Saturday, October 09, 2010

APA Releases New Guidelines On The Treatment Of Major Depressive Disorder

Interesting . . . . The APA had released new guidelines for treating major depression -
They are endorsing electroconvulsive therapy for depression. I'm not a fan of ECT (except in the most extreme cases where suicide is likely and ALL other interventions have failed), but the vagus nerve stimulation and the transcranial magnetic stimulation have both shown good outcomes with low side effects when compared to ECT - but they still do not fully endorse these less invasive approaches.
Other somatic treatments
Evidence for the efficacy of electroconvulsive therapy (ECT) in treating major depressive episodes, already compelling at the time the guideline was published, has been strengthened by additional findings. Recent meta-analyses have highlighted the superior efficacy of ECT relative to sham treatment and also relative to pharmacotherapies for depression (57, 58). In depressed patients who received an acute course of ECT, data from the Consortium for Research in ECT have shown that thrice-weekly bilateral ECT is associated with rapid initial response and high rates of sustained response and remission (59). In comparison with bilateral ECT, right unilateral ECT has been associated with fewer cognitive effects (60, 61), particularly in autobiographical memory (62). However, as with bilateral ECT, cognitive effects vary with the extent to which the electrical stimulus exceeds the seizure threshold (60). In addition, the overall efficacy of unilateral ECT appears to be less than that with bilateral ECT (57). Several additional studies highlight the diminished efficacy of barely suprathreshold electrical stimulation with right unilateral electrode placement (60, 61, 63) and a corresponding need to administer right unilateral ECT at stimulus intensities that are at least six times the initial seizure threshold (64). Additional details on the clinical use of ECT in the treatment of major depression can be found in the 2001 revision of the APA’s The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (64).

Although other somatic treatments, including repetitive transcranial magnetic stimulation, magnetic seizure therapy, and vagal nerve stimulation, have also been studied over the past 5 years, evidence is not yet sufficient to recommend their use in routine clinical practice.
One of the other more troubling recommendations is that St. John's Wort is likely ineffective - with which I disagree.
St. John’s wort
Since publication of the guideline, results from additional meta-analyses and well-designed trials of St. John’s wort have become available. Although some additional randomized, controlled trials have shown St. John’s wort to be superior to placebo (40–42) or to comparator antidepressants (43, 44) in treating mild to moderate depression, other large trials have shown it to be no better than placebo (45–47) or comparator antidepressants in efficacy (42, 46–50). Several factors continue to confound interpretation of the literature, including trial length, adequacy of comparison treatment, and the reliability, stability, and comparability of Hypericum preparations. The most recent meta-analysis noted a trend for decreasing effect sizes in trials of St. John’s wort over time, suggesting that it may be less effective in treating depression than previously thought (51). Although St. John’s wort is generally well tolerated in clinical trials, increasing attention has been given to its tendency to compromise the effectiveness of other medications (e.g., cyclosporine, HIV protease inhibitors, oral contraceptives, digoxin, warfarin, and theophylline) by interactions mediated through cytochrome P450 enzymes (e.g., CYP3A4, CYP2C9, CYP1A2, CYP2C19) and transport protein P-glycoproteins (52–56).
I think the real issue here, which they sort of acknowledge, is the lack of a standardized formulation. Some drug company could make a lot of money if they would actually focus on this herb and standardize a production and dosage protocol.

On the other hand, they are now more strongly endorsing the inclusion of lifestyle factors such as exercise as both treatment and prevention, especially in older adults. They also acknowledge that it can be effective as a preventative in the general population. In addition, they acknowledge omega-3 fats as a valuable adjunct in some patients.

Finally, while they acknowledge that therapy (and they only mention CBT) is possibly beneficial, they still seem somewhat dismissive of psychotherapy. That is silly, at best.


Marsha Lucas, PhD said...

Probably worth noting that these are the guidelines from the American Psychiatric Association (not the other APA, American Psychological Association). Makes "sense" that St. John's Wort would be deemed ineffective by them, since they're rather chummy with Big Pharma.

WH said...

Yeah, that's a rather important detail that I missed - thanks for pointing that out. That does allow a greater sense of understanding the strange perspective in these guideline (i.e., they are simply treating a disease, not a person).