Abstract
Depression affects over 300 million individuals worldwide and is responsible for most of the 800,000 annual suicides. Clinical practice guidelines (CPGs) for treatment of depression, founded on scientific evidence, are essential to improve patient care. However, economic and sociocultural factors may influence CPG elaboration, potentially leading to divergences in their recommendations. Consequently, we analyzed pharmacological recommendations for the treatment of depression from the most relevant CPGs. We included four CPGs with scores ≥ 80% for Domain 3 (rigor of development) on the Appraisal of Guidelines for Research and Evaluation and two other commonly used CPGs. The recommendations, their strengths, and the level of evidence were extracted from each CPG by two independent researchers and grouped as follows: (1) general recommendations for the pharmacological treatment for depression (suicide risk, acute treatment, continuation and maintenance phases, and treatment discontinuation); (2) treatment of non-responsive or partially responsive patients; and (3) treatment for subtypes of depression (chronic, psychotic, catatonic, melancholic, seasonal, somatic, mixed, and atypical). Only 50% of CPGs included recommendations for the risk of suicide associated with pharmacotherapy. All CPGs included serotonin selective reuptake inhibitors (SSRIs) as first-line treatment; however, one CPG also included agomelatine, milnacipran, and mianserin as first-line alternatives. Recommendations for depression subtypes (catatonic, atypical, melancholic) were included in three CPGs. The strength of recommendation and level of evidence clearly differed among CPGs, especially regarding treatment augmentation strategies. We conclude that, although CPGs converged in some recommendations (e.g., SSRIs as first-line treatment), they diverged in cardinal topics including the absence of recommendations regarding the risk of suicide associated with pharmacotherapy. Consequently, the recommendations listed in a specific CPG should be followed with caution.
Highlights
Mental illness affects approximately 22% of the population [1]
Four clinical practice guidelines (CPGs) presented a score 80% for Domain 3 and were considered high-quality [21,22,23,24]. In addition to these selected CPGs, two others were included based on their widespread acceptance [14]: the Canadian Network for Mood and Anxiety Treatments (CANMAT) and the American Psychiatric Association (APA) guidelines [25,26]
The six CPGs selected for analysis of their recommendation, based on their AGREE II Domain 3 score or on their acceptability, were as follows: Guıa Clınica AUGE [21], score = 89%; Guıa de Practica Clınica [22], score = 86%; Depression in adults [23], score = 84%; Depression, adult in primary care [24], score = 81%; Practice guideline for the treatment of patients with major depressive disorder [26], score = 46%; and CANMAT [25], score = 54%
Summary
Depression is the most prevalent psychiatric disorder, which affects more than 300 million individuals [2]. It is an incapacitating disorder, responsible for most of the 800,000 annual suicides [2]. Along with population growth and aging, the number of individuals with depression has increased considerably and led to overloaded healthcare systems, thereby generating the need for resource optimization [1,3]. A primary challenge in the field of mental health is the development of health interventions based on scientific evidence to combat depression [4]. Developed clinical practice guidelines (CPGs) can improve patient healthcare by outlining practices recommended based on scientific research [5,6,7]
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