Brazilian Psychiatric Association Guidelines for pharmacological treatment of Major Depressive Disorder: An overview of systematic reviews and meta-analyses.
Marcelo Pinheiro Machado Adelino, Julia Diniz Grossi, Marcel Vella Nunes, Ives Cavalcante Passos, André R Brunoni, Antonio Geraldo Da Silva, Leonardo Baldaçara, Acioly Luiz Tavares De Lacerda
Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999) May 1, 2026 DOI: 10.47626/1516-4446-2026-4911 via PubMed
Summary
An overview of systematic reviews and meta-analyses on pharmacological treatments for major depressive disorder (MDD) was conducted to update Brazilian clinical guidelines. Forty studies were included. For acute treatment, selective serotonin reuptake inhibitors (SSRIs), venlafaxine, mirtazapine, and vortioxetine showed consistent evidence across efficacy and tolerability. For adjunctive treatment, atypical antipsychotics had the highest certainty of evidence, with short-term support for benzodiazepines. In treatment-resistant depression, ketamine, esketamine, and atypical antipsychotic augmentation showed moderate certainty for response outcomes. In the maintenance phase, SSRIs and SNRIs had the most consistent evidence for relapse prevention and acceptability. The findings support a hierarchy of pharmacological strategies across MDD stages, but implementation should consider local healthcare context and resource availability.
Study at a glance
| Characteristics | Overview of systematic reviews and meta-analyses Peer reviewed |
|---|---|
| Population | Adults with major depressive disorder |
| Key finding | SSRIs, venlafaxine, mirtazapine, and vortioxetine showed consistent evidence for acute treatment; atypical antipsychotics had the highest certainty for adjunctive treatment; ketamine, esketamine, and atypical antipsychotic augmentation showed moderate certainty for treatment-resistant depression; and SSRIs and SNRIs had the most consistent evidence for maintenance phase relapse prevention. |
Abstract
To synthesize evidence on pharmacological treatments for major depressive disorder (MDD) to inform updated Brazilian clinical guidelines. This overview included systematic reviews and meta-analyses published in the last 10 years, identified through MEDLINE, Cochrane Library, and SciELO. Eligible studies involved adults with MDD receiving pharmacological interventions. Risk of bias was assessed using ROBIS, methodological quality using AMSTAR 2, and certainty of evidence using the GRADE approach. Forty studies were included. In acute treatment, selective serotonin reuptake inhibitors (SSRIs), venlafaxine, mirtazapine, and vortioxetine showed consistent evidence across efficacy and tolerability outcomes. For adjunctive treatment, atypical antipsychotics demonstrated the highest certainty of evidence, with short-term support for benzodiazepines. In treatment-resistant depression, ketamine, esketamine, and atypical antipsychotic augmentation showed moderate certainty for response outcomes. In the maintenance phase, SSRIs and SNRIs were associated with the most consistent evidence for relapse prevention and acceptability. These findings support a hierarchy of pharmacological strategies across different stages of MDD. Although consistent with international guidelines, their implementation should consider local healthcare context and resource availability.