disorder in adults.
This guideline is based on a systematic review of published, English-language, randomized, controlled trials from 1990 through September 2015 identified using several databases and through hand searches of references of relevant studies. Interventions evaluated include psychotherapies, complementary and alternative medicines (including acupuncture, ω-3 fatty acids, S-adenosyl-l-methionine, St. John's wort [Hypericum perforatum]), exercise, and second-generation antidepressants. Evaluated outcomes included response, remission, functional capacity, quality of life, reduction of suicidality or hospitalizations, and harms. The target audience for this guideline includes all clinicians, and the target patient population includes adults with major depressive disorder. This guideline grades the evidence and recommendations using ACP's clinical practice guidelines grading system.
ACP recommends that clinicians select between either cognitive behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient (Grade: strong recommendation, moderate-quality evidence).
Phases of treatment of major depression.
Adapted from reference 6. TX = treatment.
Table 1. Common Psychological Interventions to Treat Depression
Table 2. The American College of Physicians' Guideline Grading System*
Appendix Table 1. First-Line Treatment for MDD: SGAs Versus Nonpharmacologic Therapies*
Appendix Table 2. Second-Line Treatment in Patients With MDD Who Failed Initial Treatment With SGAs: Switching or Augmenting Strategies*
Table 3. Durations and Dosages of SGAs Used in the Trials Reviewing the Comparative Efficacy and Effectiveness of MDD*
Summary of the American College of Physicians guideline on nonpharmacologic versus pharmacologic treatment with second-generation antidepressants for adult patients with major depressive disorder.
CBT = cognitive behavioral therapy; CYP 3A4 = cytochrome P450 isoenzyme 3A4; IT = interpersonal therapy; PSYD = psychodynamic therapy; SGA = second-generation antidepressant.
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