From Our 2010 Archives

New Guidelines for Treatment of Depression

American Psychiatric Association Issues Suggestions on Medication and Talk Therapy

By Kathleen Doheny
WebMD Health News

Reviewed by Laura J. Martin, MD

Oct. 1, 2010 -- Updated guidelines for the treatment of clinical depression include suggestions on the use of medication, talk therapy, exercise, and alternative treatments, while urging doctors to more closely assess symptoms and tailor treatments to the patient.

The American Psychiatric Association released the guidelines on major depressive disorder Friday, the first update in 10 years.

Before the release of the new guidelines, an independent panel of depression treatment experts with no ties to industry reviewed the guidelines for any bias, says Joel Yager, MD, a professor of psychiatry at the University of Colorado School of Medicine, Denver, and chair of the American Psychiatric Association's steering committee on practice guidelines.

The final document, Yager tells WebMD, is a ''verification and validation of the best way to treat depression." The group took five years to research and create the guidelines, Yager says.

Nearly one in 10 U.S. adults has depression, the CDC reported this week. About 3.4% of those meet the criteria for major depression, the type addressed in the guidelines.

Yager recapped some of the highlights of the guidelines for WebMD.

''For mild to moderate depression, talking therapy -- in particular cognitive behavior therapy and interpersonal therapy -- can help reduce the symptoms of depression and prepare people not to be so vulnerable for future depression," Yager says. "There's also good evidence that modern antidepressants are effective as well."

"For more serious cases of depression, there is evidence that the medications really matter," he says. ''Talking therapy can be additionally helpful, but if you have a serious depression the odds are you are going to require these medications."

The new guidelines address depression that resists traditional treatment, suggesting that electroconvulsive therapy (ECT) has the best supporting data. In ECT, electric currents are passed through the brain to change brain chemistry and help ease symptoms.

"Electroconvulsive therapy has been around a long time," Yager says. "The evidence [for its effectiveness] remains strong for very serious depression that doesn't respond."

He likens ECT to putting paddles on the chest for heart emergencies. "Paddles on the brain will bring you back," he says.

For resistant depression, the guidelines also address other potential treatments, including older medications known as monoamine oxidase inhibitor (MAOIs) as well as two newer options: transcranial magnetic stimulation (the use of magnetic fields to stimulate nerve cells in the brain and relieve symptoms) and vagus nerve stimulation (the use of electrical impulses in the brain).

Exercise is addressed as a way to see a modest improvement in mood symptoms, with either aerobic exercise or resistance training a help. "It pumps you up a little bit, makes you feel not as ineffective," Yager says.

Under the guidelines, doctors are also urged to rate their patients' symptoms more specifically than they may do now.

Instead of simply asking "How are you today?" doctors are urged to ask: "On a scale of one to 10, how are you feeling today?" Yager says.

This more specific questioning may help doctors gauge treatment effects better, Yager says, and help patients see a pattern in their moods and symptoms.

This kind of rating approach is used in research studies, Yager says, but most doctors haven't adopted this approach yet.

Under the new guidelines, the value of maintenance treatment is strengthened. "If someone has had three or more episodes of depression, they really should probably stay on their medication continuously the way you would stay on insulin if you are diabetic," Yager tells WebMD.

Treatment during pregnancy should be discussed between a woman and her doctor, Yager says. If a woman is on medications and doing well, then gets pregnant, she should discuss whether to stay on them or not with her doctor. If she wants to come off medications, she should have talk therapy. If depression returns during pregnancy, it can be hazardous to both mother and infant, he says. Depression during pregnancy has been linked to preterm babies. New mothers who are depressed may not be able to care properly for their infants, he says.

The new guidelines ''represent a great step forward," says Ian Cook, MD, director of the University of California, Los Angeles Depression Research and Clinic Program, who reviewed the guidelines for WebMD but was not involved in them.

"They now reflect the current state of the evidence," he says.

What sets the American Psychiatric Association guidelines apart, he says, is that they rely on published scientific research, while other organizations may rely less on published research and more on expert opinion.

Perhaps of most interest to patients, he says, are the wider range of available treatments covered in the guidelines, which should give people hope, says Cook. Cook has served on the speaker's bureau or done consulting work for Wyeth and other antidepressant makers.

"People can expect for the most part they will recover with treatment."

SOURCES: Joel Yager, MD, professor of psychiatry, University of Colorado School of Medicine, Denver; chair, Steering Committee for Practice Guidelines, American Psychiatric Association.Ian Cook, MD, director, University of California Los Angeles Depression Research and Clinic Program, David Geffen School of Medicine.American Psychiatric Association.CDC: "Current Depression Among Adults--United States, 2006 and 2008.”

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