TY - JOUR
T1 - Nonpharmacologic and Pharmacologic Treatments of Adult Patients With Major Depressive Disorder A Systematic Review and Network Meta-analysis for a Clinical Guideline by the American College of Physicians
AU - Gartlehner, G.
AU - Dobrescu, A.
AU - Chapman, A.
AU - Toromanova, A.
AU - Emprechtinger, R.
AU - Persad, E.
AU - Affengruber, L.
AU - Pieh, C.S.
AU - Klerings, I.
AU - Wagner, G.
N1 - Funding Information:
American College of Physicians. (PROSPERO: CRD42020204703) The authors gratefully acknowledge Petra Wellemsen for project administration and formatting, Isolde Sommer and Barbara Nußbaumer-Streit for the internal peer review of the report, and Dawn Gartlehner for editing. The authors also thank Pelin Batur, Margaret Chesney, Bradley N. Gaynes, Madhukar Trivedi, John Williams, and Timothy Wilt for their input as members of the technical expert panel. Many thanks also to Itziar Etxeandiar-Ikobaltzeta for her support.
Funding Information:
This review was funded by ACP. The ACP Clinical Guidelines Committee assisted in the development of key questions, study inclusion criteria, and outcome measures of interest but was not involved in data collection, analysis, or manuscript preparation.
Publisher Copyright:
© 2023 American College of Physicians. All rights reserved.
PY - 2023/2
Y1 - 2023/2
N2 - Background: Primary care patients and clinicians may prefer alternative options to second-generation antidepressants for major depressive disorder (MDD). Purpose: To compare the benefits and harms of nonpharmacologic treatments with second-generation antidepressants as first-step interventions for acute MDD, and to compare second-step treatment strategies for patients who did not achieve remission after an initial attempt with antidepressants. Data Sources: English-language studies from several electronic databases from 1 January 1990 to 8 August 2022, trial registries, gray literature databases, and reference lists to identify unpublished research. Study Selection: 2 investigators independently selected randomized trials of at least 6 weeks' duration. Data Extraction: Reviewers abstracted data about study design and conduct, participants, interventions, and outcomes. They dually rated the risk of bias of studies and the certainty of evidence for outcomes of interest. Data Synthesis: 65 randomized trials met the inclusion criteria; eligible data from nonrandomized studies were not found. Meta-analyses and network meta-analyses indicated similar benefits of most nonpharmacologic treatments and antidepressants as first-step treatments. Antidepressants had higher risks for discontinuation because of adverse events than most other treatments. For second-step therapies, different switching and augmentation strategies provided similar symptomatic relief. The certainty of evidence for most comparisons is low; findings should be interpreted cautiously. Limitations: Many studies had methodological limitations or dosing inequalities; publication bias might have affected some comparisons. In some cases, conclusions could not be drawn because of insufficient evidence. Conclusion: Although benefits seem to be similar among first- and second-step MDD treatments, the certainty of evidence is low for most comparisons. Clinicians and patients should focus on options with the most reliable evidence and take adverse event profiles and patient preferences into consideration.
AB - Background: Primary care patients and clinicians may prefer alternative options to second-generation antidepressants for major depressive disorder (MDD). Purpose: To compare the benefits and harms of nonpharmacologic treatments with second-generation antidepressants as first-step interventions for acute MDD, and to compare second-step treatment strategies for patients who did not achieve remission after an initial attempt with antidepressants. Data Sources: English-language studies from several electronic databases from 1 January 1990 to 8 August 2022, trial registries, gray literature databases, and reference lists to identify unpublished research. Study Selection: 2 investigators independently selected randomized trials of at least 6 weeks' duration. Data Extraction: Reviewers abstracted data about study design and conduct, participants, interventions, and outcomes. They dually rated the risk of bias of studies and the certainty of evidence for outcomes of interest. Data Synthesis: 65 randomized trials met the inclusion criteria; eligible data from nonrandomized studies were not found. Meta-analyses and network meta-analyses indicated similar benefits of most nonpharmacologic treatments and antidepressants as first-step treatments. Antidepressants had higher risks for discontinuation because of adverse events than most other treatments. For second-step therapies, different switching and augmentation strategies provided similar symptomatic relief. The certainty of evidence for most comparisons is low; findings should be interpreted cautiously. Limitations: Many studies had methodological limitations or dosing inequalities; publication bias might have affected some comparisons. In some cases, conclusions could not be drawn because of insufficient evidence. Conclusion: Although benefits seem to be similar among first- and second-step MDD treatments, the certainty of evidence is low for most comparisons. Clinicians and patients should focus on options with the most reliable evidence and take adverse event profiles and patient preferences into consideration.
KW - Cognitive-behavioral therapy
KW - St-johns-wort
KW - Randomized controlled-trial
KW - Serotonin reuptake inhibitor
KW - To-moderate depression
KW - Primary-care patients
KW - Once-daily dosage
KW - Double-blind
KW - Antidepressant medication
KW - Hypericum-perforatum
U2 - 10.7326/M22-1845
DO - 10.7326/M22-1845
M3 - (Systematic) Review article
C2 - 36689750
SN - 0003-4819
VL - 176
SP - 196
EP - 211
JO - Annals of Internal Medicine
JF - Annals of Internal Medicine
IS - 2
ER -