Knoxville Area Psychological Association

The Profession's Pulse: Information for the Practice of Psychology 

Be Informed about the American Psychological Association’s New Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts 

by Malcolm Spica, Ph.D.

On February 16th of this year, the American Psychological Association (APA) adopted as policy the new Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts created by the 12-member APA Guideline Development Panel for the Treatment of Depressive Disorders (chaired by John R McQuaid, PhD). The guideline provides research-based recommendations for the treatment of depressive disorders and sub-clinical depressive conditions (“subsyndromal depression”) and persistent depressive disorder in a) children and adolescents, b) adults, and c) adults age 60 and older. The treatment methods covered included psychotherapies, psychoactive medications, and alternative treatments.

The panel included psychologists, psychiatrists, family practice physicians, and methodologists, as well as patient representatives who can speak from experience regarding depression’s broad effects. Through 10 separate systematic reviews and meta-analyses, the panel considered 4 factors:

• Strength of evidence
  
• Balance of a treatments benefits versus harms/burdens
  
• Patient values and preferences
  
• Applicability of the treatment
  

Here is my attempt to summarize the 213-page document:

Children and Adolescents:

As many clinicians are well aware, depression rates in children rise steeply during the teenage years, affecting 11.7% of adolescents (up from approximately > 2% younger childhood). Moreover, the rates of adolescent depression are rising across generational cohorts. Boys and girls appear equally affected, whereas young women are twice as likely than young men to be diagnosed with depression in early adulthood. 

The guideline panel did not make a specific recommendation for the treatment of depression in children; after reviewing the literature on a variety of therapies, the panel found insufficient evidence for either recommending or discouraging the specific treatments. However, for adolescents, the panel recommended use of cognitive behavioral therapy (CBT) or interpersonal psychotherapy for initial treatment of depression. 

If medication options are being considered for adolescents with Major Depressive Disorder, the guideline suggested fluoxetine (“Prozac” or “Sarafem”) over all others. The panel stated there was not enough evidence to compare the effectiveness of fluoxetine versus psychotherapy. However, the panel stated that if neither fluoxetine or psychotherapy are practical or available, alternate treatments (other than CBT or interpersonal therapy) may be helpful, provided they do not introduce greater harm or burdens to the patient. 

The panel recommended against the use of the following psychoactive substances in adolescents due to increased risk of suicide: 

• Clomipramine; e.g., Anafranil  
  
• Mirtazapine: e.g., Remeron
  
• Imipramine; e.g., Tofranil 
  
• Paroxetine e.g., Paxil
  
• Venlafaxine e.g., Effexor XR
  

Adults: 

The APA panel cited lifetime prevalence of major depressive illness as 21% among adult women and 12% among men. The new guidelines recommended either psychotherapy or second-generation antidepressants which include selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). 

The guideline panel indicated there was insufficient evidence to support one psychotherapy treatment modality over another. The overall recommendation was for a combination of either CBT or interpersonal psychotherapy combined with a second-generation antidepressant, as noted above.

Older Adults:

The APA panel adduced evidence that, perhaps contrary to common perception, many older adults prefer psychosocial treatments for depression rather than pharmacotherapy. However, based on the evidence-based treatment outcomes, the panel again recommended a combination of psychotherapy and medication. 

Specifically, for initial treatment of major depression in individuals aged 60 and older, the guideline recommends combination of second-generation antidepressants (SSRIs or SNRIs) and interpersonal psychotherapy instead of interpersonal psychotherapy alone.

Importantly, the panel noted that paroxetine (e.g., Paxil) is contraindicated in older adults due to its anticholinergic side effects; geriatric specialists prefer another SSRI (i.e., escitalopram or sertraline). 

The panel stated that subsyndromal depression in old age is responsive to early interventions to preempt the development of full-blown clinical depression. Learning-based interventions and those that are behaviorally activating (e.g., behavioral activation, cognitive-behavioral therapy, problem-solving therapy) appear to be promising methods of depression prevention.

SUMMARY:

In my view, the meta-analyses conducted by the APA guideline panel point to a greater need for psychologists to work symbiotically with primary care physicians to best treat depression across the age span. The vast majority of patients turn first to their primary care physician when asking for help with depression, perhaps never to follow up beyond tentatively voicing symptoms. 

I encourage KAPA clinicians to work out an integrated referral system with primary care providers, to be mindful of the high likelihood the patient will never follow through on a cursory referral for psychotherapy from the primary care provider, due to amotivation, shyness, or any other form of avoidance. 

For example, practitioners could avoid working through the primary care office “referral coordinator,” who often works as a go-between; instead, develop a coordinated routine through which you make telephone contact with the prospective patient as soon as is practical, to answer questions, directly negotiate the appointment schedule, and, most importantly, to humanize the process to establish a nascent alliance. Such quick contact may prove invaluable to a large portion of our community suffering from depression.

For more information on the updated guidelines, visit this website: https://www.apa.org/depression-guideline/guideline.pdf