Management of first depression or generalized anxiety disorder episode in adults in primary care: A systematic metareview

Abstract

Context: General Practitioners (GPs) are the leading antidepressants prescribers in Europe and in France. Difficulties in implementing existing recommendations in daily practice have been described.

Objective: The objective of this study was to elaborate two algorithms to guide GPs in the patient management for a first major depressive disorder (MDD) or generalized anxiety disorder (GAD) episode in primary care.

Data sources: PubMed, Cochrane, and ISI Web of Science were explored using mainly the following keywords: depressive disorder, anxiety disorders, antidepressive agents or antidepressant. PubMed was explored using Medical Subject Headings (MeSH). Grey literature was also considered through the analysis of articles references, congress publications, guidelines and clinical practice recommendations.

Study selection: A systematic meta-review (overview of reviews) including systematic reviews, meta-analyses, guidelines and clinical practice recommendations, published from January 2002 to December 2015, was performed. The methodological and report qualities were assessed by the AGREE II, PRISMA checklist and R-AMSTAR grid. Each step was performed independently by two researchers following a process derived from the PRISMA statement. A narrative synthesis on main clinical data to collect before prescription in primary care, key information for patients, and recommended follow-up was realized.

Results: Thirty articles were included: 11 meta-analyses, 19 guidelines. For moderate to severe MDD, selective serotonin reuptake inhibitors (SSRI) should be associated with psychotherapy (cognitive behavioral therapy). For GAD, SSRI or CBT should be proposed if functional impairment is marked. Two algorithms to guide GPs for the management of MDD and or the management of GAD were created based on the data synthesis of this review. A GPs expert group discussed and adapted the algorithms to match with GPs expectancies.

Limits: Few articles dealt specifically with primary care practice, and only one meta-analysis of clinical trial on antidepressants in primary care was found.

Conclusions: From the best evidence-based data, we created two algorithms to guide GPs for the management of MDD and or the management of GAD. These algorithms will be implemented through a website available for GPs consultation.