APA has approved a revised Practice Guideline for the Treatment of Patients With Major Depressive Disorder. There is a major change since the last guideline was published seven years ago: The format is more user friendly. Treatment recommendations are up front, in Part A, and the supporting evidence is to the back, in Part B.

Section I of Part A, "Summary of Treatment Recommendations," includes the main treatment recommendations, along with codes that indicate the degree of clinical confidence in each recommendation. Section II, "Formulation and Implementation of a Treatment Plan," includes all of the treatment recommendations. And Section III, titled "Clinical Features Influencing the Treatment Plan," discusses a range of clinical conditions that could alter the general treatment recommendations in Section II.

Part B, "Background Information and Review of Available Evidence," includes disease definition, epidemiology, and natural history review, as well as a synthesis of evidence regarding antidepressant medications, electroconvulsive therapy, light therapy, St. John’s Wort, and various psychotherapies—cognitive behavioral psychotherapy, behavioral therapy, interpersonal therapy, psychodynamic psychotherapy, marital therapy, family therapy, and group therapy. Studies that have explored the value of combining psychotherapy with pharmacotherapy are also discussed.

As might be expected, the information about antidepressant medications has been updated. For instance, the new guideline reports that for most patients, FDA-approved antidepressant medications are generally considered equally effective, with response rates in clinical trials ranging from 50 percent to 75 percent of patients. However, among some subgroups of patients with major depressive disorder, efficacy may differ.

Antidepressant medications also vary in their potential to cause particular side effects. The revised guideline reports that a large body of literature containing some 50 randomized, placebo-controlled trials supports the superiority of selective serotonin reuptake inhibitors (SSRIs) over placebo in the treatment of major depressive disorder. What’s more, the guideline states, in more than 50 investigations the effectiveness of SSRIs has been compared with that of other antidepressant medications, mainly tricyclic antidepressant medications (TCAs). In these trials, SSRIs’ efficacy has been generally comparable to that of antidepressant medications from other classes. In general, significant differences in efficacy between individual SSRIs have not been observed.

The guideline also discusses the side effects of other classes of antidepressants, and Table 7 lists potential treatments for side effects and the antidepressants associated with those side effects.

The guideline concludes with Part C—addressing future needs in the area of major depressive disorder. For instance, still to be learned is whether the combination of antidepressants from different pharmacologic classes (for example, SSRIs and TCAs) offers greater efficacy than giving single agents. And there is a need, it points out, to design and implement vigorous, controlled studies to evaluate the efficacy of psychodynamic psychotherapy for the treatment of patients with major depressive disorder.

The revised guideline will be published next month as a supplement to the American Journal of Psychiatry. It will also be published as a monograph by the American Psychiatric Press Inc. and can be ordered by calling (800) 368-5777. It will likewise be included in a new compendium of practice guidelines, which will be available for sale at APA’s annual meeting in May.

The revised guideline was approved in January through an executive action by APA President Allan Tasman, M.D., APA Medical Director Steven M. Mirin, M.D., and Assembly Speaker Alfred Herzog, M.D.