New American College of Physicians Guidelines Recommend CBT, SGAs for MDD

Updated guidelines issued by the American College of Physicians (ACP) recommend the use of either cognitive behavioral therapy (CBT) or second-generation antidepressants (SGAs) as initial treatment for adults with moderate to severe major depressive disorder (MDD). The guidelines and the evidence that supports them were published in Annals of Internal Medicine.

The guidelines also suggest combining CBT and SGAs could be an effective, alternative initial treatment option. 

ACP emphasizes the importance of making decisions in collaboration with patients—considering their preferences, life circumstances, comorbid conditions, and other factors.

To summarize, the ACP guidelines recommend the following guidelines:

• Monotherapy with either CBT or an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (strong recommendation, moderate-certainty evidence).
• Combination therapy with CBT and an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (conditional recommendation; low certainty-evidence).
• Monotherapy with CBT as initial treatment in patients in the acute phase of mild MDD (conditional recommendation; low-certainty evidence).
• One of the following options for patients in the acute phase of moderate to severe MDD who did not respond to initial treatment with an adequate dose of an SGA:
  • switching to or augmenting with CBT (conditional recommendation; low-certainty evidence); and
  • switching to a different SGA or augmenting with a second pharmacological treatment (see Clinical Considerations) (conditional recommendation; low-certainty evidence).

The ACP formulated these guidelines based on a comparative effectiveness living systematic review and network meta-analysis alongside 2 additional rapid reviews on values, preferences, and cost-effectiveness analyses conducted by the ACP Center for Evidence Reviews at Cochrane Austria/University for Continuing Education Krems.

The ACP’s Clinical Guidelines Committee intends to maintain and revise the guidelines as a living document, updating the systematic review and resultant clinical recommendations as warranted.

References

American College of Physicians recommends cognitive behavioral therapy or second-generation antidepressants for adults with major depressive disorder. News release. American College of Physicians. January 23, 2023. Accessed February 28, 2023.

Qaseem A, Owens DK, Etxeandia-Ikobaltzeta I, et al. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: A living clinical guideline from the American College of Physicians. Ann Inter Med. 2023;176:239-2