Latest guidelines on treatment of depression

Depression is one of the leading cause of disabilities, which results in great costs to health care systems, the society and the individuals. According to the National Institute of Mental Health In the United States, more than 20% of adults experience MDD in their lifetime, with around 10% experiencing it per year. In 2020, an estimated 21 million adults in the United States were had suffered or continued to suffer from a minimum of one mental health episode. These numbers have only increased post the pandemic. An estimated economic burden in the United States was $120 billion in 2020, including direct medical and pharmaceutical costs ($36 billion) of treating MDD, suicide-related costs ($13 billion), and effects on workplace productivity ($70 billion).

What is major depressive disorder?

Major depressive disorder is defined as the presence of a depressed mood or a loss of interest or pleasure in normally enjoyable activities that occurs during the normal course of life causing clinically significant distress or impairment in social, occupational, or other important areas of life. Based on the severity of symptoms, impairment, and level of patient distress, MDD can be characterized as mild, moderate, or severe. A minimum of one third of patients suffer from a severe form of depression, making recovery more difficult. 75% of Depression patients are at a risk of recurring anxiety and panic attacks.

What helps people cope with depression?

Treatment for management of depression include pharmacologic treatments and non-pharmacologic therapies, such as psychotherapy, complementary and alternative medicine (CAM), and exercise. Antidepressants are the most common primary care treatment methodologies. 70% of the patients that are on antidepressants are not completely cured.

The American College of Physicians (ACP) has come up with guidelines and clinical recommendations to treat depression based on on the best available evidence on the comparative benefits and harms, consideration of patient values and preferences, and costs. This update evaluates the comparative effectiveness between treatment options but does not evaluate the effectiveness of the included treatments compared with no treatment.

Read how essential oils are effective in treating depression.

How can you treat depression?

  1. For mild depressive disorder ACP suggests cognitive behavioral therapy (CBT) as initial treatment. CBT works as well as medication, without any side effects. the evidence on using CBT as initial treatment because studies mainly enrolled patients with moderate to severe MDD and downgraded the overall certainty of evidence to low and the strength of the recommendation to conditional due to the lack of direct evidence in patients with mild MDD. The CGC suggests that use of SGAs as initial treatment in these patients should be based on additional considerations, such as limited access to or cost of CBT, history of moderate or severe MDD, or patient preferences.
  2. For moderate to severe major depressive disorder: The ACP recommends combination therapy with cognitive behavioral therapy and a second-generation antidepressants. The decision to be made between the above two are based on the symptoms the patient.
  3. ACP suggests one of the following options for patients in the acute phase of moderate to severe major depressive disorder who did not respond to initial treatment with an adequate dose of a second-generation antidepressant:  Switching to or augmenting with cognitive behavioral therapy (conditional recommendation; low-certainty evidence) or Switching to a different second-generation antidepressant or augmenting with a second pharmacologic treatment.
  4. When an SGA is used as initial treatment for the acute phase of moderate to severe MDD prescribe a generic SGA, if possible, rather than a far more expensive brand-name medication.
  5. Be aware and inform patients that up to 70% of patients may not achieve remission during the initial treatment attempt and more than 60% of patients may have at least 1 adverse effect. Adverse effects including constipation, diarrhea, nausea, dizziness, insomnia, somnolence, and sexual dysfunction.
  6. Start treatment with a low or minimum dose to reduce the likelihood of adverse effects and improve adherence and monitor for worsening symptoms after 1 to 2 weeks of treatment with an SGA.
  7. Verify that the optimal tolerated dose of the SGA is used if symptoms do not improve despite adherence, and consider gradually increasing the dose up to the approved maximum before switching to a second-line treatment strategy.
  8. Monitor for new or increased suicidal or self-harming thoughts and behaviors during the first 1 to 2 months of treatment.
  9. For patients in the acute phase of mild MDD for whom CBT is not available or feasible, monotherapy with an SGA is a reasonable alternative approach.
  10. Reevaluate symptoms to monitor treatment efficacy (response and remission) and potential adverse.
  11. Once remission is achieved with an SGA, clinicians should continue the treatment strategy for at least an additional 4 to 9 months . When SGA treatment is discontinued, the dose should be gradually decreased (tapered) to minimize withdrawal symptoms.
  12. When using augmentation as a second-line treatment in patients who do not respond to initial treatment, consider augmentation of an SGA with mirtazapine, bupropion, or buspirone.
  13. Refer patients who have severe symptoms, marked functional impairment, or risk for self-harm to mental health services.
  14. Encourage exercise as a healthy lifestyle practice for adults with MDD.
  15. Consider team-based collaborative care involving ambulatory care physicians or practitioners and mental health specialists, such as psychiatrists, in adults with MDD.


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