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Guidelines for Biological Treatment of Unipolar Depressive Disorders

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Guidelines for Biological Treatment of Unipolar Depressive Disorders The World Journal of Biological Psychiatry, 2015; 16: 76–95 GUIDELINES World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders. Part 2: Maintenance Treatment of Major Depressive Disorder-Update 2015 MICHAEL BAUER 1 , EMANUEL SEVERUS 1 , STEPHAN K Ö HLER 2 , PETER C. WHYBROW 3 , JULES ANGST 4 & HANS-J Ü RGEN M Ö LLER 5; ON BEHALF OF THE WFSBP TASK FORCE ON TREATMENT GUIDELINES FOR UNIPOLAR DEPRESSIVE DISORDERS * 1 Department of Psychiatry and Psychotherapy, TU Dresden, Germany, 2 Department of Psychiatry and Psychotherapy, Charit é Universit ä tsmedizin Berlin, Berlin, Germany, 3 Semel Institute for Neuroscience and Human Behavior Los Angeles, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, CA, USA, 4 University of Z ü rich, Department of Psychiatry, Z ü rich, Switzerland, and 5 University of Munich, Department of Psychiatry, Munich, Germany Abstract These guidelines for the treatment of unipolar depressive disorders systematically review available evidence pertaining to the biological treatment of patients with major depression and produce a series of practice recommendations that are For personal use only. clinically and scientifi cally meaningful based on the available evidence. These guidelines are intended for use by all physi- cians assessing and treating patients with these conditions. The relevant data have been extracted primarily from various treatment guidelines and panels for depressive disorders, as well as from meta-analyses/reviews on the effi cacy of antide- pressant medications and other biological treatment interventions identifi ed by a search of the MEDLINE database and Cochrane Library. The identifi ed literature was evaluated with respect to the strength of evidence for its effi cacy and was then categorized into fi ve levels of evidence (CE A-F) and fi ve levels of recommendation grades (RG 1 – 5). This second part of the WFSBP guidelines on depressive disorders covers the management of the maintenance phase treatment, and is primarily concerned with the biological treatment (including pharmacological and hormonal medications, electrocon- vulsive therapy and other brain stimulation treatments) of adults and also, albeit to a lesser extent, children, adolescents and older adults. Key words: major depressive disorder; maintenance treatment; guidelines; pharmacotherapy; antidepressants World J Biol Psychiatry Downloaded from informahealthcare.com by Prof. Siegfried Kasper on 03/12/15 * Chair: Michael Bauer (Germany); Co-Chair: Jules Angst (Switzerland); Secretary: Emanuel Severus (Germany); Members: Mazda Adli (Germany), Ian Anderson (UK), José L. Ayuso-Gutierrez (Spain), David Baldwin (UK), Per Bech (Denmark), Michael Berk (Australia), Istvan Bitter (Hungary), Tom Bschor (Germany), Graham Burrows (Australia), Giovanni Cassano (Italy), Marcelo Cetkovich-Bakmas (Argentina), John C. Cookson (UK), Delcir da Costa (Brasil), Mihai D. Gheorghe (Romania), Heinz Grunze (UK), Gregor Hasler (Switzerland), Gerardo Heinze (Mexico), Teruhiko Higuchi (Japan), Robert M.A. Hirschfeld (USA), Cyril H ö schl (Czech Republic), Edith Holsboer-Trachsler (Switzerland), Rhee-Hun Kang (Korea), Siegfried Kasper (Austria), Cornelius Katona (UK), Martin B. Keller (USA), Selcuk Kirli (Turkey), Stephan K ö hler (Germany), Elena G. Kostukova (Russia), Parmanand Kulhara (United Arab Emirates), David J. Kupfer (USA), Min-Soo Lee (Korea), Brian Leonard (Ireland), Rasmus W. Licht (Denmark), Se-Won (Lim (Korea), Odd Lingjaerde (Norway), Chia-Yih Liu (Taiwan), Henrik Lublin (Denmark), Julien Mendlewicz (Belgium), Philip Mitchell (Australia), Hans- J ü rgen M ö ller (Germany), Jong-Woo Paik (Korea), Yong Chon Park (Korea), Andrea Pfennig (Germany), Stanislaw Puzynski (Poland), A. John Rush (USA), Janusz K. Rybakowski (Poland), Andr é Tadi (Germany), Andre Tylee (UK), J ü rgen Un ü tzer (USA), Per Vestergaard (Denmark), Eduard Vieta (Spain), Peter C. Whybrow (USA), Kazuo Yamada (Japan), Aylin Yazici (Turkey). Correspondence: Michael Bauer, MD, PhD, Professor of Psychiatry, Department of Psychiatry and Psychotherapy, Universit ä tsklinikum Carl Gustav Carus, Technische Universit ä t Dresden, Fetscherstr. 74, D-01307 Dresden, Germany. Tel: ϩ 49-351-4582772. Fax: ϩ 49- 351-4584324. E-mail: [email protected]. (Received 19 December 2014 ; accepted 19 December 2014 ) ISSN 1562-2975 print/ISSN 1814-1412 online © 2015 Informa Healthcare DOI: 10.3109/15622975.2014.1001786 WFSBP Guidelines on Maintenance Treatment of Unipolar Depression 77 Executive summary of recommendations tinuation phase, or lithium (in case of successful lithium General recommendations augmentation in acute treatment phase). In patients who fail to remain well on either drug alone the com- The long-term course of unipolar major depressive bination of antidepressant and lithium is indicated. disorder (MDD) is characterized by high rates of Many patients receive antidepressants during the recurrence and prolonged symptomatic chronicity. acute and continuation phase, and the best treatment The primary goals of maintenance (prophylactic) recommendation to prevent recurrence of depression treatment are to prevent a new episode of depression is to continue this medication at the same dose dur- (a recurrence), suicide and development of chronicity. ing the maintenance phase. Randomized placebo- The consideration of the patient ’ s course of illness controlled studies (usually conducted 1 or 2 years and treatment history is essential for the implementa- during maintenance treatment) indicate that tricyclic tion of maintenance-phase treatment. Continuation antidepressants (TCAs), irreversible monoamine of successful treatment for 6 – 9 months after remis- oxidase inhibitors (MAOI), selective serotonin sion of the acute depressive episode should be recom- reuptake inhibitors (SSRIs) and selective serotonin mended. Even though no defi nite recommendation norepinephrine reuptake inhibitors (SNRIs) are can be given as to when prophylactic therapy beyond effective in preventing recurrence of depression. these 6 – 9 months is warranted, it is clearly indicated Evidence suggests that the “ newer ” antidepressants in situations associated with a high risk of recurrence may have superior long-term effi cacy due to better or consequences. For patients who have had three or tolerability compared to traditional antidepressants more episodes of major depression and in patients (e.g., TCAs). In addition they possess a more benefi - with a high prior rate of recurrence (e.g., two episodes cial safety profi le. With respect to lithium therapy, within 5 years), longer-term maintenance therapy is serum lithium levels of 0.6 – 0.8 mmol/l (mEq/l) indicated. Besides a high number of previous episodes determined 12 h after last lithium intake are usually adverse prognostic indicators for recurrence include, recommended for maintenance treatment. However, residual symptoms at remission, previous longer epi- the “ optimal ” serum lithium level may vary some- sodes and chronicity, more severe previous episodes, what from patient to patient in the range of 0.4 – 1.0 onset early in life, concurrent dysthymic disorder mmol/l depending on individual effectiveness and ( “ double depression ” ), relapse/recurrence after med- side effects. There is also preliminary evidence that ication withdrawal, previous episode in the last year, quetiapine is effective in the maintenance treatment concurrent substance abuse or anxiety disorders, and of major depression, whereas the evidence that car- family history of MDD in fi rst degree relatives. For personal use only. bamazepine is an alternative medication in the main- Key elements of long-term treatment of MDD tenance treatment of MDD is rather weak. Periodic include (1) psychoeducation, (2) pharmacotherapy, (maintenance) electroconvulsive therapy (ECT) has and (3) adherence monitoring and improvement, if been recommended for patients who fully responded indicated. Adjunctive depression-targeted psycho- to ECT during the acute and continuation treatment therapy such as cognitive behavioural therapy (CBT), phase and especially for those who are not eligible or and lifestyle strategies should be considered on an who do not respond to maintenance medication individual basis. Because maintenance treatment treatment. requires adherence with medication, education and The duration of continuation treatment following a close therapeutic alliance with patients and their remission of the acute depressive episode should be families are essential. Strategies to prepare patients 6 – 9 months. Treatment length required for mainte- and their families for maintenance treatment should World J Biol Psychiatry Downloaded from informahealthcare.com by Prof. Siegfried Kasper on 03/12/15 nance treatment beyond that point is not yet fully include the following topics: typical course of the determined. Duration may vary from 3 years to life- illness, treatment options, medication effects and time, but in general the more adverse the prognosis, side effects, use of (daily) self-report instruments to the longer the maintenance therapy. Three years of track mood and early warning signs of relapse or maintenance therapy is most commonly appropriate recurrence, long-term perspectives, and projected for recurrent patients, particularly when an episode end of treatment. It is also essential to regularly prior to the present one has occurred in the last 5 check
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