APA Clinical Practice Guideline for the Treatment of Depression Across ...

APA CLINICAL PRACTICE GUIDELINE

for the Treatment of Depression Across Three Age Cohorts

GUIDELINE DEVELOPMENT PANEL FOR THE TREATMENT OF DEPRESSIVE DISORDERS APPROVED BY APA COUNCIL OF REPRESENTATIVES FEBRUARY 2019

APA|Guideline for the Treatment of Depression I

Copyright ? 2019 by the American Psychological Association. This material may be reproduced and distributed without permission provided that acknowledgment is given to the American Psychological Association. This material may not be reprinted, translated, or distributed electronically without prior permission in writing from the publisher. For permission, contact APA, Rights and Permissions, 750 First Street, NE, Washington, DC 20002-4242.

This document was approved by the APA Council of Representatives over the course of its February 2019 meeting and is set to expire in approximately 2024. It is available online at .

Please refer to p. 59 of this guideline for a statement on conflicts of interest as well as p. 61 for acknowledgments. Correspondence concerning this guideline should be addressed to Practice Directorate, American Psychological Association, 750 First Street, NE, Washington, DC 20002-4242. E-mail: cpg@

Suggested Citation American Psychological Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from

IIAPA|Guideline for the Treatment of Depression

APA CLINICAL PRACTICE GUIDELINE

for the Treatment of Depression Across Three Age Cohorts

Guideline Development Panel

John R. McQuaid (chair) Department of Veteran's Affairs San Francisco, California

Elizabeth H. Lin (vice-chair) University of Washington School of Medicine

Jacques P. Barber Gordon F. Derner School of Psychology Adelphi University

Alfiee M. Breland-Noble AAKOMA Project Arlington, Virginia

Pim Cuijpers Faculty of Behavioural and Movement Sciences Vrijie Universiteit Amsterdam, Netherlands

Leslie S. Greenberg Department of Psychology York University, Toronto, Ontario, Canada

Vanessa Y. Jones Washington, District of Columbia

Michael "Misha" Kessler New York, New York

Laura H. Mufson Department of Psychiatry Columbia University College of Physicians and Surgeons

Arthur M. Nezu Department of Psychology Drexel University

Charles F. Reynolds, III Department of Psychiatry University of Pittsburgh School of Medicine

Forrest Scogin, Jr. Department of Psychology University of Alabama

APA Staff Lynn F. Bufka Practice Transformation and Quality Practice Directorate

Raquel W. Halfond Practice Transformation and Quality Practice Directorate

Howard S. Kurtzman Science Directorate

ABSTRACT The American Psychological Association developed this clinical practice guideline to provide recommendations for the treatment of depressive disorders (including major depression, subsyndromal depression, and persistent depressive disorder). It addresses three developmental cohorts: children and adolescents; general adults; and older adults (ages 60 and over). Ten systematic reviews and meta-analyses, along with other literature and observations from practitioners and patients, served as the basis for the guideline. The guideline development panel consisted of health professionals from psychology, psychiatry, and primary care as well as community members who self-identified as having had depression. The panel examined the efficacy of psychological treatments and of complementary and alternative medicine treatments. It also examined comparative effectiveness among psychological treatments (by themselves and in combination with pharmacotherapy) and comparative effectiveness of psychological treatments in relation to pharmacotherapy and to complementary and alternative treatments. The panel made no treatment recommendations specific to children but did make recommendations for treatment of depression in adolescents, adults, and older adults. These recommendations are detailed in the guideline.

Keywords: Depression; clinical practice guideline; best practices

INTENDED USE OF GUIDELINE This guideline is intended to be aspirational and is not intended to create a requirement for practice. It is not intended to limit scope of practice in licensing laws for psychologists or for other independently licensed professionals, nor limit coverage for reimbursement by third party payers. Nor is the guideline intended to be used within a legal or judicial context to imply that psychologists or other independently licensed professionals are required to comply with any of its recommendations.

The term guideline refers to statements that suggest or recommend specific professional behavior, endeavor, or conduct for psychologists and may be useful for other clinicians. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help assure a high level of professional practice by psychologists. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional and clinical situation. They are not definitive, and they are not intended to take precedence over the judgment of psychologists. Please refer to the APA's (2015a) Professional Practice Guidelines: Guidance for Developers and Users for a discussion of the several types of guidelines produced by APA. Clinical practice guidelines are an important tool for determining intervention options but are not the only resource.

Clinicians are encouraged to consider the report from the APA Presidential Task Force on Evidence-Based Practice (APA, 2006), Evidence-Based Practice in Psychology, which emphasizes the integration of best available research; patient characteristics, culture, and preferences; and clinical expertise for making treatment decisions.

In reviewing the recommendation statements, the panel reminds the reader that a lack of evidence about a treatment does not imply that that treatment is not efficacious. Rather, there are several gaps in the

literature about treatments as well as limitations in the specific literature reviewed by the panel due to methodological constraints, as discussed later in the guideline document. Clinicians are encouraged to provide informed consent to patients.

INDIVIDUALIZING TREATMENT Clinicians strive to individualize treatments. So how might one follow evidence-based clinical practice guidelines, yet honor the individuality of patients? A comprehensive assessment can help identify factors that might require modifications to a treatment recommended by clinical practice guidelines. These include patient factors such as race; ethnicity; socioeconomic status; culture and/or heritage; or other features of their identities, values, or preferences. In addition, the patient's comorbidities, social support, and ability to obtain childcare when needed, as well as the clinician's accessibility, location, hours of operation, available appointments, proximity to public transportation, and other resources that can affect treatment, must be considered. Further, provider and setting factors like constraints tied to duration of treatment, provider availability, or other factors will impact the application of a treatment recommended by a clinical practice guideline. Combining an individual assessment with the research summarized in the clinical practice guideline can help develop a conceptualization of the change processes that underpin the effective treatment to guide individualization decisions. This can promote "flexibility within fidelity" (Kendall, Gosch, Furr, & Sood, 2008) to facilitate the use of research-supported change processes to achieve the patient's goals while individualizing the specific strategies. Especially when a recommended treatment is modified, providing full informed consent about possible treatments is necessary. It is also important across models to set individualized treatment goals collaboratively with the patient and clearly monitor progress on those goals. All these steps can help providers use the guidelines in a way that respects the enormous variability in patients' needs and backgrounds. For more information about individualizing treatments, see p. 43 of this guideline.

TABLE OF CONTENTS

AbstractII

Intended Use of Guideline

II

Table of Contents

1

Executive Summary

3

Table 1: Recommendations for the Child Population from the APA Guideline Development Panel for the Treatment of Depression7

Table 2: Recommendations for the Adolescent Population from the APA Guideline Development Panel for the Treatment of Depression8

Table 3: Recommendations for the General Adult Population from the APA Guideline Development Panel for the Treatment of Depression10

Table 4: Recommendations for the Older Adult Population from the APA Guideline Development Panel for the Treatment of Depression13

Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts18

Scope of the Problem

19

Children and Adolescents

20

General Adult Population

22

Older Adult Population

23

The Need for a Clinical Practice Guideline and Decisions

about Scope and Goals of the Clinical Practice Guideline

25

The APA Clinical Practice Guideline for the Treatment of the Problem 25

Guideline Purpose and Scope: What the Guideline Does

and Does Not Address

26

Process and Method

28

Vetting and Appointment of Members to the Depression Guideline

Development Panel

28

Conflicts of Interest

29

Scoping29

Comprehensive Search of the Professional Literature

29

Table 5: Summary of Systematic Reviews and Meta-Analyses Used for Each Age Group31

Strengths and Limitations of the Systematic Reviews and MetaAnalyses32

Characterizing the Study Samples Included in the Reviews

32

Defining Efficacy and Comparative Effectiveness

33

Evaluating the Evidence

34

External Review Process

36

Discussion of Clinical Recommendations

37

Children and Adolescents

37

General Adult Population

38

Older Adults

39

Considerations for Treatment Implementation

41

Importance of Informed Consent

41

Improving Access While Supporting Patient Culture, Values, and Preferences42

Table 6: Patients' Values and Preferences42

Adapting Treatment to Fit the Individual

43

Considering Patients' Diverse Backgrounds, Identities, and Comorbidities44

Generalizability of Treatments to Different Settings and Providers 44

Monitoring Engagement with Treatment

44

Contributions from Shared and Specific Factors

to Treatment Outcome

45

Enhancing Therapeutic Alliance and Other

Principles/Processes of Change

46

Change Principles

47

Change Mechanisms

47

Change Events

47

How the APA Clinical Practice Guideline Compares to Other

Clinical Practice Guidelines for Treatment of Depression

48

Challenges in Developing the Guideline

and Recommendations for Future Efforts

51

Considerations Regarding Guideline Scope

51

Implications of Alignment with the Institute of Medicine Standards 52

Limitations of Existing Treatment Research Literature

53

Need for a Clearer Taxonomy of Psychotherapies

55

Need for Rigorous Comparisons of Treatments

and Treatment Modality

56

Improving Methodology and Reporting in Treatment Studies

56

Testing Moderators and Mediators of Treatment Outcome

56

Funding Needs

57

Conclusion58

Conflicts of Interest

59

Author Disclosures

59

Developer61

Funding Source/Sponsor

61

Acknowledgments61

References62

APA|Guideline for the Treatment of Depression 1

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