Quality Management Information for Providers
Clinical Practice Guideline
Major Depressive Disorder
Member Information
Summary Form
Practice Guideline for the Treatment of Patients
with Major Depressive Disorder (Revision)
American Psychiatric Association
Major depressive disorder is a real illness that many people experience. Some symptoms of depression are depressed mood, loss of interest or pleasure, changes in appetite, changes in sleep pattern, fatigue or loss of energy, feelings of worthlessness or guilt, and inability to make decisions or concentrate. Significant progress has been made in the understanding of the disorder and its treatment. Depression may begin at any age but usually appears in the late 20's. The length of a depression is variable and can be decreased with treatment. Without treatment, depression can last six months or longer.
Some individuals will also have manic episodes. A definition of mania is excess energy with little need for sleep. A manic person often increases activities like shopping, cleaning, gambling, or walking. Persons with both depression and mania will have a diagnosis of bipolar disorder.
Studies indicate that people who experience one episode of depression have a 50% to 85% greater chance of experiencing another episode. The next episode is usually within two to three years. There can be many years between each depression experience. Other individuals may have clusters. At times, the frequency can increase with age. The pattern of depression can also follow the seasons. The symptoms may begin and end at the same time each year. In this part of the world, symptoms typically appear in October or November and leave between February and April. Between each depression, life usually returns to normal. Only 20% to 35% of the cases experience on going symptoms. A family history of recurrent major depressive disorder increases the possibility that a person's own illness will be recurrent and will not fully recover between episodes.
In addition to a family history, there are other demographic and psychosocial variables which can impact the identification and treatment of depression. Major depressive disorder may follow a significant life event such as the loss of a loved one. Bereavement is considered a severe stressor and often includes depressive signs and symptoms. Family distress can predispose an individual to depression and hinder the response to treatment. Cultural differences such as a language barrier may also hinder accurate assessment. Symptoms may vary between cultures. Both ethnicity and gender can impact on responses to medications. There are also generational differences in presentation. Small children often have behavioral problems while adolescents may present with somatic complaints, poor grades in school, and rebelliousness. Symptoms of depression in older age often involve more cognitive, sleep, appetite, and energy disturbance. The elderly complain less and may be misdiagnosed with physical illness, dementia, or as simply getting older.
There are many complications related to depression. Major depressive disorder can result in suicide or other violent acts. It can also cause marital, parental, social, and employment problems. The family and friends of the individual may also experience distress. Depression often interferes with personal relationships and decreases the ability to parent. Work attendance and quality often suffer and could lead to unemployment. Major depressive disorder may also complicate recovery from medical illnesses.
Treatments are both needed and available. Treatment begins with an evaluation. The evaluation compares the symptoms of the individual to the definition in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) to determine the diagnosis. A physical is important to determine if medical problems including the effects of drugs and alcohol are causing or contributing to the depression. The provider will make treatment suggestions after completing the evaluation. Treatment options include medication, counseling, and electroconvulsive therapy (ECT). Symptoms and individual preference will direct the treatment choice.
A single type or combination of treatments may be used. Research shows that the use of psychotherapy and medication has better results than a single modality alone. Recent studies indicate that adding therapy for persons who only experiences a partial response to medication may be beneficial and prevent relapse. If more than one clinician is providing care, communication is important. The clinicians should have regular contact with each other and the individual in treatment. The sharing of information will help guide treatment decisions. It is also important to keep appointments and take medications as directed for treatment to be successful.
TREATMENT
Medication
Psychiatrists and other medical doctors prescribe medication. Medication is often the treatment of choice for severe symptoms. Severe sleep and appetite disturbance, agitation, or if medication helped in the past are reasons to think about medication. Food and Drug Administration (FDA) approved medications are 50% to 75% effective. Individuals can respond differently to some medications. The doctor will consider the individual's symptoms, side effects, research results, cost, individual preference, and previous response of the individual or family member when choosing a medication.
Medications are typically started at a lower dose and increased over a period of a few weeks. The physician will give instruction on how to take the medication, potential side-effects, and actions to take in case of emergency. It will take two to four weeks for the medication to be helpful. If there is little improvement after four to eight weeks, a change may be considered. The doctor may increase the dose, change the time of day it is taken, or consider a different type of medication. Some types of medications need two to five weeks before starting a new one. Others will need to be decreased a little at a time. It is important not to stop medications without consulting the prescribing physician. Information on specific medications is readily available from your physician.
The visits to the doctor's office may be only a few weeks apart at first. There is a need to monitor closely for improvement and side-effects. The appointments usually decrease over time as symptoms decrease. Medications are often continued to prevent relapse for at least 16 - 20 weeks after remission. Once stable, visits can be two to four times per year. Medication can be used on an on-going basis when there is a high risk for relapse. Risk factors are identified as a diagnosis of an additional psychiatric illness, prior history of multiple depressive episodes, continued symptoms after recovery from an episode, and the presence of a chronic medical condition.
These risk factors are also taken into consideration when the decision is made to discontinue treatment. Again, the psychiatrist may decide to decrease the medication over several weeks. During this process the doctor will monitor for relapse symptoms and there will be decreased risk for discontinuation syndrome. This syndrome can be mistaken for relapse because the symptoms are similar to depressive symptoms. Once the decision is made to leave treatment, it is important to discuss these risks and identify the early signs of relapse. The identification of relapse signs and symptoms are important so the individual can seek treatment early to potentially avoid a full depressive episode.
Psychotherapy
Psychotherapy alone may be considered for persons with mild to moderate depressive symptoms with significant psychosocial stressors or interpersonal conflicts. Therapy may be considered as an initial treatment in the case of pregnancy, breast feeding, or the desire to become pregnant. The type of therapeutic approach is largely based on individual preference.
Cognitive behavioral therapy is based on the belief that irrational beliefs and distorted attitudes about the self, environment, and the future contribute to depression. The goal of therapy is to challenge and change these beliefs and attitudes. Results from studies suggest that cognitive behavioral therapy may be more effective than other types of therapy.
Behavior therapy is based on behavior and social learning theory. Techniques include activity scheduling, self-control therapy, social skills training, and problem solving. There have been relatively few studies conducted on the efficacy of behavior therapy but it appears to be comparable to other types of therapy. A positive response to behavior therapy may be more likely with less severe depressive symptoms.
Interpersonal therapy focuses on factors that may impact on depression such as losses, social isolation, poor social skills, and life transitions. The goal is to facilitate mourning and life transitions, overcome social skill deficits, and develop social supports. Interpersonal therapy has been proposed to be more effective than cognitive behavior therapy for depressed persons with obsessive personality traits and single persons living alone.
Marital and family therapy includes the family in the treatment of the individual with depression. Family problems are commonly related to depression. Such problems can be a consequence of depression or increase vulnerability to depression and can slow recovery. The techniques that have been developed include behavioral approaches, psychoeducation, and strategic therapy. Two of 17 studies show that marital therapy is effective in reducing depressive symptoms and relapse risk. Another showed that a greater portion of persons with marital distress responded to marital therapy than cognitive therapy. This same study showed that individuals without marital conflict responded better to cognitive therapy than marital therapy. There is also documented research that both marital and cognitive therapy are equally as effective with the presence of marital discord.
Group therapy has been shown to be effective in the treatment of major depression when using a cognitive behavioral or interpersonal approach. Research related to the effectiveness of group therapy versus individual therapy have not been specific to persons with depression. Supportive group therapy has been suggested to be helpful in the treatment of major depression. Self-help support groups lead by nonprofessionals have not been studied for efficacy. The possibility remains that self-help support groups may be beneficial by increasing the support network and self-esteem of the participants.
Electroconvulsive Therapy (ECT)
ECT is indicated for persons with major depressive disorder experiencing severe symptoms, functional impairment, and have had a poor response to medication. It is also recommended for individuals that are refusing food and have become nutritionally compromised, unable to take antidepressant medications due to a medical condition, or identified as having a history of a positive response to ECT. It is found to be 80% to 90% effective in individuals with major depression. Medication-resistant persons show at least a 50% satisfactory response.
ECT is a procedure during which electricity briefly stimulates the brain causing a seizure. It is given under general anesthesia and medication. The anesthesia causes a loss of sensation and consciousness and the medication relaxes the muscles to eliminate body movement during the procedure. The duration of the seizure is typically 15 to 25 seconds. The electrical stimulation is believed to cause changes in the chemistry of the brain that are beneficial to the depressed individual.
Although identified as a generally safe treatment, ECT does have side effects. The chief side effects are cognitive, including confusion and memory impairment. It is difficult to separate these side effects from the actual depressive symptoms. They are typically resolved in a few weeks. The risks of mortality are not higher than those associated with anesthesia.
The course of treatment is individualized depending on the response to treatment. The person should reach full recovery or a plateau. Generally 6 to 12 treatments are required to achieve the desired result. The treatments are typically administered every other day. After ECT is complete, the individual should be maintained on antidepressant medication or lithium. Medication resistant individuals may require maintenance ECT treatment.
St. John's wort
St. Johns wort is a plant product with antidepressant properties. It is not FDA approved, although studies continue. This results in a lack of preparation standards for ingredients, composition, and potency. Limited trials have indicated that it has greater benefit than placebo and is comparable to low-dose tricyclic medications for those with mild to moderate depression. However, the use of St. John's wort and MAOIs is not recommended. The safety of use with other antidepressants is unknown.
