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The clinical practice guideline statements contained in Depression in Primary Care were developed to assist both patients and primary care practitioners in the diagnosis of depressive conditions and the treatment of major depressive disorder. This guideline is an abbreviated version of a far larger Depression Guideline Report and is divided into two volumes: this one, Volume 2: Treatment of Major Depression, and its companion volume, Volume 1: Detection and Diagnosis. The Depression Guideline Report contains more than 3,500 relevant references.
Treatment of Major Depression systematically reviews the indications, contraindications, benefits, and harms of the four major treatments for major depressive disorder: medication, psychotherapy, combined medication and psychotherapy, and electroconvulsive therapy (ECT). It also makes brief reference to other less frequently used treatments and the special circumstances in which they may be appropriate. The guideline considers the three phases of treatment for major depressive disorder— acute, continuation, and maintenance—and the indications for each.
Major depressive disorder consists of one or more episodes of major depression with or without full recovery between episodes. The clinically depressed patient must suffer either a sustained sad mood or a significant loss of interest/pleasure plus associated criterion symptoms for a period of 2 weeks or more. Nearly all patients with major depressive disorder also report significant life stresses. Up to one in eight individuals may require treatment for depression during their lifetimes; up to 70 percent of psychiatric hospitalizations are associated with mood disorders. According to data obtained from a 1980 population base, the total number of cases of major depressive disorder among those 18 or older in a 6-month period would be 4.8 million; in addition, over 60 percent of suicides can be attributed to major depressive disorder.
Based on 1980 data, mood disorders account for more than 565,000 hospital admissions, 7.4 million hospital days, and 13 million physician visits annually. The total cost of mood disorders to society, including the indirect costs that result from lost productivity, is estimated to be $16 billion annually. In addition to economic costs, depression can carry great personal costs because of the social stigma associated with the diagnosis and treatment of a “mental” illness. This stigma likely plays a large role in patients’ reluctance to seek, accept, and adhere to treatment. Yet, when identified, depression can almost always be treated successfully, either with medication, psychotherapy, or a combination of the two. The potential savings to be derived from the appropriate treatment of people who suffer from depression are socially and economically significant.
The high prevalence of depression and the success of available treatments prompted these guidelines. The Depression Guideline Panel that prepared them is composed of experts from various mental health and primary care disciplines and a consumer representative, selected for their range and diversity of expertise. The guidelines are based on systematic l terature reviews commissioned by the a p net and conducted by experts in numerous areas relevent to de ressip on, with special a ttention to the clinical issues most pertinent to the diagnosis and treatment of depression in primary care. Guideline development also inluded and individuals. The guidelines have undergone peer review and field review with intended users in clinical sites to evaluate the document both conceptually and operationally.
In making its recommendations for interventions, the panel chose to focus on randomized controlled clinical trials as the highest level of credible evidence for treatment efficacy. Thus, where data are available, conclusions are virtually certain. Where evidence is either lacking or incomplete, this is noted: in these instances, either no guideline has been derived or options are provided, based on logical inference, available date, and panel consensus.
Because of space and time constraints, this guideline does not address the treamtment of children and adolescents, bipolar disorder, or depressive syptoms insufficient to meet the criteria for major depressived disorder. Development of guidelines in these areas would be fruitful ares for followup activities.
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