Comparison of guidelines for the treatment of unipolar depression: a focus on pharmacotherapy and neurostimulation

Objective: To determine the level of agreement across a set of evidence-based guidelines for management of the unipolar depressive disorders and with a focus on physical treatments.

Method: A literature search was undertaken using the terms 'depression', 'depressive' and 'guidelines', using PubMed, Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. Twelve national psychiatric or professional guideline-producing organizations were identified from the period 2007-2017, with guidelines qualitatively reviewed by two assessors.

Results: For major depressive disorder (MDD), there was general consensus to use an antidepressant (AD) in cases of greater severity, although disagreement on AD use in mild to moderate depression. There was some agreement on choice of AD class in first-line treatment recommendations, though great variability in second- and third-line management particularly in recommended augmentation and combined AD strategies. Electroconvulsive therapy was considered in all but one guideline, with other neurostimulation treatments being less consistently covered and with variable recommendations. Finally, there was low consistency in the management of dysthymia, persistent depressive disorder and treatment resistant depression.

Conclusion: Our review identifies varying levels of consistency in guideline recommendations. Strategies to improve reliability in guideline formulation should also improve their validity.