MacQueen Glenda, Santaguida Pasqualina, Keshavarz Homa, Jaworska Natalia, Levine Mitchell, Beyene Joseph, Raina Parminder
1 Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta.
2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario.
Can J Psychiatry. 2017 Jan;62(1):11-23. doi: 10.1177/0706743716664885. Epub 2016 Sep 24.
This systematic review critically evaluated clinical practice guidelines (CPGs) for treating adults with major depressive disorder, dysthymia, or subthreshold or minor depression for recommendations following inadequate response to first-line treatment with selective serotonin reuptake inhibitors (SSRIs).
Searches for CPGs (January 2004 to November 2014) in English included 7 bibliographic databases and grey literature sources using CPG and depression as the keywords. Two raters selected CPGs on depression with a national scope. Data extraction included definitions of adequate response and recommended treatment options. Two raters assessed quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.
From 46,908 citations, 3167 were screened at full text. From these 21 CPG were applicable to adults in primary care and outpatient settings. Five CPGs consider patients with dysthymia or subthreshold or minor depression. None provides recommendations for those who do not respond to first-line SSRI treatment. For adults with MDD, most CPGs do not define an "inadequate response" or provide specific suggestions regarding how to choose alternative medications when switching to an alternative antidepressant. There is variability between CPGs in recommending combination strategies. AGREE II ratings for stakeholder involvement in CPG development, editorial independence, and rigor of development are domains in which depression guidelines are often less robust.
About half of patients with depression require second-line treatment to achieve remission. Consistency and clarity in guidelines for second-line treatment of depression are therefore important for clinicians but lacking in most current guidelines. This may reflect a paucity of primary studies upon which to base conclusions.
本系统评价对治疗成人重度抑郁症、心境恶劣障碍或阈下或轻度抑郁症的临床实践指南（CPG）进行了严格评估，以获取关于选择性5-羟色胺再摄取抑制剂（SSRI）一线治疗反应不佳后的推荐建议。
2004年1月至2014年11月以英文检索CPG，检索范围包括7个书目数据库和灰色文献来源，检索词为CPG和抑郁症。两名评估者选择了具有全国范围的抑郁症CPG。数据提取包括充分反应的定义和推荐的治疗方案。两名评估者使用《研究与评价指南评估II》（AGREE II）工具评估质量。
从46908条引文中筛选出3167篇全文。其中21篇CPG适用于初级保健和门诊环境中的成人。5篇CPG考虑了心境恶劣障碍或阈下或轻度抑郁症患者。没有一篇为对一线SSRI治疗无反应的患者提供推荐建议。对于患有重度抑郁症的成人，大多数CPG未定义“反应不佳”，也未就改用其他抗抑郁药时如何选择替代药物提供具体建议。CPG在推荐联合策略方面存在差异。AGREE II对利益相关者参与CPG制定、编辑独立性和制定严谨性的评分是抑郁症指南通常不够完善的领域。
约一半的抑郁症患者需要二线治疗才能实现缓解。因此，抑郁症二线治疗指南的一致性和清晰度对临床医生很重要，但目前大多数指南都缺乏这一点。这可能反映了缺乏可作为结论依据的基础研究。
