TITLE:
Practice guideline for the treatment of
patients with major depressive disorder.
SOURCE(S):
Am J Psychiatry 2000 Apr;157(4 Suppl):1-45. [325 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another source.
RELEASE DATE:
1993 (revised 2000)
MAJOR RECOMMENDATIONS:
Each recommendation is identified as falling into one of three categories of
endorsement, by a bracketed Roman numeral following the statement. The three
categories represent varying levels of clinical confidence regarding the
efficacy of the treatment for the disorder and conditions described.
[I] indicates recommended with substantial clinical confidence.
[II] indicates recommended with moderate clinical confidence.
[III] indicates options that may be recommended on the basis of
individual circumstances.
Successful treatment of patients with major depressive disorder is
promoted by a thorough assessment of the patient [I]. Treatment consists of an
acute phase, during which remission is induced; a continuation phase, during
which remission is preserved; and a maintenance phase, during which the
susceptible patient is protected against the recurrence of subsequent major
depressive episodes. Psychiatrists initiating treatment for major depressive
disorder have at their disposal a number of medications, a variety of
psychotherapeutic approaches, electroconvulsive therapy (ECT), and other
treatment modalities (e.g., light therapy) that may be used alone or in
combination. The psychiatrist must determine the setting that will most likely
ensure the patient's safety as well as promote improvement in the patient's
condition [I].
A.
Psychiatric
Management
Psychiatric management consists of a broad array of interventions and
activities that should be instituted by psychiatrists for all patients with
major depressive disorder [I]. Regardless of the specific treatment modalities
selected, it is important to continue providing psychiatric management through
all phases of treatment. The specific components of psychiatric management that
must be addressed for all patients include performing a diagnostic evaluation,
evaluating safety of the patient and others, evaluating the level of functional
impairments, determining a treatment setting, establishing and maintaining a
therapeutic alliance, monitoring the patient's psychiatric status and safety,
providing education to patients and families, enhancing treatment adherence,
and working with patients to address early signs of relapse.
B.
Acute
Phase
1.
Choice of an
initial treatment modality
In the acute phase, in addition to psychiatric management, the
psychiatrist may choose between several initial treatment modalities, including
pharmacotherapy, psychotherapy, the combination of medications plus psychotherapy,
or electroconvulsive therapy [I]. Selection of an initial treatment modality
should be influenced by both clinical (e.g., severity of symptoms) and other
factors (e.g., patient preference).
a.
Antidepressant
medication
If preferred by the patient, antidepressant medications may be provided
as an initial primary treatment modality for mild major depressive disorder
[I]. Antidepressant medications should be provided for moderate to severe major
depressive disorder unless electroconvulsive therapy is planned [I]. A
combination of antipsychotic and antidepressant medications or
electroconvulsive therapy should be used for psychotic depression [I].
b.
Psychotherapy
A specific,
effective psychotherapy alone as an initial treatment modality may be
considered for patients with mild to moderate major depressive disorder [II].
Patient preference for psychotherapeutic approaches is an important factor that
should be considered in the decision. Clinical features that may suggest the
use of psychotherapeutic interventions include the presence of significant
psychosocial stressors, intrapsychic conflict, interpersonal difficulties, or a
comorbid axis II disorder [I].
c.
Psychotherapy
plus antidepressant medications
The combination of a specific effective psychotherapy and medication may
be a useful initial treatment choice for patients with psychosocial issues,
interpersonal problems, or a comorbid axis II disorder together with moderate
to severe major depressive disorder [I]. In addition, patients who have had a
history of only partial response to adequate trials of single treatment
modalities may benefit from combined treatment. Poor adherence with treatments
may also warrant combined treatment modalities.
d.
Electroconvulsive
therapy
Electroconvulsive therapy should be considered for patients with major
depressive disorder with a high degree of symptom severity and functional
impairment or for cases in which psychotic symptoms or catatonia are present
[I]. Electroconvulsive therapy may also be the treatment modality of choice for
patients in whom there is an urgent need for response, such as patients who are
suicidal or refusing food and nutritionally compromised [II].
2.
Choice of
specific pharmacologic treatment
Antidepressant medications that have been shown to be effective are
listed in the full-text guideline document -- see the table titled
"Commonly Used Antidepressant Medications" [II]. The effectiveness of
antidepressant medications is generally comparable between classes and within
classes of medications. Therefore, the initial selection of an antidepressant
medication will largely be based on the anticipated side effects, the safety or
tolerability of these side effects for individual patients, patient preference,
quantity and quality of clinical trial data regarding the medication, and its
cost (for more information, see Section V.A.1 of the original guideline
document) [I]. On the basis of these considerations, the following medications
are likely to be optimal for most patients: selective serotonin reuptake
inhibitors (SSRIs), desipramine, nortriptyline, bupropion, and venlafaxine. In
general, monoamine oxidase inhibitors (MAOIs) should be restricted to patients
who do not respond to other treatments because of their potential for serious
side effects and the necessity of dietary restrictions. Patients with major
depressive disorder with atypical features are one group for whom several
studies suggest monoamine oxidase inhibitors may be particularly effective;
however, in clinical practice, many psychiatrists start with selective
serotonin reuptake inhibitors in such patients because of the more favorable
adverse effect profile.
a.
Implementation
When pharmacotherapy is part of the treatment plan, it must be
integrated with the psychiatric management and any other treatments that are
being provided (e.g., psychotherapy) [I]. Once an antidepressant medication has
been selected, it can be started at the dose levels suggested in the full-text
guideline document -- see the table titled "Commonly Used Antidepressant
Medications" [I]. Titration to full therapeutic doses generally can be
accomplished over the initial week(s) of treatment but may vary depending on
the development of side effects, the patient's age, and the presence of
comorbid illnesses. Patients who have started taking an antidepressant
medication should be carefully monitored to assess their response to
pharmacotherapy as well as the emergence of side effects, clinical condition,
and safety [I] (see "Management of Medication Side Effects" in the
original guideline document.). Factors to consider in determining the frequency
of patient monitoring include the severity of illness, the patient's
cooperation with treatment, the availability of social supports, and the
presence of comorbid general medical problems. Visits should also be frequent
enough to monitor and address suicidality and to promote treatment adherence.
In practice, the frequency of monitoring during the acute phase of
pharmacotherapy can vary from once a week in routine cases to multiple times
per week in more complex cases.
b.
Failure to
respond
If at least moderate improvement is not observed following 6-8 weeks of
pharmacotherapy, a reappraisal of the treatment regimen should be conducted
[I]. Section II.B.2.b in the original guideline document reviews options for
adjusting the treatment regimen when necessary. Following any change in
treatment, the patient should continue to be closely monitored. If there is not
at least a moderate improvement in major depressive disorder symptoms after an
additional 6-8 weeks of treatment, the psychiatrist should conduct another
thorough review. An algorithm depicting the sequence of subsequent steps that
can be taken for patients who fail to respond fully to treatment is provided in
the full-text guideline document --see "Acute Phase Treatment of Major
Depressive Disorder."
3.
Choice of
specific psychotherapy
Cognitive behavioral therapy and interpersonal therapy are the
psychotherapeutic approaches that have the best documented efficacy in the
literature for the specific treatment of major depressive disorder, although
rigorous studies evaluating the efficacy of psychodynamic psychotherapy have
not been published [II]. When psychodynamic psychotherapy is used as a specific
treatment, in addition to symptom relief, it is frequently associated with
broader long-term goals. Patient preference and the availability of clinicians
with appropriate training and expertise in the specific approach are also
factors in the choice of a particular form of psychotherapy.
a.
Implementation
When psychotherapy is part of the treatment plan, it must be integrated
with the psychiatric management and any other treatments that are being
provided (e.g., medication treatment) [I]. The optimal frequency of psychotherapy
has not been rigorously studied in controlled trials. The psychiatrist should
take into account multiple factors when determining the frequency for
individual patients, including the specific type and goals of psychotherapy,
the frequency necessary to create and maintain a therapeutic relationship, the
frequency of visits required to ensure treatment adherence, and the frequency
necessary to monitor and address suicidality. The frequency of outpatient
visits during the acute phase generally varies from once a week in routine
cases to as often as several times a week. Regardless of the type of
psychotherapy selected, the patient's response to treatment should be carefully
monitored [I].
If more than one clinician is involved in providing the care, it is essential
that all treating clinicians have sufficient ongoing contact with the patient
and with each other to ensure that relevant information is available to guide
treatment decisions [I].
b.
Failure to
respond
If after 4-8 weeks of treatment at least a moderate improvement is not
observed, then a thorough review and reappraisal of the diagnosis, complicating
conditions and issues, and treatment plan should be conducted [I]. Figure 3 and
Section II.B.3.b. in the original guideline document review the options to
consider.
4.
Choice of
medications plus psychotherapy
In general, the same issues that influence the specific choice of
medication or psychotherapy when used alone should be considered when choosing
treatments for patients receiving combined modalities [I].
5.
Assessing the
adequacy of response
It is not uncommon for patients to have a substantial but incomplete
response in terms of symptom reduction or improvement in functioning during
acute phase treatments. It is important not to conclude the acute phase of
treatment for such patients, as a partial response is often associated with
poor functional outcomes. When patients are found to have not fully responded
to an acute phase treatment, a change in treatment should be considered as
outlined in the full-text guideline document -- see "Acute Phase Treatment
of Major Depressive Disorder" [II].
C.
Continuation
Phase
During the 16-20 weeks following remission, patients who have been
treated with antidepressant medications in the acute phase should be maintained
on these agents to prevent relapse [I]. In general, the dose used in the acute
phase is also used in the continuation phase. Although there has been less
study of the use of psychotherapy in the continuation phase to prevent relapse,
there is growing evidence to support the use of a specific effective
psychotherapy during the continuation phase [I]. Use of electroconvulsive
therapy in the continuation phase has received little formal study but may be
useful in patients for whom medication or psychotherapy has not been effective
in maintaining stability during the continuation phase [II]. The frequency of
visits must be determined by the patient's clinical condition as well as the
specific treatments being provided.
D.
Maintenance
Phase
Following the continuation phase, maintenance-phase treatment should be
considered for patients to prevent recurrences of major depressive disorder
[I]. Factors to consider are discussed in the full-text guideline document --
see the table titled "Considerations in the Decision to Use Maintenance
Treatment" -- and Section II.D of the original guideline document.
In general, the treatment that was effective in the acute and
continuation phases should be used in the maintenance phase [II]. In general,
the same full antidepressant medication doses are employed as were used in
prior phases of treatment; use of lower doses of antidepressant medication in
the maintenance phase has not been well studied. For cognitive behavioral therapy
and interpersonal therapy, maintenance phase treatments usually involve a
decreased frequency of visits (e.g., once a month). The frequency of visits in
the maintenance phase must be determined by the patient's clinical condition as
well as the specific treatments being provided. The frequency required could
range from as low as once every 2-3 months for stable patients who require only
psychiatric management and medication monitoring to as high as multiple times a
week for those in whom psychodynamic psychotherapy is being conducted.
E.
Discontinuation
of Active Treatment
The decision to discontinue active treatment should be based on the same
factors considered in the decision to initiate maintenance treatment, including
the probability of recurrence, the frequency and severity of past episodes, the
persistence of dysthymic symptoms after recovery, the presence of comorbid
disorders, and patient preferences [I]. In addition to the factors listed in
the full-text guideline document -- see the table titled "Considerations
in the Decision to Use Maintenance Treatment" and the table titled
"Risk Factors for Recurrence of Major Depressive Disorder"
-- patients and their psychiatrists should consider the patient's
response, in terms of both beneficial and adverse effects, to maintenance
treatments.
Edward
E. Rylander,M.D.
D.A.B.F.P. AND D.A.B.P.M.