Last week, the American College of Physicians (ACP) released a practice guideline in the treatment of depression through the use of medications.
MedPage Today covered some reaction to it from some psychiatrists, who lamented the lack of a comprehensive treatment approach guideline to depression (the ACP guideline focused only on the use of medications).
While I agree, in theory, that any guideline that focuses solely on one treatment method for a common mental disorder such as depression, while completely ignoring other treatment options, is a bad thing, I’m not sure we could’ve expected anything different from this physicians group. After all, physicians treat medical diseases, not mental disorders, and have no training or background in anything other than diseases and medications. Logically, why should a physicians group write a treatment guideline that suggests the use of a treatment that a physician can’t administer (such as psychotherapy)?
The guideline, however, is a short-sighted, simplistic attempt to try and “grade” research on antidepressants and their efficacy, when there is already some much better treatment studies that have already done most of the heavy lifting. For instance, refer any physician to the STAR*D findings, and that’s a nice capsule of what you need to know about modern antidepressant prescriptions. There are also a half-dozen meta-analyses done over the past two decades that already have been published on this or similar topics.
The ACP guideline concluded, in a nutshell, that a physician can feel comfortable prescribing any second-generation antidepressant and not worry about which one, which class of medication, or even what specific type of depression that person may be experiencing.
What a helpful finding that is (sarcasm alert – “Prescribe pretty much any antidepressant, just as you’ve been doing for years!”), but not one without its objectors. The MedPage Today article noted some of the objections from a psychiatrist regarding the ACP guideline:
Dr. Karasu said the ACP guideline committee made “a serious mistake” in suggesting that norepinephrine reuptake inhibitors were interchangeable with SSRIs.
Dr. Karasu also said the ACP guideline failed to distinguish between different types of depressive disorders or stages of depressive episodes.
In making treatment decisions, he suggested, “those are different diseases. … How dysthymia, major depression, subsyndromal depressions are put together with the phases of acute-continuation-maintenance, it’s a bizarre combination. People don’t use SSRIs of any sort for some of these conditions.”
But here’s the kicker for me. The guideline makes the a priori assumption that a general practitioner or family physician is the best health professional equipped to handle and deal with major depressive illness. In fact, that’s probably not true in most cases. Physicians aren’t in the mental health business, and they only prescribe the large amount of antidepressants that they do because so many people turn to them first for such assistance.
There’s nothing wrong with that. But one of the physician’s recommendations should nearly always be, “And I’m going to give you a referral to a [psychiatrist/psychologist/clinical social worker/therapist] to help you further with treatment of this issue. These things are best treated with a combination of medication and psychotherapy and if you only take the medication, research shows it might not work, this may not be the right medication for you, and/or it may be weeks before you start feeling any effect.” How hard is that for a doc to say? And why aren’t more docs making such valuable referrals??
I don’t have the answer, but I do know that guidelines like this one from the ACP may be doing a disservice to the public health by making the assumption (and then publicizing it widely) that physicians are readily equipped and can handle the treatment of severe, major depression in a 15-minute office visit.
Mental health professionals the world over and decades worth of research would beg to differ.
Read the MedPage Today article: Medical News: Psychiatrists Give Mixed Reviews on ACP Antidepressant Guideline
Read the ACP guideline: Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the American College of Physicians
PS – How seriously should I take research that is published without simple fact-checking too? The researchers, for instance, still refer to the PsycINFO database by its old name, and then go on to actually misspell it (the article referred to a database called PsychLit [sic], when it’s old name was actually PsycLIT). I mean, if you can’t even get the name of what you’re searching right, it does make one wonder a little about the accuracy and details found in the rest of the article.
The criteria seemed a bit random as well — “adults 19 years of age or older, human, and English-language articles.” I get the human criteria, but why 19 years of age or older, rather than the traditional adult cutoff of 18? And why not include studies published in a non-English language?
6 comments
There’s a danger to prescribing antidepressants to those Bipolar patients who present with depression rather then mania. Key questions should be asked before writing a script for any antidepressent. I think more training is needed for primary care docs in this department. I know what this is like, as I whom am Bipolar presented with depression and was given Prozac. This sent me to the moon and made me so manic I was out of control. So, I encourage all primary docs who prescribe antidepressents to do so with this in mind!
Despite my own pecuniary interests, I would argue that PCP’s can, and must, treat a range of low-grade depressive and anxious disorders. Just as every sore knee does not require a referral to an orthopedic surgeon, not every mood complaint requires a psychiatrist or psychologist.
To be sure, many PCP’s aren’t as good at evaluating depression as they are with a sore knee, but the answer to this is better training of PCP’s, not automatic punting/referral. After all, a large number of patients just aren’t willing to see a mental health specialist (stigma, expense, inconvenience) and even if they were, there wouldn’t be enough such specialists to treat them.
Regarding medications, psychiatry has tried for decades to show that certain types of antidepressants work better for certain “types” of depression (e.g. MAOI’s for “atypical depression”). However, this hasn’t really panned out, although some seem to like to think it has because it makes our treatments seem more precise than they are.
To be sure, there are a few major things we do know (like, as the first commenter said, don’t treat bipolar depression with antidepressants alone), but otherwise antidepressants are very broad relievers of emotional distress syndromes. Educate me if I’m wrong, but I’m not aware of any conclusive research that shows specific exceptional efficacy for any one antidepressant class for any one subtype of depression.
For these reasons, I find the ACP guidelines to be realistic given the very limited state of our knowledge and our health care system.
Some psychiatrists do offer therapy (and are in fact trained to do so). Some psychiatry programs emphasize psychotherapy, in fact. I think it is important not to generalize from this to ALL psychiatrists…
We have known for a while now that SSRI’s are mostly placebo. I’m not sure whether knowing you are being given a placebo undermines its efficacy or not… But I guess best that word doesn’t get out… Or something…
help me