Management of Major Depressive Disorder (MDD)

Clinical Practice Guideline

Management of Major Depressive Disorder (MDD)

May, 2009

VA/DoD Evidence Based Practice

Change of Information Subsequent to CPG Completion

The toll-free line for the Suicide Prevention Lifeline is: 1-800-273 TALK (8255)

X National Suicide Prevention Lifeline is referred to in this guideline in:

? Appendix C (Page 156)

VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF

MAJOR DEPRESSIVE DISORDER (MDD)

Department of Veterans Affairs Department of Defense Prepared by:

The Management of MDD Working Group

With support from: The Office of Quality and Performance, VA, Washington, DC

& Quality Management Directorate, United States Army MEDCOM

QUALIFYING STATEMENTS The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. Also, they should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in any particular clinical situation.

Version 2.0 ? 2008

VA/DoD Clinical Practice Guideline For Management of Major Depressive Disorder

Table of Contents

Page

Introduction

1

Guideline Update Working Group

5

Key Elements Addressed by the Guideline

6

Algorithms and Annotations

11

Appendices

Appendix A: Appendix B:

Severity

Appendix C: Appendix D:

Appendix E: Appendix F: Appendix G:

Guideline Development Process Screening and Assessment Instruments B-1. Quick Guide to the Patient Health Questionnaire (PHQ) B-2. Example of Diagnosing MDD & Calculating PHQ-9 Depression

B-3. PHQ-9 Scores and Proposed Treatment Actions B-4. Nine Symptom Checklist (PHQ-9) Suicidality Pharmacotherapy D-1. Antidepressant Dosing and Monitoring D-2. Antidepressant Adverse Drug Effects: Receptor Affinities and

Relative Comparisons D-3. Drug-Drug Interaction Participant List Acronym List Bibliography

Tables

page

Table 1. Diagnosis of MDD (DSM-IV-TR Criteria, 2000)

15

Table 2. Classification of MDD Symptoms Severity

17

Table 3. Medication-induced Depression or Depressive Symptoms

35

Table 4. Pathobiologies Related to Depression

37

Table 6. Diagnostic Nomenclature for Clinical Depressive Conditions

42

Table 7. Symptom Severity Classification

46

Table 8. Treatment Strategies

51

Table 9. Treatment Response and Follow-up

80

Table of Contents - Page 1

VA/DoD Clinical Practice Guideline For Management of Major Depressive Disorder

Introduction

The Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD) was developed under the auspices of the Veterans Health Administration (VHA) and the Department of Defense (DoD) pursuant to directives from the Department of Veterans Affairs (VA). VHA and DoD define clinical practice guidelines as:

"Recommendations for the performance or exclusion of specific procedures or services derived through a rigorous methodological approach that includes:

? Determination of appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction; and

? Literature review to determine the strength of the evidence in relation to these criteria."

The intent of the guideline is to:

? Reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes

? Provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with MDD

? Identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines.

Major Depressive Disorder (MDD) Depression is a major cause of disability worldwide. Evidence for the effectiveness of various pharmacological and psychological treatments is abundant, yet outcomes are often disappointing. This may reflect poor patient understanding of the illness, poor adherence to treatment or inadequate systems to support high quality care. Given the low detection and recognition rates, it is essential that primary care and mental health practitioners have the required skills to assess patients with depression, their social circumstances and relationships, and the risk they may pose to themselves and to others. This is especially important in view of the fact that depression is associated with an increased suicide rate, a strong tendency for recurrence and high personal and social costs. The effective assessment of a patient, including risk assessment, and the subsequent coordination of the patient's care, is likely to improve outcomes and should therefore be comprehensive.

? Depression is a major cause of impaired quality of life, reduced productivity, and increased mortality. o Social difficulties are common (e.g. social stigma, loss of employment, marital break-up). o Associated problems, such as anxiety symptoms and substance misuse, may cause further disability.

? People with depression are at increased risk of suicide. Mortality from suicide is reported to be as high as 15% among people hospitalized for severe depression. In primary care populations, the prevalence of suicidal ideation is approximately 20-30% among depressed patients, but serious suicide attempts (7/10,000) and completed suicides (4/10,000 ) are relatively infrequent [Simon GE, 2006]

Introduction - Page 1

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