Guidelines for depression treatment revised

The American Psychiatric Association recently revised its guidelines for treating Major Depressive Disorder, covering everything from clinician-patient rapport to the full range of antidepressants to alternative therapies. Key recommendations included more frequent use of rating scales during assessment; use of electroconvulsive therapy as well as new, technologically advanced therapies in patients with treatment-resistant depression; and regular aerobic exercise as an adjunct to treatment.

A group of Association members with extensive experience in assessing and treating Major Depressive Disorder (MDD) reviewed more than 13,000 articles published between 1999, shortly before the last guidelines were released and 2006. Through the five-year review and revision process, the group aims to incorporate the practices most strongly supported by recent research into treatment. Here is a look at some of the highlights.

Measurements in assessment and management

Clinician-rated or patient-rated scales can help better determine the course of an illness and the effects of treatment, the group wrote in its report on the guidelines. Some commonly used scales include the Inventory of Depressive Symptoms, the Hamilton Rating Scale for Depression and the Patient Health Questionnaire.

“The perception of the clinicians in our group was that a lot of psychiatrists and psychologists don’t measure what they’re treating very often,” says Joel Yager, M.D., chair of the Association’s steering committee on practice guidelines. “If you do some kind of rating, you’ll have some way of knowing that the symptoms you’re targeting are getting better and that when you make a decision, it will be based on something more than impulse.”

Even if paper-and-pencil assessments are not common during treatment, psychologists may be incorporating rating scales into their sessions in informal ways, says Philip Levendusky, Ph.D., director of the psychology department at McLean Hospital in Belmont, Mass. “If you look at the Beck [inventory], all of those items could be integrated into an interview,” he says. “The argument to do it systematically is just that, so you have a consistent snapshot over time.”

The report notes that increased access to technological tools is making electronic monitoring more feasible. Patients can transmit symptom-related information by telephone or by Internet, while computerized decision support systems can be helpful in implementing evidence-based treatment.

 ECT, TMS and VNS

Electroconvulsive therapy (ECT), seen by some as the gold standard in treating intractable depression, was strongly endorsed in the guidelines as a last-resort measure.

“There’s been pretty good evidence that ECT is very effective for treatment-resistant depression and for very severe melancholic depression,” Yager says. “It’s always been known that it’s better than medication.”

For a narrow group of people with treatment-resistant depression or depression accompanied by psychotic symptoms, ECT might be considered as a first-line therapy, Yager adds.

“You use it when it’s absolutely necessary, the way you would use cardioversion,” he says. “ECT and the paddles can be just as lifesaving.”

Vagus nerve stimulation (VNS) and transcranial magnetic stimulation (TMS) were added to the guidelines as options for patients with treatment-resistant depression. Although VNS has been approved by the FDA and has shown promise as a long-term treatment, access to it is limited as most insurance companies do not cover it, says Audrey Tyrka, M.D., Ph.D., associate chief of the mood disorders program at Butler Hospital in Providence, R.I. Transcranial magnetic stimulation, more recently approved by the FDA, may be more accessible.

“More insurance companies are beginning to pay for it, and a growing database is supporting its efficacy,” says Tyrka, who has researched both TMS and VNS. Other pluses include it doesn’t require surgery, as VNS does and side effects are limited. The downside, Tyrka acknowledges, is that it’s a significant time commitment, though as doctors more accurately pinpoint the brain areas to target, it could become less so.

 Exercise

Perhaps not so surprising, the research supports routine workouts – particularly in the form of aerobic exercise or resistance-training – as a way to help improve mood. Mildly depressed patients may try exercise alone as a first-line treatment, provided they are monitored. Even patients with major depressive disorder receive at least a modest boost from vigorous workouts, the report notes.

“I think [the recommendation] is a fantastic idea,” Levendusky says. “If you look at the relationship between lifestyle issues and mood disorders and general medical conditions, lifestyle choices like exercise can have a tremendous impact. That said, it’s not going to cure you if you’re severely depressed.”

The report found a specific benefit to exercise in older adults with co-occurring medical problems.

 Psychotherapy

The Association group recommends depression-focused psychotherapy alone as an initial treatment for patients with mild to moderate MDD. The research reviewed most strongly supported cognitive-behavioral therapy (CBT) and interpersonal psychotherapy.

Some studies have suggested that CBT is less effective for patients with more severe depression, while patients with moderate to severe depression may need more skilled CBT therapists in order to benefit. Levendusky attributes CBT’s success to its dual components, particularly learning helpful self-management skills.

“The idea of an acquired skill being generalized and used in the future is a lot more promising than patients thinking, ‘this is only working because I’m seeing the doctor right now,” he says. “Their feelings of competence and self-confidence go up.”

The report noted research suggesting the behavioral component of CBT may be more effective than the cognitive component, particularly for people with more severe depressive symptoms, and underscored CBT’s value in reducing the odds of relapse.

The Major Depressive Disorder guidelines can be found on the American Psychiatric Association’s website, www.psych.org.