title: Systematic Review of Clinical Practice Guidelines for Failed Antidepressant Treatment Response in Major Depressive Disorder, Dysthymia, and Subthreshold Depression in Adults.
abstract: 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.
authors.affiliation: 1 Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta.
authors.forename: Glenda
authors.initials: G
authors.lastname: MacQueen
authors.affiliation: 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario.
authors.forename: Pasqualina
authors.initials: P
authors.lastname: Santaguida
authors.affiliation: 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario.
authors.forename: Homa
authors.initials: H
authors.lastname: Keshavarz
authors.affiliation: 3 Department of Psychiatry, McGill University, Montreal, Quebec.
authors.forename: Natalia
authors.initials: N
authors.lastname: Jaworska
authors.affiliation: 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario.
authors.forename: Mitchell
authors.initials: M
authors.lastname: Levine
authors.affiliation: 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario.
authors.forename: Joseph
authors.initials: J
authors.lastname: Beyene
authors.affiliation: 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario.
authors.forename: Parminder
authors.initials: P
authors.lastname: Raina
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use*; D003863:Depression / Q000188:drug therapy*; D003865:Major Depressive Disorder / Q000188:drug therapy*; D061218:Depressive Disorder, Treatment-Resistant / Q000188:drug therapy*; D019263:Dysthymic Disorder / Q000188:drug therapy*; D006801:Humans; D017410:Practice Guidelines as Topic / Q000592:standards*
chemical_list: D000928:Antidepressive Agents
keywords: clinical practice guidelines; depression; inadequate response; systematic review