Release Date : September 02 2022
Depression: American Psychological Association Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (2019)
About the Guideline
- The clinical practice guideline was developed by the American Psychological Association (APA) and Guideline Development Panel for the Treatment of Minor Depressive Disorders.
- The members of the Guideline Development Panel consisted of health care providers with backgrounds in psychology, psychiatry, and primary care, along with community representatives who had experienced the diagnosis of depression.
- The guideline provides recommendations for the treatment of major depressive disorders (MDD), including major depression, persistent depressive disorder, and subsyndromal depression.
- Psychotic depression is not addressed in the guideline.
- Three developmental cohorts—adults, older adults 60 years of age or more, and children and adolescents—are addressed in this guideline, although no specific treatment recommendations for children are made.
- The efficacy of psychological, complementary, and alternative medicine treatments is examined.
- The guideline indicates that clinicians are encouraged to offer treatment through shared decision-making with the patient and to consider the challenges and barriers to treatment faced by the patient.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline.
Overview
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- Major depressive disorder (MDD) was the second leading cause of disability in the United States and worldwide as of 2013.
- In 2015, 6.7% of all U.S. adults over 18 years experienced at least one major depressive episode during the year, with 4.3% of adults reporting a major depressive episode with severe impairment.
- In 2015, the adult group with the highest percentage of having a major depressive episode leading to severe impairment was among 18- to 25-year-olds.
Children
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- There are no treatment recommendations specific to children.
Adolescents
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- Initial treatment should include one of the following psychotherapies:
- Cognitive behavioral therapy (CBT), or
- Interpersonal psychotherapy for adolescents (IPT-A)
- FLUoxetine is recommended as a first-line medication.
- Additional research evidence is needed before recommending the use of medication rather than psychotherapy. There is limited support for using the combination treatment of both CBT and FLUoxetine.
- If neither CBT and IPT-A is available or acceptable to the patient and parent or guardian, an alternative model is suggested. The following psychotherapies for adolescents have been evaluated, but there are no recommendations for or against any one therapy as superior over the others:
- Cognitive therapy
- Behavioral therapy
- Problem-solving therapy
- Psychodynamic therapy
- Family therapy
- Supportive therapy
- It is recommended that if FLUoxetine is not an option for treatment, shared decision-making with the patient and parent or guardian, child psychiatrist, and clinician about other medication options should be initiated.
- Due to safety concerns, recommendations are against use of the following medications in adolescents with MDD: clomiPRAMINE, imipramine, mirtazapine, PARoxetine, or venlafaxine.
- If these medications are being considered, PARoxetine is recommended over clomiPRAMINE, and PARoxetine is recommended over imipramine.
General Adult Population
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- Either psychotherapy or the use of second-generation antidepressants is recommended for initial treatment. No specific monotherapy is recommended.
- Comparable psychotherapy treatments include supportive therapy, psychodynamic therapy, interpersonal psychotherapy (IPT), behavioral therapy, CBT, and mindfulness- based cognitive therapy (MBCT).
- For combined treatment, CBT or IPT plus a second-generation antidepressant is recommended.
- If depression and relationship distress are experienced and if recommended treatment is not available or acceptable, problem-focused couples therapy is suggested. Other suggested options include:
- Behavioral therapy rather than antidepressants alone, or
- Combined treatment with cognitive therapy plus antidepressants.
- There is no recommendation for or against the use of a cognitive behavioral analysis system of psychotherapy or a brief problem-solving therapy versus usual treatment.
- Complementary and alternative treatments such as exercise monotherapy or St. John’s Wort monotherapy are suggested if psychotherapy or pharmacotherapy is unacceptable or ineffective.
- If neither is available or acceptable, yoga, bright light therapy, and acupuncture as adjunctive to antidepressant medication can be considered.
- There is no recommendation for or against the use of Tai Chi, acupuncture monotherapy, acupuncture combined with second-generation antidepressant therapy, omega-3 fatty acids monotherapy, omega-3 fatty acids combined with antidepressant therapy, S-adenosyl methionine monotherapy, and exercise combined with second-generation antidepressant therapy.
- For subclinical depression, psychotherapy is suggested.
- For patients with no response or only a partial response to initial antidepressant medications, recommendation options include either switching to cognitive therapy alone from antidepressant medication alone, or switching to another antidepressant from antidepressant medication alone.
- Suggested options include offering either adding psychotherapy to antidepressant therapy, or adding another antidepressant medication.
- There is no recommendation for or against switching to a different second-generation antidepressant, switching to a nonpharmacologic monotherapy, or adding guided CBT self-help.
- If remission is achieved, psychotherapy is suggested to prevent a relapse rather than continuing antidepressants or treatment as usual. There is no recommendation for or against CBT, MBCT, or interpersonal psychotherapy.
Older Adult Population with MDD
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- Initial recommended treatment recommendations are as follows:
- Group CBT or group life review is recommended over no treatment, or
- Combined second-generation pharmacotherapy and IPT, over IPT alone.
- If recommended treatment is not available or unacceptable, one of the following is suggested:
- CBT alone or combined with usual care, or
- CBT and individual nonspecific therapeutic techniques with pharmacotherapy, or
- IPT and pharmacotherapy, or
- Group problem-solving therapy (rather than group reminiscence therapy), or
- Individual IPT (rather than supportive care).
- There is no recommendation for or against offering in-person or telehealth for problem-solving therapy or attention control work, which focuses on the patient’s ability to concentrate.
Older Adult Population with Subthreshold/Minor Depression
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- Suggested therapies include the following:
- Individual CBT via telehealth for subthreshold depression
- Individual CBT and usual care for MDD
- Combination CBT and usual treatment (rather than individual talking control and usual care) for minor or MDD
- Group life review (rather than an educational video) for subclinical depression, or
- Individual problem-solving therapy
- PARoxetine after shared decision-making regarding its benefits versus harms.
- There is no recommendation for or against either of the following:
- Self-guided behavioral bibliotherapy or usual treatment for subthreshold depression, or
- Individual life review therapy or usual treatment for subclinical depression.
Older Adult Population with MDD or Minor Depression and Cognitive Impairments/Dementia
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- One of the following is suggested for treatment of minor depression or MDD:
- Individual problem-solving therapy for older adults with MDD and executive dysfunction
- Individual problem-solving behavioral therapy or individual pleasant-events behavioral therapy for older adults with minor or MDD and dementia
- There is no recommendation for or against combination individual behavioral activation therapy and usual treatment in older adults with mild or moderate cognitive impairment and depressive symptoms.
Older Adult Population with Persistent Depressive Disorder
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- Individual problem-solving therapy or PARoxetine is suggested for the treatment of MDD or minor depression in the context of cognitive impairment or dementia.
Older Adult Population with MDD with Medical or Other Complications
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- A combination of individual CBT and usual treatment is suggested for minor or MDD in patients with type II diabetes mellitus or chronic obstructive pulmonary disease.
- The use of multiple intervention strategies is suggested to address manifestations of depression in homebound African American adults.
- Group coping strategies are preferred over individual psychotherapy in mild to severe cases of depression and HIV.
Prevention of MDD Recurrence in Older Adults
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- For older adults with a history of depression, the treatment recommendation is either pharmacotherapy and combination interpersonal psychotherapy, or pharmacotherapy and combination supportive care.
- If prior options are not available or acceptable, individual interpersonal psychotherapy alone is suggested.
- There is no recommendation for or against the use of group CBT plus pharmacotherapy, or pharmacotherapy alone to prevent recurrence.
Reference
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