1. American College of Physicians recommends cognitive behavioral therapy or second-generation antidepressants for adults with major depressive disorder
Doctors and Patients should discuss treatment benefits, harms, adverse effect profiles, costs, accessibility, and patient preferences when selecting a first-line and second-line treatment
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The American College of Physicians (ACP) has issued an update of its guideline with clinical recommendations for nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder (MDD). In the updated clinical guideline, ACP recommends the use of either cognitive behavioral therapy (CBT) or second-generation antidepressants (SGAs) as initial treatment in adults with moderate to severe MDD, and suggests the combination of both, as an alternate initial treatment option. The guideline and supporting evidence reviews are published in Annals of Internal Medicine.
ACP also suggests initiating CBT in adults with mild major depression. ACP stresses the importance of informed decision making when selecting treatment and taking patient preferences into account. In summary, ACP recommends:
Monotherapy with either CBT or an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (strong recommendation, moderate-certainty evidence).
Combination therapy with CBT and an SGA as initial treatment in patients in the acute phase of moderate to severe MDD (conditional recommendation; low certainty-evidence).
Monotherapy with CBT as initial treatment in patients in the acute phase of mild MDD (conditional recommendation; low-certainty evidence).
One of the following options for patients in the acute phase of moderate to severe MDD who did not respond to initial treatment with an adequate dose of an SGA:
switching to or augmenting with CBT (conditional recommendation; low-certainty evidence),
switching to a different SGA or augmenting with a second pharmacological treatment (see Clinical Considerations) (conditional recommendation; low-certainty evidence).
The informed decision on the options should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients’ specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), co-morbidities, concomitant medication use, and patient preferences
The guideline is based on an accompanying comparative effectiveness living systematic review and network meta-analysis, and on two additional rapid reviews on values and preferences and cost-effectiveness analyses completed by the ACP Center for Evidence Reviews at Cochrane Austria/University for Continuing Education Krems (Danube University Krems). ACP’s Clinical Guidelines Committee is planning to maintain this topic as a living guideline with literature surveillance and periodic updating of the systematic review and the clinical recommendations. An accompanying editorial from the University of Toronto, calls ACP’s guideline a step in the right direction with its focus on the patient's role in shared decision making around depression. However, the editorialists point to important gaps in the recommendations with regard to non-pharmaceutical approaches to treatment. The editorialists also suggest that physicians may need more information about helping patients safely discontinue medications without suffering from potentially severe withdrawal symptoms.
2. Both high- and low-intensity exercise therapy beneficial for knee osteoarthritis
Small increased benefits found for knee function in sports and recreation with high-dose therapy
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A randomized controlled trial comparing high- and low-dose exercise therapy for patients with knee osteoarthritis found that both types of exercise therapy produced similar outcomes in pain, function, and quality of life. High-dose therapy provided superior outcomes related to function in sports and recreation in the short term, with results subsiding after 6 months. The findings are published in Annals of Internal Medicine.
Knee osteoarthritis is associated with chronic pain, knee stiffness, decreased function, and reduced quality of life. The preferred treatment is exercise therapy, including medical exercise therapy, which consists of self-paced exercises set by the patient and a physiotherapist. The type, intensity, duration, and frequency of these exercises can be categorized as low- or high-dose. Studies of other patient populations with conditions including diabetes and cardiovascular disease have demonstrated positive dose-response relationships to exercise, but this is not true of musculoskeletal pain.
Using a superiority design, researchers from the Karolinska Institutet, Holten Institute, Sweden, and Norwegian University of Science and Technology, and Rosenborg Fysioterapiklinikk, Norway, randomly assigned 189 persons with knee osteoarthritis with pain and decreased function to either low- or high-dose exercise therapy to compare exercise dose response with regard to knee function, pain and quality of life. The researchers hypothesized that exercise at a higher dose would produce superior outcomes in this patient population. Results were measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS) biweekly for 3 months and then again at 6 and 12 months. At all follow-up periods, KOOS scores improved in both groups, findings that did not support the authors’ hypothesis. The only differences favoring high-dose exercise were in the domain of knee function during sports and recreation at the end of treatment and 6 months after the intervention and in the quality-of-life domain at 6 months. The authors note that high-dose treatment could be preferable to low-dose treatment in the long run for people who lead active lives. However, adherence could be an issue, as those in the low-dose group had nearly perfect adherence to the intervention, while the high-dose participants had a higher drop-out rate.
Media contacts: For an embargoed PDF, please contact Angela Collom at email@example.com. To speak with corresponding author, Wilhelmus Johannes Andreas Grooten, PhD, RPT, please email Björn Äng at Bjorn.Ang@regiondalarna.se.
Also new in this issue:
Second Identified Human Infection With the Avian Influenza Virus H10N3: A Case Report
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Annals of Internal Medicine
Method of Research
Subject of Research
Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians
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