No abstract

Depression affects over 300 million individuals worldwide and is responsible for most of the 800,000 annual suicides. Clinical practice guidelines (CPGs) for treatment of depression, founded on scientific evidence, are essential to improve patient care. However, economic and sociocultural factors may influence CPG elaboration, potentially leading to divergences in their recommendations. Consequently, we analyzed pharmacological recommendations for the treatment of depression from the most relevant CPGs. We included four CPGs with scores � 80% for Domain 3 (rigor of development) on the Appraisal of Guidelines for Research and Evaluation and two other commonly used CPGs. The recommendations, their strengths, and the level of evidence were extracted from each CPG by two independent researchers and grouped as follows: (1) general recommendations for the pharmacological treatment for depression (suicide risk, acute treatment, continuation and maintenance phases, and treatment discontinuation); (2) treatment of non-responsive or partially responsive patients; and (3) treatment for subtypes of depression (chronic, psychotic, catatonic, melancholic, seasonal, somatic, mixed, and atypical). Only 50% of CPGs included recommendations for the risk of suicide associated with pharmacotherapy. All CPGs included serotonin selective reuptake inhibitors (SSRIs) as first-line treatment; however, one CPG also included agomelatine, milnacipran, and mianserin as first-line alternatives. Recommendations for depression subtypes (catatonic, atypical, melancholic) were included in three CPGs. The strength of recommendation and level of evidence clearly differed among CPGs, especially regarding treatment augmentation strategies. We conclude that, although CPGs converged in some recommendations (e.g., SSRIs as first-line treatment), they diverged in cardinal topics including the absence of recommendations regarding the risk of suicide associated with pharmacotherapy. Consequently, the recommendations listed in a specific CPG should be followed with caution.

INTRODUÇÃONo século XX, com o aumento da eficiência da prevenção de doenças e atendimento médico, a expectativa de vida, menor que quarenta anos até a década de 1940, ultrapassou os sessenta e cinco anos (década de 1990) (WHO, 1997). Todavia, com o crescimento dos custos com equipamentos, materiais e medicamentos, surgiu a impossibilidade do acesso universal aos recursos e tecnologia moderna disponíveis (Crozara, 2001).Assim, visto que os medicamentos se apresentam como um dos fatores responsáveis pelos gastos com saú-de, a questão de sua utilização de modo adequado nunca esteve tão presente no cotidiano da população, nem foi tão discutida: segundo Nascimento (2003), o número de reportagens publicadas em jornais e revistas da grande imprensa escrita sobre medicamentos e saúde durante os anos 70, 80 e 90 foram 26, 135 e 250, respectivamente. É de conhecimento geral a necessidade de formulação e aplicação de política de medicamentos que favoreça a

Neck metastases and diseased margins of oral cavity carcinomas are the prognostic factors that can most impact the survival rate.