Overview
Major depression is the second-leading cause of disability worldwide. In the United States, an estimated 6.7% of adults and 11.7% of adolescents experienced at least one episode of major depression in the past year, according to the National Survey on Drug Use and Health by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Yet, too often, depression goes untreated, exacting a significant human toll. Depression impairs quality of life and interpersonal functioning, increases the risk of suicide and substance use disorders and is associated with a raft of physical health problems, including an increased risk of heart disease, stroke, diabetes and Alzheimer’s disease.
But those outcomes aren’t inevitable, says John R. McQuaid, PhD, who chaired a panel that created APA’s new Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. The guideline provides research-based recommendations for treating depressive disorders including major depression, subsyndromal depression and persistent depressive disorder in children and adolescents, adults, and older adults, using methods including psychotherapy, pharmacotherapy and alternative treatments. (Psychotic depression, the panel members noted, was outside the scope of this guideline.)
“The big takeaway is that there are effective options available to treat people with depression,” says McQuaid, a clinical psychologist with the Department of Veterans Affairs in San Francisco and a professor at the University of California, San Francisco.
The guideline-development panel included experts from several countries besides the United States and from a variety of disciplines, including psychology (both clinicians and researchers) and medicine (both psychiatrists and primary-care physicians), as well as methodologists and patient representatives who could speak to the experience of living with depression.
Their goal was to create a comprehensive guideline that compared the efficacy of various types of treatments in multiple patient populations. To do so, the panel members used 10 separate systematic reviews and meta-analyses and followed the best practices recommended by the National Academy of Medicine (formerly the Institute of Medicine). When reviewing the research, the members considered four factors: the overall strength of the evidence, the balance of a treatment’s benefits versus its harms or burdens, patient values and preferences, and applicability of the treatment.
“Most of the existing guidelines for depressive disorders from other professional associations have focused mainly on pharmacotherapy,” says Elizabeth H. Lin, MD, MPH, a family medicine physician and clinical professor at the University of Washington School of Medicine who was vice chair of the APA guideline panel. Those who do take a more comprehensive look tend to focus on a specific population, such as military members and veterans. The APA guideline panel took a much broader approach, reviewing the literature and making recommendations for treating depression in three groups: children and adolescents, the general adult population, and adults 60 and older.
“This is truly the first guideline to take such an in-depth look at the rigorous research available in psychotherapy as well as pharmacotherapy,” Lin says. “It will help practicing clinicians and researchers determine which evidence-based treatments can contribute to the overall improvement of depression.”
A summary of the literature review and guideline follows.
Treating children and adolescents
Depression is less common in children, with studies suggesting a prevalence rate of 0.4% to 2.5%, the guideline panel reported. But rates climb steeply as children approach their teenage years, with depression affecting 11.7% of adolescents. What’s more, depression in adolescents appears to be rising. The rate at which adolescents experienced a major depressive episode increased 2.6% between 2005 and 2014.
In younger children, boys and girls are affected equally. After puberty, however, young women are twice as likely as young men to develop depressive disorders. The depression rate among adolescent members of marginalized populations is believed to be significantly higher as well, though the research on those groups is limited.
While many children and adolescents live with depression, they are much less likely than adults to receive mental health treatment. In fact, less than 1% of children and adolescents with depression receive outpatient treatment for depression.
Unfortunately, the guideline panel was unable to make a recommendation for treating depression in children. The members reviewed literature on a wide variety of psychotherapies as well as pharmacotherapy, but they found insufficient evidence for either recommending or not recommending those treatments.
For adolescents, the panel found more published evidence that met the inclusion criteria. The guideline recommends the use of cognitive-behavioral therapy (CBT) or interpersonal psychotherapy for the initial treatment of depression in adolescents. For clinicians considering medication options for their adolescent patients with major depressive disorder, the guideline recommends fluoxetine over other medications. There was not enough evidence, however, for the panel to determine the comparative effectiveness of psychotherapy versus fluoxetine.
If those treatments are ineffective, unavailable or unacceptable to the patient, the guideline suggests providers consider other treatment options, though the evidence for their effectiveness is less robust. Research on forms of psychotherapy other than CBT and interpersonal psychotherapy was too limited for the panel to be able to recommend a particular type of intervention as an alternative treatment. Information was also lacking regarding alternative medication options.
In some cases, the guideline panel made a conditional recommendation for treatments that were superior to control conditions, but which were less effective than other active treatments, had greater harms or burdens than other treatments or for which there was insufficient evidence that the treatment was equivalent to other effective treatments. For adolescents, the guideline offers a conditional recommendation that patients and providers might consider alternative antidepressants, but recommends against the use of clomipramine, imipramine, mirtazapine, paroxetine and venlafaxine because of the potential for increased suicide risk in youth taking these drugs. If fluoxetine is not an option, the guideline recommends the clinician share decision-making with a child psychiatrist in addition to the provider, the patient and the patient’s parents/guardians or other family members actively involved in his or her care.
Recommendations for adults and older adults
Depression is common among young and middle-aged adults. SAMHSA estimates that 6.7% of U.S. adults—15.7 million people—experience at least one major depressive episode each year. For 10.2 million of them, that episode results in “severe impairment.” As among adolescents, women are twice as likely to experience depression as men, with a lifetime prevalence of major depression of 21% among women, compared with 12% among men.
For the initial treatment of depression in adults, the guideline recommends either psychotherapy or second-generation antidepressants, which include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). There was not enough evidence to recommend one psychotherapy treatment over another, but in general, there was support for behavioral therapy; cognitive therapy, CBT and mindfulness-based cognitive therapy; interpersonal psychotherapy; psychodynamic therapies; and supportive therapy. For clinicians considering combination treatments, the guideline recommends combining CBT or interpersonal psychotherapy with a second-generation antidepressant.
An estimated 2.6% of older adults experience depression. Research has shown that late-life depression rates are higher among those with more medical problems and with disabilities. Evidence indicates that many older adults prefer psychosocial treatments for depression rather than pharmacotherapy, the panel members note.
As the initial treatment for major depression in adults age 60 and older, the guideline recommends either group life review treatment or group CBT. When considering combined treatment, the panel recommends a combination of second-generation antidepressants and interpersonal psychotherapy over interpersonal psychotherapy alone.
Recognizing research gaps
While the guideline covers a lot of ground, the panel members found notable gaps in the science. Many studies didn’t meet the rigorous methodological criteria set for inclusion in the reviews, McQuaid says, and some areas were thin on any research, high-quality or otherwise. “Particularly in the child and adolescent population, and the older adult population, there was far less scientific literature than for the general adult population,” he says. “There’s also a real dearth of literature addressing the needs of underserved populations, whether you define them by ethnicity, gender, sexual orientation, socioeconomic status or medical disability. There are broad questions that need to be addressed about these groups.”
The guideline panel sees those gaps as a call to action. “We need more research to move forward with our understanding of treating depression in those populations,” Lin says. “It’s a call to researchers, but also to policymakers and funders. We really need to address this.”
Limitations aside, the new guideline offers a wealth of evidence-based recommendations for clinicians in psychology and across health care, McQuaid says. In addition to the guideline document itself, a complementary website provides additional resources for health-care providers and patients, including materials for assessment, detailed descriptions of treatments, information for patients and their families, case examples and a resource page that includes links to treatment manuals, books and other relevant sites and sources. “We really hope this will be used broadly by health-care professionals,” McQuaid says.
Indeed, depression treatment is something that many types of medical providers are—and should be—involved in, Lin adds. “Most of the people in society who have depression don’t initially seek care from psychologists or psychiatrists, but from primary-care physicians or other providers,” she notes.
She encourages psychologists to work closely with primary-care physicians, making themselves available for referrals and reaching out to patients who don’t follow through with a referral for psychotherapy. “We all need to be part of a team” to treat depression, she says.
Those teams must also include the patients and, for youth, their parents, McQuaid adds. “It’s important for clinicians to have a collaborative discussion with patients about psychotherapy and pharmacotherapy options for treating depression, incorporating both the patient’s preferences and the provider’s expertise,” McQuaid says. “These guidelines will support that shared decision-making.”
