Major Depressive Disorder (MDD) is defined by the experience of a depressed mood or anhedonia (a loss of interest or pleasure) persisting nearly all day, every day for at least two weeks, which distinguishes it from an occasional sad mood or lack of interest that lasts for a few hours or days. (1) Based on the severity of symptoms, functional impairment, and level of patient distress, MDD can be characterized as mild, moderate, or severe. In the United States, more than 20% of adults experience MDD in their lifetime. (2)
This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of major depressive disorder in adults.
Diagnostic Considerations for MDD in Adults
Is your patient experiencing five or more of the following, most days? One of the 5 must be depressed mood or anhedonia for at least 2 weeks
- Depressed mood
- Loss of interest or pleasure in all, or almost all, things they previously enjoyed (anhedonia)
- Loss of appetite
- Difficulty falling or staying asleep, or excessive sleep
- Loss of energy
- Psychomotor agitation or retardation
- Feeling guilty, worthlessness, hopelessness
- Trouble concentrating
- Suicidal ideation
Have the above symptoms negatively impacted the patient’s ability to function in important areas of life, such as in relationships, at work, at school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc)?
It’s important to note, that the above symptoms and experiences may also be attributable to an alternative disorder (such as persistent depressive disorder, postpartum depression, or bipolar disorder), a neurological cause, or due to the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining if MDD is the clinically indicated diagnosis.
For complete diagnostic criteria of Major Depressive Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787
| When documenting care, be sure to include the specific symptoms of MDD experienced by the patient and how they fit within the DSM-5 diagnostic criteria |
Symptom Screening and Monitoring
The Patient Health Questionnaire - 9 item (PHQ-9)(3) is a brief validated, patient self-report screening tool used to assess the frequency and severity of depressive symptoms. Routine use of this measure is foundational to providing effective care for individuals who experience depression, as it supports accurate diagnoses, identification of treatment plan goals based on symptom severity, and can guide effective clinical interventions. Please utilize this tool during all new intake visits to establish a baseline measurement and in your follow-up visits as a way to track progress.
| It may be helpful to draw labs to help rule out any medical causes of depression including thyroid issues or anemia. If the psychiatric provider feels this is necessary based on presentation and history, you can order this through AMD. If you have a Kaiser patient, please let psych support know what labs you wish to order for the patient. |
Evidence-Based Approaches to Treatment
The American Psychological Association (APA) recommends several evidence-based psychotherapy interventions for the treatment of MDD in adults. There is research that mild depression could be treated with psychotherapy alone. For patients who experience moderate to severe depressive symptoms, the use of antidepressants in addition to psychotherapy has demonstrated efficacy. (4)
Psychotherapy
Psychiatric providers are encouraged to become familiar with each of the different evidence-based approaches, as well as engage in shared decision-making with the patient to determine which intervention is right for each clinical situation.
- Cognitive-behavioral therapy (CBT) is the most studied psychotherapy for depression and has the largest weight of evidence for its efficacy.
- Interpersonal psychotherapy (IPT)
- Problem-solving therapy (PST)
Meta-analyses that compare the effectiveness of CBT, IPT, and PST indicate no large differences in effectiveness between these treatments.
Behavioral activation is an effective structured treatment approach that aims to increase enjoyable activities and adaptive behaviors while decreasing behaviors that increase the risk of depression or maintain it. Activities can fall into different categories, including (12):
- Pleasure activities: These activities increase joy or delight, such as hobbies, interests, play, socializing, or sensory experiences. Examples include relaxing activities like baths or massages, nature walks, mindful cooking, sports, games, creative projects, and learning or practicing a skill.
- Mastery activities: These activities involve developing skills and accomplishing things, such as work or sports.
- Emotional activities: These activities aim to experience or accept feelings.
- Mental activities: These activities challenge you to think about new ideas.
- Physical activities: These activities improve your physical health.
- Social activities: These activities connect you with others.
- Spiritual activities: These activities show your values.
Medication
The class of antidepressants includes SSRIs, SNRIs, SPARIs, and NDRIs, and are recommended as “first-line” medications for use in the treatment of depression. These medications regulate the neurotransmitters serotonin, norepinephrine, glutamate, GABA, and dopamine, which are involved in brain functions related to mood and behavior. There has been newer research that shows that these medications increase the density of synapses which is why they can take weeks to be effective.
Some examples of evidence-based effective medications include:
SSRIs
- Sertraline (Zoloft)
- Escitalopram (Lexapro)
SNRIs:
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor)
NDRIs
- Bupropion (Wellbutrin)
SPARIs
- Vilazodone (Viibryd)
Multimodal antidepressant
- Vortioxetine (Trintellix)
Alpha-2 Antagonist
- Mirtazapine (Remeron) - usually used as an adjunct
NMDA antagonist
- Dextromethorphan-Buproprion (Auvelity) - newest approved antidepressant for MDD
- Must check blood pressure on initiation and throughout treatment
- Contraindications of this medication include seizures, hx of eating disorders, and any regular alcohol/sedative usage.
- Should not be combined with other antidepressants
There are times when the psychiatric provider may need to treat treatment-resistant depression in which SSRIs, SNRIs, SPARIs, and Multimodal antidepressants are combined with other classes of medication including but not limited to:
- Bupropion, Mirtazapine, Abilify, Rexulti, Vraylar, Lamictal, Lithium, es-ketamine (Spravato), and Synthroid
Also, there are times when medications may not be enough for the patient in which TMS or ECT is considered.
**Benzodiazepines (such as diazepam and clonazepam) are generally not recommended for the treatment of depression due to their high potential for dependence as well as their limited long-term effectiveness.
Considerations of treatment in uncomplicated MDD include but are not limited to (11)
|
Factors to be considered in Treatment Choice include but are not limited to: (11)
|
Assessing Risk and Higher Level of Care Needs
The risk of suicide in individuals with major depression is about 20 times that of the general population. (5) Research has shown that feelings of hopelessness, worthlessness, delusionally depressive thoughts, anxiety, and sleep disturbances, directly and indirectly contribute to an increase in the risk of suicide attempts.
Particularly for patients who respond affirmatively to thoughts of suicide or self-harm on the PHQ-9 (Question #9) or any item on the C-SSRS (Columbia Suicide Severity Rating Scale) Screener, it is imperative that psychiatric providers engage in (and document) thorough risk assessment, completion of a safety plan and, if clinically indicated, referral for additional services (such as inpatient care, IOP, PHP, Group therapy).
What if my patient has passive SI and/or chronic SI?
There are times when patients will endorse passive SI and/or chronic SI. It is important to complete the C-SSRS to determine the risk level of the patient, if the patient is not a high risk with active SI, then we can engage the patient in the following ways
- The first step for a patient who is expressing passive and/or chronic SI is to identify protective factors and future orientation.
- Next, we should complete a safety plan in collaboration with the patient. We use the Stanley-Brown Safety Plan that can be found in the AMD note template. It is important to do this with the patient to engage them in their treatment.
- It is important to document that a safety plan was completed and patient agrees to safety
- Sometimes patients may struggle to answer questions on the safety plan including internal coping skills, people they can ask for help when/if a crisis occurs, and/or places that provide distraction.
- We can offer coping skills that may be of use i.e. deep breathing, coloring, music, grounding techniques, etc. See what the patient likes to do to help ease their emotions.
- Sometimes patients may not have people but have pets that they can go to when in a crisis
- It is important to assess SI at every follow-up visit as well as going over the safety plan to make adjustments, if needed.
- It may be that the patient would benefit from increased therapy sessions. We can collaborate with the therapists by asking the psych support team for their emails.
- We may want to see the patients more frequently than every month i.e. every 2 weeks until SI is stable.
- It is important to ask if the patient is using substances, if they are, it is important to talk about decreasing substance usage as this can increase impulsivity.
- If the patient does not have resources or support, it is helpful to connect them to Resources for People who Think About Suicide (and their supporters) | NAMI Massachusetts.
|
Rula’s team of care coordinators is available to support your patient in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC). Care coordination will assist in helping the patient get into IOP, PHP, Group therapy, etc. However, if your patient is an acute risk to self or others i.e. active SI with plan, intent, or means then please follow this protocol here. Please reach out to the RNs and Lead NPs to help you in this situation for additional support. |
Cultural Considerations
The expression of depressive symptoms is often influenced by cultural contexts, including perceptions of illness and symptoms (including their causes), social pressures and stigma, gender, and racial identification, what life experiences are considered typical in a particular cultural environment as well as how one is expected to respond or cope with those stimuli. In some cultures, depressive symptoms might not be expressed in words at all, but in the form of physical symptoms, such as headaches, backaches, or stomach discomfort. Some clients may feel their symptoms are better explained through a lens of religious or spiritual beliefs and values. (7) As a result, it is important to always consider the social and cultural contexts of a client's treatment needs as part of the diagnostic process.
“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.”(8)
Resources:
To learn more about children/adolescent treatment in MDD click here
References
-
Anxiety & Depression Association of America. https://adaa.org/resources-professionals/practice-guidelines-mdd
-
American College of Physicians. https://www.acpjournals.org/doi/10.7326/M22-2056
-
American Psychiatry Association https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
-
American Psychological Association. https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
-
American Psychological Association. https://www.apa.org/depression-guideline/adults
-
American Academy of Suicidology. https://www.cga.ct.gov/asaferconnecticut/tmy/0129/Some%20Facts%20About%20Suicide%20and%20Depression%20-%20Article.pdf
-
Mental Health Clinician. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213890/pdf/i2168-9709-8-6-275.pdf
-
Anxiety and Depression Association of America https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/influences-cultural-differences-diagnosis-and
-
Kaiser Permanente https://wa.kaiserpermanente.org/static/pdf/public/guidelines/depression.pdf
-
National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/
-
VaDOD Clinical Practice Guidelines
https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPG_ProviderSummary_Final_508_updated.pdf
12. NIH: Behavioral Activation for Depression
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061095/
Updated