Pharmacological treatment of depression

Overview

This systematic review, published in PLOS ONE in 2020 by Gabriel and colleagues, compares what clinical practice guidelines recommend for the drug treatment of depression in adults. Depression affects more than 300 million people worldwide and is responsible for most of the 800,000 suicides each year. Guidelines are meant to improve care, but economic and sociocultural factors can shape them, so their recommendations do not always agree.

Methods

The authors searched MEDLINE, Embase, the Cochrane Library and 12 guideline websites for guidelines published between 2011 and 2016, and updated the search in April 2019. Guideline quality was rated with AGREE II. Six guidelines were analysed in detail: four scoring at least 80% for rigour of development (from Chile, Colombia, NICE in England and ICSI in the USA), plus the widely used CANMAT and APA guidelines. Recommendations were grouped into general treatment (suicide risk, acute, continuation and maintenance phases, discontinuation), treatment of non-responders, and treatment of depression subtypes.

Main findings

All six guidelines accepted SSRIs as first-line treatment, but only half addressed the suicide risk associated with starting drug therapy. CANMAT also listed agomelatine, milnacipran and mianserin as first-line options, and the Colombian guideline included amitriptyline on cost grounds. For partial response or non-response, all advised adjusting the dose or switching drugs, and most suggested augmentation with an antipsychotic, although the strength and level of evidence differed, notably for lithium and thyroid hormones. Psychotic depression had the most consistent advice (an antipsychotic combined with an antidepressant), while catatonic, atypical, melancholic, seasonal, somatic and mixed forms were covered by only some guidelines.

Implications for practice

The guidelines largely agree on the basics but diverge on important details, so the recommendations of any single guideline should be applied with caution. The authors argue that advice on suicide risk in the first weeks of antidepressant treatment should be included in every guideline.