DEPRESS

Guidelines for Clinical Care
Ambulatory
Depression
Depression Patient population. Adults with depressive disorders
Guideline Team
Objectives. (1) Improve the early recognition and treatment of depression in the primary care setting.
Team leaders (2) Improve patient‟s understanding of depression and its treatment.
Thomas L Schwenk, MD (3) Familiarize clinicians with appropriate treatment options, i.e. medications and psychotherapies.
Family Medicine
(4) Identify when referral is indicated.
Linda B Terrell, MD
General Medicine Key points
Team members Epidemiology
 Common. Depression is common, under-diagnosed, and under-treated.
R Van Harrison, PhD
Medical Education  Recurrent. Depression is frequently a recurrent/chronic disorder , with a 50% recurrence rate
after the first episode, 70% after the second, and 90% after the third.
Amy L Tremper, MD
 Care provider. Most depressed patients will receive most or all of their care through primary
Obstetrics & Gynecology
care physicians.
Marcia A Valenstein, MD
Psychiatry
Diagnosis. Depressed patients frequently present with somatic complaints to their primary care doctor
rather than complaining of depressed mood [C*].
Consultant Treatment. Mild major depression can be effectively treated with either medication or psychotherapy.
Jolene R Bostwick, PharmD Moderate to severe or chronic depression may require an approach combining medication and
College of Pharmacy psychotherapy [IIA*].
 Drug treatment. 40-50% of patients respond to the first antidepressant [A*]. No particular
antidepressant agent is superior to another in efficacy or time to response. Choice is often guided
by matching patients‟ symptoms to side effect profile, presence of medical and psychiatric co-
Updated
August 2011
morbidity, and prior response [IIA*]. Relative costs can also be considered because of the large
selection of antidepressants available in generic form. Patients treated with antidepressants
should be closely observed for possible worsening of depression or suicidality, especially at the
beginning of therapy or when the dose increases or decreases [IC*].
 Frequent initial visits. Patients require frequent visits early in treatment to assess response to
Ambulatory Clinical intervention, suicidal ideation, side effects, and psychosocial support systems [ID*].
Guidelines Oversight  Continuation therapy. Continuation therapy (9-12 months after acute symptoms resolve)
Connie J Standiford, MD
decreases the incidence of relapse of major depression [IA*]. Long-term maintenance or life-time
Grant M Greenberg, MD,
MHSA, MA drug therapy should be considered for selected patients based on their history of relapse and other
R Van Harrison, PhD clinical features [IIB*].
 Education/support. Patient education and support are essential. Social stigma and patient
reluctance to accept a diagnosis of depression or enter treatment continue to be a problem [IIC*].
Literature Search Service
* Strength of recommendation:
Taubman Medical Library I = generally should be performed; II = may be reasonable to perform; III = generally should not be performed.
Level of evidence supporting a diagnostic method or an intervention:
A = randomized controlled trials; B = controlled trials, no randomization; C = observational trials; D = opinion of expert panel
Clinical Background
For more information call Clinical Problem and However, depression is under-diagnosed and under
GUIDES: 734- 936-9771
Management Issues treated because of competing priorities in primary
care with the care of other chronic medical conditions,
Depression is a common disease with substantial patient stigma, and variability in physician skills and
© Regents of the morbidity and mortality. Approximately 5% of the interest.
University of Michigan population has major depression at any given time,
with men experiencing a lifetime risk of 7-12%; Diagnosing and treating depression in the primary
and women 20-25%. The direct and indirect costs care setting has many obstacles. The physician-
These guidelines should not be associated with major depressive disorder are
construed as including all patient encounter time is brief, making it difficult for
proper methods of care or significant, with an estimated cost of $59 billion in the physician to fully assess the patient for depressive
excluding other acceptable 2006, including direct patient care, time lost from
methods of care reasonably signs and symptoms. Depressed primary care patients
directed to obtaining the same work and potential income loss due to suicide. typically present with physical complaints, often not
results. The ultimate judgment Mortality rates by suicide are estimated to be as admitting to a depressed mood and are reluctant to
regarding any specific clinical
procedure or treatment must be
high as 15% among patients hospitalized for severe discuss depression. In one study, about two-thirds of
made by the physician in light depression. patients with depression presented only with somatic
of the circumstances presented
by the patient.
Most patients receive much or all of their care for (Continued on page 9)
major depression from their primary care physician.
1
Figure 1. Overview of Treatment for Depression
* Mild depression: Depression that meets criteria for MDD but without prominent vegetative symptoms, suicidal ideation,
or significant functional impairment.
**Moderate to severe depression: Depression with significant vegetative symptoms, hopelessness, or suicidal ideation.
* Levels of evidence for the most significant recommendations:

A = randomized controlled trials; B = controlled trials, no randomization; C = observational trials; D = opinion of expert panel.
2 UMHS Depression Guideline Update, August 2011
Table 1. Common Presentations of or Factors Associated with Depression in Primary Care
Multiple organ systems. Symptoms from multiple organ systems (particularly neurologic, gastrointestinal, and cardiac) that are
difficult if not impossible to ascribe to a single medical condition
Emotions. Patients who are emotionally flat, verbally withdrawn or tearful, or who are worried or are upset out of proportion to
the apparent severity of the problem
Sleep. Sleep disturbance, either with initiation or maintenance of sleep
Medical visits. Frequent, often unscheduled, patient-initiated visits to the physician or the emergency room for unclear reasons
"Difficult". Patients labeled by the physician as “difficult” or a “problem”, as well as a sense of dysphoria by the physician
when seeing the patient
Dysfunction. Patients who have cognitive or emotional dysfunction i.e., forgetfulness, irritability and loss of motivation or
energy
Recurrence. Past history of similar depressive or anxious episodes, unspecified “breakdowns” or suicide attempts.
Family history. A family history of psychiatric disease, suicide, or abuse of any kind (sexual, physical, or substance)
Chronic pain syndromes. Irritable bowel syndrome, fibromyalgia, pelvic pain, migraines, etc.
Comorbid medical conditions. Diabetes, coronary artery disease, recent stroke, COPD, asthma, sickle cell disease, parents of
children with chronic medical conditions
Special conditions in women. Post-partum, post-induced or spontaneous abortion, or emotional, physical, or sexual abuse
Table 2. Depressive Symptoms and Diagnostic Criteria for Depressive Disorders
Core Depressive Symptoms
 Depressed mood  Diminished ability to concentrate, or indecisiveness

 Anhedonia or markedly diminished interest or pleasure in  Recurrent thoughts of death, recurrent suicidal ideation
all, or almost all, activities without a specific plan, a suicide attempt or a specific
 Significant unintentional weight loss or gain plan for committing suicide
Additional Dysthymic Symptoms (qualifying symptoms for
 Insomnia or hypersomnia
Dysthymic Disorder)
 Psychomotor agitation or retardation
 Poor appetite without weight change
 Fatigue or loss of energy
 Low self esteem
 Feelings of worthlessness or excessive or inappropriate
 Feelings of hopelessness
guilt
Diagnostic Category by Symptom Grouping
Diagnostic Category Number of Symptoms Duration
Major Depression > 5 depressive symptoms, one of which is > 2 weeks

depressed mood or anhedonia
Minor Depression1 2-4 depressive symptoms, one of which is > 2 weeks
depressed mood or anhedonia
Bipolar Disorder Periods of meeting criteria for MDD plus either > 2 weeks for depressive symptoms
periods with > 4 manic symptoms2 if patient has > 7days for manic symptoms, shorter
elevated mood, or > 5 manic symptoms if patient duration required if hospitalized
has irritable mood
Dysthymic Disorder 3-4 depressive or dysthymic symptoms > 2 years
Source: DSM-IV-TR American Psychiatric Association, 2000

1
Minor depression is not yet a full categorical diagnosis in the DSM-IV but is included as a research diagnostic category.
2
Manic symptoms include elevated or irritable mood, inflated self-esteem or grandiosity, decreased need for sleep, increased talking or
pressured speech, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity or
psychomotor agitation, and excessive involvement in pleasurable activities that may have a high potential for adverse consequences.

Table 3. Screening for Depression
Quick Screen
A quick way of screening patients for depression is to ask patients these two questions:
During the past month, have you often been bothered by:
1. Little interest or pleasure in doing things? Yes No
2. Feeling down, depressed or hopeless? Yes No
If the patient's response to both questions is "no", the screen is negative.

If the patient responded "yes" to either question, consider asking more detailed questions or using PHQ-9 patient questionnaire,
Appendix A.
Note: These two items are the PHQ-2. The PHQ-9 is described in more detail at the Pfizer website: http://www.phqscreeners.com/
Link to PHQ-9: http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf
Figure 2. Phases of Treatment for Major Depression
Adapted from: Kupfer DJ: Long-term treatment of depression. J Clin Psychiatry 1991: 52(Suppl):28-34.
Table 4. Information the Patient Needs to Know
Clearly communicate the following with patients:

Common. Depression is one of the most common illnesses treated by doctors and mid-level providers and as common as many
other chronic diseases, such as diabetes, asthma and arthritis.
Risk factors. Several factors in the family or past history are associated with depression, including:
• Gender (female) • First degree relative with depression • Drug or alcohol abuse
• Anxiety disorder • Eating disorder
• Major medical conditions, e.g., coronary artery disease, stroke, diabetes, COPD, chronic pain (back, abdomen, head, etc.).
Responsive. Depression is as responsive to treatment as are other major chronic diseases, but several visits and medication
adjustments / or psychotherapy trials may be required before full remission is achieved.
Delayed response. All antidepressant medications require several weeks to produce their full effects.
"Not tranquilizers." Antidepressant medications are neither “tranquilizers” nor addicting, although withdrawal syndromes
may exist, especially for agents with shorter half-lives.
Recurrence. Depression is frequently a recurrent condition.

Table 5. Matching Antidepressants to Patients: Selection Dosing & Cost (page 1 of 4)
Mechanisms of action Serotonin Selective Reuptake Inhibitorsa
Generic name citalopram escitalopram fluoxetine
(Brand Name) (Celexa) (Lexapro) (Prozac & Sarafem)
[No benefit over citalopram but
significantly higher cost]
Side effects and other attributes May be initially sedating or Negligible drug-drug Tends to produce more initial
used in patient selection initially increase alertness. interactions. nervousness and arousal than
Mild initial sedation is dose- other SSRIs.
dependent. May be least Very long half-life (7-15 days),
stimulating SSRI. Negligible so less likely to cause
drug-drug interactions. withdrawal on abrupt
Dose-dependently linked to discontinuation.
prolonged QT interval
Sexual dysfunction Common Common Common
Pregnancy b /Lactation c C, L3 C, L1 – may be safer than C, L2 – may be SSRI with
citalopram greatest risk
Selected important drug-drug Minimal inhibitor of CYP 2D6 Comparable to citalopram. Potent inhibitor of CYP 2D6
interactions d, e isoenzymes. Good choice for isoenzymes; decreases
medical /surgical patients tamoxifen efficacy
without severe renal
impairment.
Patient profile most likely to Patient with limited financial Elderly patient, patient with an Patient with limited financial
benefit resources, elderly patient, agitated depression, or patient resources, nonadherent or
patient with an agitated with GI distress /sensitivity. “forgetful” patient (i.e., used
depression, or patient with GI Claims of more rapid efficacy as a “depot” oral
distress / sensitivity. may be exaggerated. antidepressant); excessive
fatigue.
Patient profile least likely to Elderly patient with excessive Patients who have failed Patient on several medications
benefit sleep and apathy. citalopram. Elderly patient and/or frequent medication
with excessive sleep and changes anticipated.
apathy.
Available preparations & doses 10, 20, 40 mg tablets; 10 5 (unscored), 10, 20 mg scored 10,20,40 mg capsules; 10, 20
mg/5ml solution tablets. mg tabs; 20 mg/5ml solution
Usual dose, cost/mo. f; Max 20-40 mg/d $6 generic 15-20mg/d $106-$199 20-40 mg/d $4-$15 generic
dose, cost/mo f $105-$112 brand 40 mg/d $213 $191-$382 brand
80 mg/d $91 generic
$765 brand
Dosing for youthful, reasonable 20 mg P.O. Qam (or QHS if 10 mg/d P.O. Qam (or QHS if 20 mg P.O. Qam; increased
health sedating.) Titrate upward to sedating). May titrate to 20 doses may be given a.m. and
40 mg if no response after 6 mg/d if no response in 6 weeks. noon, if excessive arousal.
weeks. 20 mg/d failed to demonstrate Titrate upward if no response
benefit over 10 mg/d. in 6 weeks.
Dosing for frail, elderly (>60 5-10 mg P.O. Qam x 3 d, 10-20 5-10mg/d P.O. Qam (or Qpm if 10 mg P.O. every other a.m. for
years old), medically ill mg P.O. Qam x 3 d, etc. until sedating). Use with caution 3-4 days (i.e., two doses) then
desired initial dose. Max in severe renal impairment. similarly titrate upward to 20
recommended dose 20 mg/d. mg P.O. Qam.
Use with caution in severe
renal impairment.
Adapted by Jolene R Bostwick, PharmD from tables developed by David J. Knesper, M.D., University of Michigan, Department of Psychiatry.
Note: It is the responsibility of the treating physician to stay current with the psychopharmacology of antidepressants and to determine dosages
and drug interactions. All antidepressant medication labeling includes a black box warning for increased suicidality. Patients treated with
antidepressants should be closely observed for possible worsening of depression and suicidality, or unusual behavior, especially at the beginning
of therapy or with dosage changes.
(Footnotes continue)

Table 5. Matching Antidepressants to Patients: Selection Dosing and Cost (page 2 of 4)
Mechanisms of action Serotonin Selective Reuptake Inhibitorsa

Generic name paroxetine (generic available) paroxetine controlled release sertraline
(Brand Name) (Paxil) (Paxil CR) (Zoloft)
Side effects and other Tends to cause less agitation/ Initial nausea rate is less than Tends to initially increase alertness;
attributes used in patient insomnia (common with immediate release; otherwise patients with psychomotor
selection SSRIs); possesses some anti- side-effect profiles nearly retardation may benefit. Patients
cholinergic effects. identical. Somnolence and experience more GI distress
Somnolence and nausea is nausea are dose-related. Short (diarrhea) compared to other
dose-related. Short half-life, half-life, withdrawal effects SSRIs.
withdrawal effects common. common. Similar response
rate compared to immediate
release.
Sexual dysfunction Common, may be higher than Common Common
other SSRIs.
Pregnancy b /Lactation c D, L1 – Considered safe in D, L1 – Considered safe in C, L1 – A preferred SSRIs in
breastfeeding breastfeeding breastfeeding
Selected important drug- Potent inhibitor of CYP 2D6 Same as paroxetine immediate Moderate inhibitor of CYP 2D6
drug interactions d, e isoenzymes; decreases release. isoenzymes. Good choice for
tamoxifen efficacy medical /surgical patients.
Patient profile most likely Less likely to produce initial Less likely to produce initial Initial activation and increased
to benefit anxiety and/or insomnia. nausea than immediate alertness desired.
release. Nausea rate at 25
mg/d comparable to
escitalopram at 20 mg/d.
Patient profile least likely Patients who may require high Same as paroxetine immediate Patient sensitive to any of the typical
to benefit doses or elderly (who are more release. SSRI side-effects (e.g. increased
susceptible) are more prone to arousal, GI distress).
anticholinergic effects (e.g.
delirium). Half-life increased
by 170% in elderly.
Available preparations & 10,20,30,40 mg tabs; 10mg/5ml 12.5,25, 37.5 mg enteric-coated 25, 50, 100 mg tabs, 20 mg/ml
doses suspension tabs. solution (12% alcohol)
Usual dose, cost/mo. f; Max 20-40 mg/d $15-$20g generic 25-50 mg/d $120-239 75-150 mg/d $10-17 generic
dose, cost/mo f $116-$232 brand 62.5 mg/d $243 $ 228-341 brand
60 mg/d $120 generic 200 mg/d $187 generic
$348 brand $ 228 brand
Dosing for youthful, 20 mg P.O. Qam; titrate by 10 25 mg/d P.O. Qam ; may titrate 50 mg P.O. Qam; titrate weekly
reasonable health mg/week. Give QHS if dose by 12.5 mg increments based on response up to 200 mg/d.
sedating. weekly up to 62.5 mg/d if no
response in 6 weeks.
Dosing for frail, elderly, 10 mg P.O. Qam Upon titration, 12.5 mg/d P.O. Qam. May 12.5-25 mg P.O. Qam. Titrate to
medically ill dosage should not exceed 40 increase dose up to 50 mg/d. desired effect. Lower doses
mg/d. generally required.
a
If a patient fails one SSRI class of antidepressants, another SSRI may tried (don't try a third SSRI). During the initial phase of treatment all SSRI's
may produce one or all of the following: Increased arousal (agitation), insomnia, nausea, diarrhea (due to increased GI motility), initial weight
loss and subsequent weight gain after about 6 months, sexual dysfunction. Uncommon adverse events include: akathisia (restlessness),
psychomotor slowing, mild parkinsonism; apathy.
b c
Pregnancy Risk Category: Lactation Risk:
A: Controlled studies show that the possibility of fetal harm is remote L1: Low levels detected in milk
B: No controlled studies in pregnant women, but no fetal risk has been shown
C. Drugs should be given only if the patient benefit justifies the potential risk to the L2: Higher levels detected in milk
fetus
D. Positive evidence of human fetal risk, but benefits may be acceptable sometimes L3: Low levels of drug detected in infants
X. Contraindicated in women who are or may become pregnant. From LactMed Database, U.S. National Library of
Medicine. Bethesda, MD.
d
Do not combine any of the listed antidepressants with monoamine oxidase inhibitors (MAOIs) (ex. selegiline, tranylcypromine, phenelzine).
e
The following drug interaction databases are recommended: hanstenandhorn.com, http://medicine.iupui.edu/clinpharm/ddis/
f
Cost = Average wholesale price based -10% for brand products and Maximum Allowable Cost (MAC) + $3 for generics on 30-day supply,
Amerisource Bergen item Catalog 12/10 & Blue Cross Blue Shield of Michigan Mac List, 11/10.

Mechanisms of Action Serotonin/Norepinephrine Reuptake Inhibitor

Generic name venlafaxine extended release desvenlafaxine extended duloxetine
(Brand Name) (Effexor XR) release (Pristiq) (Cymbalta)
[No benefit over venlafaxine but
significantly higher cost]
Side effects and other Similar to those common to all Major metabolite of Similar to SSRIs and venlafaxine;
attributes used in patient SSRIs with more nausea. BP venlafaxine with similar side nausea (dose-dependent) and
selection increases, including sustained effect profile. Side effects constipation most troublesome,
hypertension, are dose- are similar to those common but, unlike venlafaxine, does not
dependent, with a linear dose- to all SSRIs with more appear to produce sustained
response. Primarily functions as nausea. Can increase blood hypertension. NOT TO BE
an SSRI at doses below 225 mg. pressure as well as PRESCRIBED if concurrent
Should not be combined with triglycerides and LDL heavy alcohol use and/or
other SSRIs. High rates of cholesterol. evidence of chronic liver
withdrawal. Side effect profile disease.
similar to immediate release.
Sexual dysfunction Less common Less common Less common
Pregnancy b /Lactation c C, L3 C, L3 C, L1
Selected important drug- Usually clinically insignificant due Usually clinically insignificant. Major substrate of CYP1A2 &
drug interactions d, e to low protein binding and weak Metabolized via conjugation CYP2D6 – inhibitors
inhibition of P450 enzymes. and to a minor extent by (quinolones,
CYP3A4. Strong CYP3A4 fluvoxamine/fluoxetine,
inhibitors (ketoconazole, paroxetine, quinidine) may
ritonavir, clarithromycin, increase levels. Also, CYP1A2
nefazodone) may increase inducers may decrease effect
levels. (modafinil, omeprazole).
Duloxetine is a moderate
inhibitor of CYP2D6.
Patient profile most likely Patients who fail an SSRI or with Same as venlafaxine. Patient with depression and
to benefit menopausal symptoms or chronic pain (effects on pain are
comorbid anxiety. dose-dependent). Patient failing
At higher doses (e.g., at least 225 an SSRI trial.
mg), patients with chronic pain.
Patient profile least likely Patients with unstable BP and Same as venlafaxine. Since Patient with preexisting liver
to benefit perhaps, those who are GI desvenlafaxine and disease and/or heavy alcohol
sensitive. A clinically venlafaxine are equally use; preexisting or treatment-
significant withdrawal syndrome active and potent, patients related anorexia, constipation,
requires slow taper. who fail venlafaxine would and/or other GI symptoms.
not likely respond to
desvenlafaxine.
Available preparations & 37.5, 75, 150, 225 mg capsules 50, 100 mg tablets 20, 30, 60 mg capsules.
doses (immediate release tablets also No additional benefit in doses
available) > 50mg.
Usual dose, cost/mo. f; Max 150-225 mg/day , $68-89 generic 50 mg/day $135 40 mg/day $277
dose, cost/mo f $153-$292 brand 60 mg/day $503
375-450 mg/day$161-204 generic
$381-$390 brand
Dosing for youthful, Every 3-7 day titrate upward, 50 mg/d; higher doses do not Starting dose 20 mg BID, may
reasonable health starting at 37.5 mg to reduce risk increase efficacy and are increase to 30 mg BID (or 60
of nausea; dose may be titrated associated with higher mg QHS). If nausea is
to 225 mg/d. Reduce dose 50% discontinuation rates and problematic, start with 20 or 30
for hepatic impairment; 25-50% adverse effects. In patients mg once daily. Usual dose for
for renal. with ESRD or severe renal pain is 60 mg/day. Doses of 120
impairment, use 50 mg every mg/day appear safe but efficacy
other day. data fail to justify this dose.
Dosing for frail, elderly, Every 7 day titrate upward, 50 mg/d unless severe renal Start at 20 mg with breakfast;
medically ill starting at 37.5 mg; initial trial at impairment is present, then titrate upward every 3-7 days
150 mg/d. Reduce dose 50% for reduce dose to 50 mg every until 40-60 mg/d in divided
hepatic impairment; 25% for other day. doses. If tolerated, may
renal. administer in a single dose. Do
not administer in hepatic
insufficiency or severe renal
impairment (CrCl < 30 mL/min)
.

Mechanisms of action Serotonin & alpha-2 receptor blocker Norepinephrine/Dopamine Reuptake Inhibitor
(increases release of serotonin & norepinephrine)
Generic name mirtazapine bupropion
(Brand Name) (Remeron) (Wellbutrin SR, Wellbutrin XL, Wellbutrin IR,
Aplenzin, Budeprion)
Side effects and other Produces sleep; lower doses produce more sleep Least likely to switch patient to mania. Most activating
attributes used in patient than higher doses. Weight gain may be > 10 antidepressant available. DO NOT USE if history of
selection lbs. and is greater than with other newer seizure, head trauma, bulimia (especially if current),
antidepressants. Has antiemetic properties anorexia or electrolyte disturbance. Use with caution in
(blocks 5HT3 receptor as does ondansetron/ patients with a history of substance abuse.
Zofran). Rare neutropenia and agranulocytosis.
Onset of action within 1-2 weeks may be faster
than some SSRIs, but response rates are
comparable at week 4.
Sexual dysfunction Unlikely Rare
Pregnancy b /Lactation c C, L1 C, L1
Selected important drug- Usually clinically insignificant due to extensive Metabolized primarily by CYP2B6. Drugs inhibiting
drug interactions d, e metabolism via CYP1A2 and 2D6. Does not CYP2B6 are not currently identified. Strong inhibitor of
appear to interfere with the metabolism of other CYP2D6.
drugs.
Patient profile most likely to The medically ill patient with weight loss, Depressed patients who are actually or potentially bipolar.
benefit insomnia and nausea. The apathetic, low energy patient. Patients motivated to
stop smoking. Helpful for ADHD i.
Patient profile least likely to The obese patient with fatigue and hypersomnia. Patients who are agitated, very anxious and/or panicky.
benefit Patients with neutropenia. Patients at risk for seizures and/or with history of head
trauma, substance abuse, eating disorder, or electrolyte
disturbance.
Available preparations & 7.5, 15, 30, 45 mg tablets; 15, 30, 45 mg unscored For SR: 100, 150, 200 mg coated tablet
doses orally disintegrating tablets (Remeron SolTab). For XL: 150, 300 mg coated tablet
For IR: 75, 100 mg tablets
Usual dose, cost/mo. f; Max 30-45 mg/d $9-$12 generic For SR: 300-400 mg/d $113-$120 generic
dose, cost/mo f $108-$128 brand (max 450 mg/d) $212-393 brand
60 mg/d $18 generic For XL: 300-450 mg/d $194-$450 brand
$255 brand (max dose 450 mg/d)
For IR: 200-450 mg/d $105-212 generic
(max dose 450 mg/d) $192-335 brand
Dosing for youthful, 7.5 (more sleep) to 15 mg (less sleep). May For SR: 150 mg with breakfast and before 5 pm; increase to
reasonable health titrate up to 45 mg QHS. Dose increases should 150 mg BID after 1 week. Maximum dose: 200 mg BID.
not be made more frequently than every 1-2 For XL: 150 mg with breakfast for 3 days, increase as
weeks. tolerated to 300-450 mg/d.
For IR: 100 mg BID, increase to TID after 3 days, max dose
450 mg/d in 3-4 divided doses.
DO NOT DOUBLE-UP MISSED DOSES.
Dosing for frail, elderly, 7.5 to 15 mg at night; increase to 30mg or 45 mg For SR: Every 3-4 day titrate upward, starting at 100 mg;
medically ill if no improvement. Reduce dose by 25-50% initial trial at 150 mg BID; last dose before 5 pm.
for hepatic or renal impairment. For XL: Every 5-7 days titrate upward, starting at 150 mg;
plateau at 300 mg for 2-3 weeks before advance to 450
mg.
For IR: Every 3-4 days titrate upward, starting at 50-100
mg/d, increasing by 50-100 mg, up to max of 300 mg/d.
DO NOT DOUBLE-UP MISSED DOSES.
i
“ADHD” means attention deficit hyperactivity disorder.

(continued from page 1) Treating primary disorders such as hypothyroidism is
important. Minimizing functional limitations from
complaints. Reimbursement restrictions can interfere with comorbid medical conditions is also important. However, in
comprehensive treatment. Other medical co-morbidities general, depression occurring with comorbid conditions
compete for time and attention by both physician and patient. should be treated according to its diagnostic criteria and
functional impact, irrespective of the presence of the
Rationale for Recommendations associated medical illness.
Bereavement. Grieving is a “normal” reaction to a major

Definitions
loss, such as the death of a close relative or friend. Patients
may exhibit many symptoms of MDD following such a
Specific criteria for diagnoses of depressive disorders are loss. However, individuals suffering from bereavement are
presented in Table 2. usually not preoccupied with ideas of worthlessness or guilt
and do not experience suicidal ideation. The duration of
Major depressive disorder (MDD). A severe form of symptoms varies, but generally symptoms remit or lessen
depression that is often accompanied by significant within a few months. Supportive counseling and education
functional impairment and increased health services use. usually suffices for treatment, with occasional use of short-
Major depressive disorder is the primary focus of these term medications for symptom control. Grief may be
treatment guidelines, as this disorder is common and has the prolonged beyond 6 months and more severe, and
largest evidence-base for treatment. Both psychotherapy distinguishing it from major depressive disorder may be
and pharmacotherapy have been shown to be effective difficult.
treatments for major depression, and may be used together.
Diagnosis of Depression
Dysthymia. A chronic, "smoldering" form of depression
with fewer, less severe depressive symptoms than MDD but Common presentations of depression in primary care.
with functional impairment that can sometimes equal the Depression is commonly found in patients who may present
impairment seen among patients with MDD. Although to primary care or subspecialty physicians with irritable
antidepressants are somewhat less efficacious in dysthymic bowel syndrome, fibromyalgia, chronic fatigue syndrome,
disorder than in MDD, a substantial proportion of patients or chronic pain such as headache, low back pain, and pelvic
will respond to antidepressants or structured pain. Patients with anxiety or depression may deny mood
psychotherapies. Patients with dysthymic disorder may or psychiatric symptoms because of social stigma or
have periods of time when they also meet criteria of MDD, because they truly do not experience mood symptoms.
often called “double depression”. Overall, symptom-sign mismatch (many seemingly severe
symptoms, a negative physical examination, and an
Minor depression. Minor forms of depression (less than 5 increasingly long list of normal laboratory tests) should
depressive symptoms or duration of symptoms of less than alert the clinician to a high likelihood of depression or
2 weeks) are common. Although minor depression anxiety. However, the clinician should maintain the usual
produces less functional impairment in affected individuals vigilance for undiagnosed medical disease. Intimate partner
than MDD or dysthymic disorder, because of its frequency, violence is associated with depression in pregnancy and
most work days that are missed in the US are attributable to should be considered in all women with depression.
this milder disorder. Specific treatments such as
antidepressants or psychotherapy may not be indicated as Assessing patients for clues that a psychiatric diagnosis
there are high rates of improvement among these may be present can be helpful (Tables 1-3). The DSM-IV
individuals with watchful waiting. criteria for the diagnosis of major depression are presented
in Table 2. In addition, consider the following:
Seasonal affective disorder (SAD). A seasonal form of
major depression with features similar to MDD but History. Establish the duration of illness, history of prior
occurring on a cyclical basis related to ambient light episodes, family history, history of prior manic or
deprivation during winter months. Both phototherapy and hypomanic episodes, substance abuse, and other comorbid
medications are frequently used. disorders. Patients will sometimes initially deny a prior
personal or family history of depression. On further
Mood disorder associated with a general medical questioning they will often admit to having a relative who
condition. A form of depression with features similar to was „moody‟ or had to „take a rest‟ for several weeks. They
MDD but is part of the physiological sequelae of a major may relate having to drop out of school for a time because
medical condition such as cancer, stroke, myocardial of difficulty coping. It is important to screen for bipolar
infarction, major trauma, or neurodegenerative disorders disorder in any patient presenting with depression.
such as Alzheimer’s disease. Perimenopausal mood Traditional teaching has suggested that as many as 30-50%
disorder is addressed in Table 8 (following guideline text). of patients with underlying bipolar disorder will develop
Mood disorders may infrequently arise from the use of acute mania when started on antidepressant
certain medications and, more frequently, from substance pharmacotherapy. However, switching to mania is more
abuse. among patients who have been hospitalized for depression,
rather than the typical depressed patient seen by most
primary care physicians. A focus on symptoms of
hypomania characteristic of Bipolar II disorder may be Treatment of Depression
helpful. Screen for concomitant anxiety disorders which
may occur in more than 50% of patients with depression. Figure 1 and Tables 4–8 summarize operational information
regarding treatment. Figure 1 outlines the overall process
Evaluation. Evaluate severity, suicidal tendencies and for monitoring, assessing, and possibly augmenting
psychotic features. If asked directly, patients are usually treatment. Principles concerning five general components of
very honest regarding suicidal thoughts, plans and treatment are discussed below.
intentions. Table 3 presents some quick screening • Supportive care
questions for depression. Consider using a self-rating scale • Pharmacotherapy
or direct questions to measure initial and subsequent • Psychotherapy
severity as the patient is treated. Several self-rating scales • Ongoing clinical assessment
are available. As an example, the Patient Health • Treatments for severe or refractory depression
Questionnaire (PHQ-9) and its scoring key are included at
the end of this guideline. Once a clinician thinks that that Comorbid psychiatric illnesses and other special
the likelihood of depression is sufficient to warrant the use situations. Patients with a Major Depressive Disorder
of a structured questionnaire, a questionnaire may not be frequently suffer from other psychiatric disorders and their
necessary for determining whether depression diagnostic treatment is influenced by the presence of these comorbid
criteria are met; however, these questionnaires may be conditions.
helpful in establishing a baseline for ongoing monitoring
and determining response to treatment. Table 7 describes common psychiatric comorbidities and
special treatment considerations. In addition, Table 8
Physical examination. Look for clues to chronic illnesses, presents diagnostic and treatment considerations for
hypothyroidism, and other comorbid illness as described patients in complicating circumstances, e.g., partner
previously. Fatigue is a common presenting complaint in violence, pregnancy. (Tables 7 and 8 are placed after the
depressed patients in primary care. Consider screening for guideline text.)
anemia, liver/renal dysfunction and thyroid disease if other
findings suggest possible risk. Many physicians will obtain Supportive care principles. The treatment of all patients
routine screening tests for chronic disease if the patient has diagnosed with major depression should include patient
not been seen previously or not had recent routine care. It education and exercise.
is often helpful to introduce the diagnosis of depression to
the patient as part of the differential diagnosis at the initial Patient education. Depression remains poorly understood by
visit. One can then see the patient back within 1-2 weeks to the general public. Patients are often reluctant to accept a
further discuss the diagnosis and treatment of depression. diagnosis of depression due to stigma, an underestimation of
its severity, or a view that depression is an expected
Laboratory testing. Laboratory tests have no routine value response to a life situation. Many patients attempt to deal
in the diagnosis of depression, beyond judicious use to rule with the symptoms alone, or seek care only from lay
out medical conditions that might cause the same counselors, pastoral counselors, friends or relatives.
symptoms. Adherence with treatment recommendations is often poor
because of the above factors. These attitudes and beliefs
General medical illnesses associated with depression. need to be countered by the physician who emphasizes the
Depression commonly coexists with certain medical severity of the disease, and the importance of its treatment
conditions, including myocardial infarction, stroke, cancer, (see Table 4).
major trauma, multiple sclerosis, Parkinson's Disease, or any
major new diagnosis, particularly if hospitalization is Exercise. Several small controlled clinical trials show that
involved. Depression can interfere with effective treatment regular physical exercise (2-3 times/week; either aerobic or
of the other conditions, delaying recovery and significantly anaerobic) is more effective than no treatment in relieving
increasing morbidity. Depressed patients are three times symptoms of depression. In at least two trials the outcome
more likely to be non-adherent with medical in the exercise group was comparable to that of
recommendations. Depression is a more powerful predictor psychotherapy at 12 weeks, at least for patients with mild
of mortality from myocardial infarction than physiological depression.
measures such as cardiac ejection fraction. Depression is
prevalent in patients with heart failure and is associated with Pharmacotherapy and psychotherapy comparisons. In
a poorer short-term prognosis. Major depressive disorder patients with mild to moderate depression, initial treatment
may occur in greater than 50% of patients after CVA and has may be with medication, psychotherapy or both as guided
been associated with impaired recovery and worsened by the patient's and physician's preferences. Medication is
mortality. Conversely, depression itself may be an frequently the first-line treatment for patients with more
independent risk factor for stroke and coronary heart disease . severe depression. In Level 2 of the STAR*D trial (see
Certain medications may be implicated in the cause of “Drug trials” below), cognitive therapy and medication had
depression as well, such as retinoids and interferon. similar remission rates although time to remission was
shorter in the medication group.
Pharmacotherapy principles. Table 5 provides practical

guidelines for matching first-line antidepressants to patients
as well as information on dosing and cost. The following
issues should also be taken into account when considering Rare case reports suggest the potential for a patient taking
pharmacotherapy. serotonergic antidepressants to develop a serotonin
syndrome (altered mental status, agitation, myoclonus,
Choice of agent. In selecting an agent, consider the hyperreflexia) with the concomitant use of buspirone,
following. dextromethorphan, tramadol, St. John's Wort, and the
• No superior agent. Several systematic reviews have triptan class of drugs (used for migraine headache).
not shown a clear cut difference amongst the second- However, the clinical significance of this risk is unclear and
generation antidepressants in efficacy or tolerability. probably extremely low with these combinations. There are
combinations, however, that do pose a greater threat.
• Previous success. Use what has worked for the patient
Specifically, when monoamine oxidase inhibitors (MAOIs),
in the past.
like phenelzine, selegiline, or tranylcypromine, are used.
• First choice. SSRIs and Serotonin Norepinehprine Other medications with MAOI activity, including linezolid
Reuptake Inhibitors (SNRIs) are the agents of first and methylene blue, also increase the risk of serotonin
choice due to ease of use, usually tolerable side effects syndrome when used in combination with any serotonergic
and safety in overdose. Paroxetine might not be a first medication, including SSRIs and SNRIs.
choice, given potential teratrogenic effects and issues
with withdrawal symptoms. Tricyclic antidepressants
Trials of drugs. Trials of drugs should consider the
and MAOIs are considered second or third line
following:
treatment. MAOIs are usually prescribed by
specialists. • Response rate. Rates of 50% response and 30%
remission have been demonstrated with an adequate
• Cost. Drugs within a class can vary appreciably in
trial (4-6 weeks) of first agent, compared to a 20-40%
cost. Several medications are now available
response rate for placebo. The most common cause of
generically.
treatment failure is an inadequate medication trial.
• Response to specific medication not predictable. No
• Change. If the patient shows no response to an
reliable predictor exists for response to a particular
antidepressant trial at 6-8 weeks, consider switching
medication.
the antidepressant or augmenting with another agent.
• Explain potential side effects. Side effects are common
Measuring response to treatment at each follow-up visit
and should be explained in detail to the patient at
with serial measurement tools may be helpful. Tools
initiation of medication. The most common side
include the PHQ9, ECS-D, and the Hamilton Rating Scale
effects include constipation, diarrhea, nausea,
for Depression.
dizziness, headache, insomnia, somnolence. Sexual
side effects are particularly common (up to 60%) and
The Sequenced Treatment Alternatives to Relieve
are probably less frequent with bupropion or
Depression (STAR*D) Trial was a landmark NIH
mirtazapine. However, mirtazapine (Remeron) is more
sponsored study designed to evaluate the best next-step for
likely to cause weight gain.
depressed patients who failed to respond to an initial trial of
• History of seizure. Use SSRIs in patient with a history an SSRI. As opposed to many industry-sponsored short-
of seizure disorder. Bupropion lowers the seizure term efficacy trials of antidepressants, the patients in the
threshold. STAR*D study were drawn from real world primary and
• Chronic pain. Despite theoretical pharmacologic specialty care clinical practices, had moderate to severe
properties of some of the second generation agents, for depression, chronic difficulties, and multiple psychiatric
the evidence regarding the superiority of one agent and medical comorbidities.
over another for the treatment of chronic pain is mixed.
In general, SSRIs may be less helpful for pain, and a The detailed design of the STAR*D study and remission
mixed agent such as mirtazaine, venlafaine or rates at each level are presented in Figure 3 (located after
duloxetine or a tricyclic agent may be considered. the text, following Table 8). The end point of the study was
• Drug interactions. A theoretical concern exists for full remission (defined as the absence of symptoms) rather
using antidepressants with CYP2D6 inhibiting than response to medication (>50% reduction in depression
properties together with SERMS (selective estrogen measurement scores). All patients were treated with
receptor modulators). Some oncologists recommend citalopram at Level 1 for 12 weeks. Those whose
against using tamoxifen with fluoxetine, paroxetine, depression failed to fully remit progressed to Level 2 where
bupropion, duloxetine. SSRIs and SNRIs which are they were switched from citalopram to a medication either
not potent inhibitors of this enzyme, include within or outside class (bupropion SR, venlafaxine XR or
venlafaxine, citalopram, escitalopram and sertraline. sertraline), were switched from citalopram to cognitive
therapy, or had citalopram augmented with bupropion SR,
• Side effects. Some evidence suggests that SSRIs may
buspirone or cognitive therapy. Those who were intolerant
increase bone loss and increase the risk for fragility or failed to remit advanced to Level 3 where they were
fractures in older patients. In addition, risk may again either switched to mirtazapine or nortriptyline or
increase for upper gastrointestinal bleeding, especially
augmented with lithium or triiodothyronine (T3). Those
in patients who are also on NSAIDS. These data are
who failed to remit at Level 3 advanced to Level 4 where
preliminary, with more research required to clarify the
all medications were discontinued and they were switched
absolute risk.
to tranylcypromine (an MAOI) or a combination of women on paroxetine, sertraline, and fluvoxamine during
mirtazapine and venlafaxine XR. pregnancy also failed to reveal an increased teratogenic risk.
However, another study found that infants exposed to SSRIs
Important findings include the following: during late pregnancy are at increased risk for serotonergic
 After an initial treatment failure, it is reasonable to: central nervous system adverse effects in the days after
switch to antidepressant medications within or outside delivery, with the severity of these symptoms being
of class; switch to cognitive therapy; or augment with significantly related to cord blood 5-HIAA levels.
bupropion, buspirone, or cognitive therapy.
 No medication is a clear 'winner.' Switching within or A small risk for persistent pulmonary hypertension may
outside a drug class does not seem to matter. occur in newborns of mothers taking SSRIs at the time of
 There was little difference in tolerability or side effects delivery, most likely due to vascular effects of serotonin, but
between medications. the risk is extremely small, if it exists at all, and should be
balanced with the consequences of untreated depression in
 As patients progressed through subsequent levels due the mother.
to failed treatments, remission rates were low and the
chance of remission diminished. For mild to moderate depression, psychotherapy (e.g.,
 Many patients will require multiple steps to achieve cognitive behavioral therapy, interpersonal therapy) may be
remission. the initial approach. Medication should be included for
 Patients who achieve full remission have a lower risk moderate to severe depression or for suicidal ideation.
of relapse than patients who achieve only diminished Antidepressant use in pregnancy/lactation should follow the
symptoms. same guidelines as any drug in pregnancy: older drugs have
more data on fetal risk and should be selected over newer
 There was no difference in the severity of depression or
drugs when possible. The American Psychiatric Association
psychiatric comorbidities between the primary and
and the American College of Obstetrics and Gynecology
specialty care practices although the primary care
have jointly developed a clinical practice guideline
patients tended to have more medical comorbidities.
addressing the specific issues of diagnosing and treating
 Remission rates did not differ for patients receiving
pregnant women.
primary care or specialty care.
 Attrition rates were very high at all levels.
Psychotherapy principles. Table 6 (placed after guideline
text) outlines several psychotherapeutic treatments for
Referral. Consider referral after 1-2 failed drug trials or in
depression. Psychotherapy alone is as efficacious as
patients with concomitant substance abuse, personality
antidepressant medication in patients with mild to moderate
disorder or suicidality.
major depression and may be efficacious even among
patients with more severe depression. However, most
Pregnancy. The risks of taking medications during clinicians recommend combining psychotherapy with
pregnancy or lactation should be weighed against the risk of pharmacotherapy for patients with severe or chronic
a woman being severely depressed during pregnancy or in depression. Patients treated with psychotherapy alone
the early stages of newborn parenting. When counseling the should be monitored. Patients having an insufficient
patient who has depression and wishes to conceive, potential response after 12-16 weeks should be considered for
risks and benefits of pharmacotherapy must be weighted. antidepressant medication.
Women considering pregnancy may want to pursue
psychotherapy instead of medication. Physicians should also consider initiating treatment with a
combination of psychotherapy and antidepressants if
Maternal depression plays a significant role in child patients have:
development both ante-partum (e.g., behavior affecting • a history of only partial response to previous trials of
maternal health) and post-partum (e.g, interactions with medication or psychotherapy.
child). Treatment goals are to maintain mood stability during
• a history of two or more episodes of major depression
pregnancy and to prevent post partum decompensation.
with poor interval functioning.
Prophylaxis to prevent recurrent post-partum depression
should be considered, initiating medication in the third • a depressive episode of 2 or more years.
trimester (at least 4 to 6 weeks prior to birth). • psychosocial difficulties that interfere with treatment
adherence.
SSRIs should be the first line drug of choice. Animal
studies have shown no risk of fetal anomalies with these Many different forms of psychotherapy exist. However,
drugs. Consider Sertraline due to its shorter half-life only a few short-term psychotherapies that lend themselves
compared to Fluoxetine. Paroxetine should be avoided due to codification in manuals have been tested in randomized
to evidence of fetal cardiac malformations (although recent controlled trials. Psychotherapy practiced in the
studies question this finding). SNRIs should also be community may or may not resemble the standardized
considered. Patients already on these medications prior to psychotherapies proven effective in RCTs.
pregnancy with good response should remain on them.
Ongoing clinical assessment. Patients should initially be
Limited information exists regarding fetal risks of seen relatively frequently (weekly to biweekly) to assess
medications for depression. One recent prospective study of the patient‟s response to the treatment intervention,
assess/reassure the patient regarding side effects, evaluate • Sexual dysfunction: While sexual dysfunction with
suicidal tendencies, and rule out comorbid disorders. antidepressants is common in both men and women,
Expert opinion varies regarding visit frequency but 3-7 distinguishing between side effects of a drug and
visits in the first 12 weeks of treatment have been symptoms of the disease can be difficult. Bupropion is
suggested. Some patients treated with antidepressants may least likely to produce this side effect and can be used
experience increased agitation, anxiety, and hostility, concomitantly with SSRIs or SNRIs. Other less well-
particularly in the early stages of treatment, potentially proven or studied strategies include the use of
placing them at increased risk of suicidal behavior, and sildenafil, cyproheptadine, and gingko biloba.
there is now a Black Box warning regarding potential
increased suicidal risks among adolescents and young Treatment of refractory depression. Although no single
adults. Many patients are also non-adherent with treatment definition of treatment refractory depression exists, patients
and more frequent visits have been associated with have often been considered to be treatment refractory if
increases in adherence. they have been treated with two successive trials of
antidepressants in adequate doses for adequate periods of
Approximately 40%–50% of treated patients will show a time (6 to 12 weeks). Approximately 40% of patients with
good response to pharmacotherapy within about 8-12 MDD will not respond to two trials of antidepressant
weeks, although a smaller percentage (approximately 30%) medication. If symptoms are moderate to severe, patients
will meet criteria for complete remission. When remission might be referred to a psychiatrist at this time for further
is achieved, medication should then be continued for an evaluation and treatment.
additional 9-12 months. Discontinuing medication too
soon, or decreasing dosage below that required for Psychiatrists will usually re-evaluate the diagnoses of these
treatment response, is associated with a higher rate of patients, looking for complicating factors that might explain
relapse. Office visits during the continuation phase of the lack of treatment response, e.g., concomitant alcohol or
treatment are conducted on an as-needed basis. Remember substance abuse, accompanying psychiatric disorders, or
to assess patients for risk factors for recurrence or relapse continuing adverse psychosocial circumstances. Additional
and to consider lifetime maintenance on antidepressants for treatment strategies may include more intensive or specific
those with a high risk of relapse. psychotherapies such as intensive outpatient treatment of
alcohol abuse, alternative environmental supports such as
Conceptualize treatment as occurring in three phases (see social work case management, or augmentation of
Figure 2), with many/most patients requiring only acute and antidepressant medication with a variety of pharmacologic
continuation therapy: agents.
1. Acute: Aim for remission of all depressive
symptoms. The mean time to remission when it Some primary care physicians will feel comfortable using
occurs, is 6 to 12 weeks after starting antidepressant pharmacologic augmentation strategies with their patients
medications, although the STAR*D study also who do not respond to standard antidepressant regimens.
indicated that many patients may need more than 12 Primary care physicians might consider the following
weeks to remit. strategies, which are commonly used by experts in
2. Continuation: For 9-12 months after symptom relief depression care.
in order to prevent relapse. • Combination of antidepressant medication, particularly
3. Maintenance: Recommended for patients with 3 or those with different neurotransmitter actions [B-C*].
more episodes of major depression, history of • Lithium in addition to an antidepressant [A*] – titrated
psychotic depression, or first onset of depression at by blood level, with a goal of 0.6-1.0 m Eq/l
age 55 years or older.
• Thyroid hormone supplementation in addition to an
Managing side effects. Insomnia, akathisia (a syndrome antidepressant in euthyroid patients [A*].
characterized by motor restlessness), weight gain, and sexual • Antipsychotic medication (aripiprazole, risperidone or
dysfunction are commonly associated with the use of olanzapine) augmentation of antidepressant medication
antidepressant agents. Consider the following strategies for [A*].
managing related side effects:
• Electroconvulsive therapy – a highly efficacious
• Insomnia: Add a small dose of trazodone (25-50mg treatment, which may be the treatment of choice for the
QHS) to an SSRI. frail elderly or acutely suicidal patients but requires
• Akathisia: This side effect has been associated with referral
newer antidepressants. Consider adding a small dose • Stimulant medication in addition to an antidepressant.
of clonazepam (0.5 mg QHS).
• Monoamine Oxidase Inhibitors (MAOIs).
• Weight gain: No proven remedies exist. Patients
should be warned about this potential side effect and • Mood stabilizers.
regular exercise encouraged both for its weight
maintenance effect and for its potential to further help Many of the above augmentation strategies have limited
with depressive symptoms. Bupropion may be less evidence of efficacy and studies supporting their
likely to result in weight gain. effectiveness often have methodological limitations. The
exceptions to this are ECT, MAOIs and lithium

supplementation, and perhaps antipsychotic augmentation, • Female sex
although, to date, most studies examining the effectiveness • Social isolation, widowed, divorced or separated
of the latter strategy have been drug company supported. • Lower socioeconomic status
• Comorbid medical diagnosis, pain, insomnia,
Referral. Consider referral for patients: functional and cognitive impairment
• who fail 2 or more medication trials
• are suicidal Depression is a major risk factor in suicide in the elderly.
• with psychotic or bipolar depression They attempt suicide less often than younger people, but are
• with comorbid substance abuse more successful at completion. Risk factors for suicide
• who have severe psychosocial problems include: medical comorbidities, poorly treated chronic pain,
• who require specialized treatments such as ECT terminal or worsening illness, social isolation, personality
disorders, previous attempt of suicide, and family history of
• who have quickly increasing depressive symptoms
suicide.
• with unclear diagnosis or patients with suspected
personality disorders
The diagnosis and assessment of depression in older adults
is similar to that for all depressed patients as described
previously.
Special Considerations:
Adolescents and Older Patients Successful treatment of depression is similar to that for all
depressed patients. Psychotherapy, medical therapy, and
Adolescents electroconvulsive therapy have all been found effective in
older patients. Medication response generally takes longer
In adolescence, presentation of a major depressive disorder (up to 4-6 weeks). and up to 3 trials may be necessary to
(MDD) may include substance abuse, antisocial behavior, determine whether a therapy is appropriate. Monotherapy
social withdrawal and academic failure, with suicide is recommended to minimize side effects and drug
attempts and ideation common. Few long-term studies have interactions. Starting doses for medications should be half
been performed on adolescents. Information is limited for the dose for younger adults. Evaluation of response should
this age group on prevalence, treatment, and impact on long occur every 2-4 weeks. SSRIs are first line therapy. Second
term prognosis. line agents include dual action drugs (Venlafaxine,
duloxetine), with merazapine also used as a second line
drug.
Guidelines for Adolescent Depression in Primary Care
(GLAD-PC) offers recommendations for treatment of the
adolescent in a primary care setting, that are consistent with Patients with failure of 3 medical trials, suicidality,
those for all depressed patients. The guidelines and depression complicated by other psychiatric diagnoses, and
supporting toolkit are available at: preference for non pharmacologic treatment should be
www.thereachinstitute.org/guidelines-for-adolescent- referred to psychiatry.
depression-primary-care.html .
In 2003 concerns were raised regarding suicide ideation and Controversial Areas
behavior in adolescents on SSRIs. The FDA issued a “black
box” warning in 2004 for use of SSRIs in adolescence. St. John’s Wort (Hypericum Perforatum)
Since then the use of antidepressants in this group has
decreased by 58%. A paralleling increase in suicide St John‟s Wort (Hypericum Perforatum) is claimed to
completion has occurred. While meta analysis have shown improve depressive symptoms particularly in patients with
consistent but modest increase in suicidal risks, the mild-moderate depression. (900 mg daily may be effective
American Association of Child and Adolescent Psychiatry in mild to moderate depression.) Studies have produced
has expressed concern that the major depressive disorders conflicting results, making recommendations regarding St.
themselves carry considerable risk of other morbidity and John‟s Wort difficult. Early studies carried out in Europe
of mortality. suggested reported rates of improvement at 4-6 weeks
comparable with antidepressants (40%-50% response) with
Late Life Depression 20-30% placebo response. Side effect frequency was
notably lower than with standard antidepressants and
included gastrointestinal side effects, allergic reactions,
Depression is not a normal consequence of aging. Healthy
tiredness and restlessness. More recent, larger, and
independent elders have a lower prevalence of major
rigorous studies conducted in the United States have been
depression than the general population. Rates increase with
less positive. The more recent studies suggest the benefit
medical illness such as cancer, heart attack, stroke and
may only apply to patients with relatively mild depression.
Parkinsons disease.
Determining the bioavailability of the active ingredient is a
problem in evaluating either the results of a clinical trial or
Patients who experience their first episode of depression the clinical benefit in an individual patient.
later in life are less likely to have familial or genetic
predisposition as a cause. Other risk factors include:
Ascertaining use of St. John‟s Wort before prescribing pharmacologic agents; pregnancy and pharmacologic
usual antidepressants is critical, because of the possible agents, breast feeding and pharmacologic agents;
serotonergic effects of Hypericum. In addition, St. John‟s pharmacotherapy not included above; mindfulness based
Wort induces CYP3A4. Consequently, numerous drug therapy; problem solving therapy; interpersonal
interactions can be expected with chronic use of St. John‟s psychotherapy, cognitive behavioral therapy, short-term or
Wort in patients taking drugs dependent on metabolism via focal psychodynamic psychotherapy, marital therapy,
CYP3A4, e.g., statins. psychotherapy, not included above; other treatment not
included above; ongoing clinical assessment; medical
Withdrawal Syndrome comorbidity; alcohol abuse; panic (including generalized
anxiety disorder or phobia); obsessive compulsive disorder;
Several reports and semi-controlled studies suggest that post-traumatic stress disorder; eating disorders and anorexia
many patients, possibly a majority, experience withdrawal nervosa; partner violence; sexual assault; pregnancy (not
symptoms, especially when agents with short half-lives are included above), postpartum (not included above); and
stopped suddenly after a long period of use. The syndrome depression not included above. Specific search strategy
consists of agitation, sudden flashes of light, edginess and available upon request.
disquiet. Some investigators believe these are merely the
symptoms for which treatment was originally started, while The search was conducted in components each keyed to a
others believe these agents can cause a withdrawal, specific causal link in a formal problem structure (available
although not a physiological addiction. The symptoms only upon request). The search was supplemented with very
last for a matter of days to weeks, and can be avoided recent clinical trials known to expert members of the panel.
through a slow taper of medication over several weeks or Negative trials were specifically sought. The search was a
even months when a patient has been treated for a year or single cycle. Conclusions were based on prospective
more. randomized controlled trials if available, to the exclusion of
other data; if randomized controlled trials were not
available, observational studies were admitted to
consideration. If no such data were available for a given
Strategy for Evidence Search link in the problem formulation, expert opinion was used to
estimate effect size.
The literature search for this update began with results of
the literature search performed in 1997 to develop the initial
guideline released in 1998 and the search performed in
Related National Guidelines
2002 for the update released in 2004. The literature search
for this update used keywords that were very similar to
The UMHS Clinical Guideline on Depression is consistent
those used in the previous searches. However, instead of
with:
beginning the search with literature in 2002, the guideline
team accepted the search strategy and results for the search APA Practice Guideline for the treatment of patients with
performed through 12/31/06 for the VA/DoD clinical major depressive disorder (2010)
Practice Guideline for Management of Major Depressive The management of depression during pregnancy a report
Disorder (MDD). from the American Psychiatric Association and the
American College of Obstetricians and Gynecologists
The search for this update was conducted prospectively on (2009)
Medline using the major keywords of: depression,
depressive disorders; clinical guidelines, controlled clinical Guidelines for Adolescent Depression – Primary Care
trials, cohort studies; adults; English language, and (2007)
published 1/1/07 – 1/31/10. Terms used for specific topic United States Preventive Services Task Force. Screening
searches within the major key words included: for depression in adults (2009)
epidemiology, national cost of treatment (economics);
spectrum of depression, seasonal affective disorder, Using second-generation antidepressants to treat depressive
dysthemia; screening for depression; screening for bipolar disorders: A clinical practice guideline from the
disorder; diagnosis; suicide risk assessment; patient American College of Physicians (2008)
education; exercise; pharmacotherapy and psychotherapy – VA/DoD clinical Practice guideline for Management of
comparison and in combination; combinations of more than Major Depressive Disorder (MDD) (2008)
one pharmacologic agent; serotonin selective reuptake
inhibition (citalopram, escitalopram, fluoxetine, paroxetine, See full references below.
sertraline); serotonin/norephinephrine reuptake inhibition
(desvenlafaxine, duloxetine, mirtazapine, tricyclic
antidepressants, venlafaxine); norephinephrine/dopamine
reuptake inhibition (bupropion); serotonin-2
Disclosures
antagonist/reuptake inhibition (nefazodone, trazodone); St.
John‟s Wort (Hypericum Perforatum); maintenance on The University of Michigan Health System endorses the
pharmacotherapy, continuation duration; withdrawal Guidelines of the Association of American Medical
syndrome (paroxetine/Paxil, cesvenlafaxine, venlafaxine); Colleges and the Standards of the Accreditation Council for
medication adherence; managing sexual side effects of Continuing Medical Education that the individuals who

present educational activities disclose significant Departments of Veterans Affairs and of Defense, 2008.
relationships with commercial companies whose products Available at:
or services are discussed. Disclosure of a relationship is not www.healthquality.va.gov/Major_Depressive_Disorder_M
intended to suggest bias in the information presented, but is DD_Clinical_Practice_Guideline.asp (accessed 10/4/10).
made to provide readers with information that might be of
potential importance to their evaluation of the information. Qaseem A, Snow V, Denberg TD et al. Using second-
generation antidepressants to treat depressive disorders: A
Team Member Relationship Company clinical practice guideline from the American College of
Physicians. Annals of Internal Medicine, 2008;
Jolene R Bostwick, PharmD None 149(10:725-233. Available at:
R Van Harrison, PhD None www.annals.org/content/149/10/725.full.pdf+html
Thomas L Schwenk, MD None (accessed 10/4/10).
Linda B Terrell, MD None
Amy L Tremper, MD None United States Preventive Services Task Force. Screening
Marcia A Valenstein, MD None for depression in adults. Annals of Internal Medicine, 2009;
151:784-792. Available at:
www.uspreventiveservicestaskforce.org/uspstf09/adultdepr
Review and Endorsement ession/addeprrs.htm (accessed 10/4/10).
Drafts of this guideline were reviewed in clinical Yonkers KA, Wisner KL, Stewart DE, et al. The
conferences and by distribution for comment within management of depression during pregnancy: a report of
departments and divisions of the University of Michigan the American Psychiatric Association and the American
Medical School to which the content is most relevant: College of Obstetricians and Gynecologists. Obstetrics &
Family Medicine, General Medicine, General Obstetrics & Gynecology, 2009; 114(3):703=713.
Gynecology, and Psychiatry. The Executive Committee for
Clinical Affairs of the University of Michigan Hospitals Zuckerbrot RA, Cheung AH, Jensen PS, Stein REC,
and Health Centers endorsed the final version. Laraque D, and the GLAD-PC Steering Group. Guidelines
for Adolescent Depression in Primary CARE (GLAD-PC):
I. Identification, Assessment, and Initial management.
Acknowledgments Pediatrics, 2007; 120(5):1299-1312.
Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque
The following individuals are acknowledged for their D, Stein REK, and the GLAD-PC Steering Group.
contributions to previous major versions of this guideline: Guidelines for Adolescent Depression in Primary Care
(GLAD-PC): II. Treatment and Ongoing Management.
1998: Thomas L. Schwenk, MD, Family Medicine, Linda Pediatrics, 2007; 120(5):1313-1326.
B. Terrell, MD, General Internal Medicine, Elizabeth Full report and supporting toolkit available at:
M. Shadigian, MD, Obstebrics & Gynecology, www.thereachinstitute.org/guidelines-for-adolescent-
Christopher G. Wise, PhD, Clinical Affairs, Marcia A. depression-primary-care.html (accessed 1/25/11).
Valenstein, MD, Psychiatry. Consultant, David J.
Knesper, MD, Psychiatry
2004: Thomas L. Schwenk, MD, Family Medicine, Linda
B. Terrell, MD, General Internal Medicine, R. Van
Harrison, PhD, Medical Education, Elizabeth M.
Shadigian, MD, Obstebrics & Gynecology, Marcia
Valenstein, MD, Psychiatry. Consultant, David J.
Knesper, MD, Psychiatry
General References
American Psychiatric Association Work Group on Major
Depressive Disorder (Gelenberg AJ, Freeman MP,
Markowitz JC, et al). Practice guideline for the treatment of
patients with major depressive disorder, third edition.
American Journal of Psychiatry, 2010; 167(10 supplement).
Also available at
www.psychiatryonline.com/pracGuide/pracGuideTopic_7.a
spx (accessed 11/18/10).
The Management of MDD Working Group. VA/DoD

clinical Practice guideline for Management of Major
Depressive Disorder (MDD). Washingon, DC: U.S.

Table 6. General Principles of Psychotherapy
Psychotherapy Brief Description Evidence of Effectiveness

Modality
Any Psychotherapy Most psychotherapies have many commonalties, such Many forms of psychotherapy are more effective
as a socially sanctioned therapist, emphasis on than "wait list" controls [A*].
developing a treatment alliance, a theory that offers a A few short term structured psychotherapies have
plausible explanation for symptoms, expectations of been shown to be effective in the treatment of
change, and a structured series of contacts between MDD [A*] .
therapist and patient to bring about change. .
Interpersonal Focuses on clarification and resolution of Effective in reducing symptoms as the sole agent
Psychotherapy (IPT) interpersonal difficulties. Explores interpersonal in mild to moderate depression [A*].
losses, role disputes, role transitions, and social skill
deficits.
Cognitive Behavioral Identifies and attempts to modify negatively-biased Effective in reducing symptoms as the sole agent
Therapy (CBT) cognitions. Behavioral component includes activity in mild to moderate depression [A*].
scheduling and social skills training. Possibly lower relapse rates after treatment
discontinuation compared to medication [A*] .
Can be successfully delivered in a computer based
format [A*]
Evidence for increased efficacy in combination

with pharmacotherapy for chronic depression [A*].
Marital Therapy Focuses on improving the marital relationship of Marital therapy appears to be effective for
patients with depression. depressed women in discordant marital
relationships [A*]. Marital therapy should only be
considered if violence is screened for and absent in
the relationship.
* Levels of evidence for the most significant recommendations:

A = randomized controlled trials; B = controlled trials, no randomization; C = observational trials; D = opinion of expert panel.

Table 7. Prevalence and Treatment of Co-Morbid Depression
Co-Morbid Epidemiology Diagnosing Co-Morbid Conditions Special Rx Considerations

Depression
 Approximately15-30% of Consider asking the AUDIT-C questions (see below).*  If there is concurrent alcohol abuse and depression,
Depression patients with MDD have an address the alcohol use to attempt to achieve a period
accompanied alcohol use disorder of sobriety. Depressive symptoms may resolve [C*].
by Alcohol  10-30% of patients with an  If unable to achieve sobriety, patients with concurrent
Abuse or alcohol use disorder have depression and alcohol abuse may be treated with an
Hazardous concurrent depression SSRI [A*].
Alcohol  Suicide rates are higher among depressed patients with
misuse alcohol abuse. Be vigilant in assessing suicidal risk
[C*] .
Depression  45% of patients with MDD have Consider asking :  MDD accompanied by anxiety disorders has a
accompanied significant anxiety symptoms  Are you troubled by repeated, unexpected "attacks" relatively poorer prognosis than MDD alone [A*, C*].
by Anxiety  Approximately 40-60% of where you suddenly feel very afraid for no apparent  Patients with MDD and anxiety may need their
patients with anxiety disorders reason? antidepressants started at lower doses and increased
have MDD during their lifetime  Do you often experience periods with rapid heart rate; more slowly than individuals with depression alone
sweating; dizziness; trembling; feelings of unreality; [C*].
shortness of breath or choking; fear of going crazy or  SRIs are effective in panic disorder. Bupropion is less
dying; chest pain; numbness or tingling; chills or hot effective [B*] .
flashes?
Depression  Perhaps as many as 5-6% of Be alert for eating disorders among depressed women  MDD in patients with anorexia may be refractory to
accompanied young women with MDD may who are dieting when not “over” weight, have frequent treatment until normal weight is re-established [C*].
by Eating have an eating disorder weight fluctuations, or are amenorrheic.  If using antidepressants, consider use of an SSRI [A*].
Disorders  30-50% of patients with eating If considering psychotherapy, consider formal
disorders have concurrent MDD cognitive behavioral therapy.
Depression  Approximately 20-30% of Be alert for expressions of worthlessness, crying,  One RCT suggests benefit with treating depression
accompanied patients with dementia may have decreased interest and pleasure in activities among patients with Alzheimers, a small RCT suggests
by Dementia significant depressive symptoms no benefit. Overall the literature is sparse in this area.
and 10-20% may have MDD
* AUDIT-C Questions and Scoring

Q#1: How often did you have a drink containing Q#2: How many drinks did you have on a typical day Q#3: How often did you have six or more drinks on one
alcohol in the past year? when you were drinking in the past year? occasion in the past year?
Never 0 points 1 or 2 0 points Never 0 points
Monthly or less 1 point 3 or 4 1 point Less than monthly 1 point
Two to four times a month 2 points 5 or 6 2 points Monthly 2 points
Two to three times per week 3 points 7 to 9 3 points Weekly 3 points
Four or more times a week 4 points 10 or more 4 points Daily or almost daily 4 points
The AUDIT-C is scored on a scale of 0-12 (scores of 0 reflect no alcohol use). In men, a score of 4 or more is considered positive; in women, a score of 3 or more is
considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient‟s drinking is affecting his/her health and safety.
18 UMHS Depression Guideline Update, Month 2011

Table 8. Special Issues for Women
Issues Epidemiology Diagnostic Considerations Treatment considerations

Partner  One quarter of women are victims of partner Ask in the history:  Getting out of the relationship is recommended, but
Violence violence in their lifetimes and 1 in 10 women  Have you ever been in a relationship where homicide rates increase after separation.
report violence in the last 12 months. you have been beaten, punched, choked or  Couples therapy is not recommended.
hurt in any way?  The “battered women syndrome” (a form of post-
 Screen for stalking, homicide risk, sexual traumatic stress disorder [PTSD]) is very common.
assault
Sexual  1/3 of all sexual assault victims are depressed. Ask in the history:  Therapists with expertise with sexual assault survivors
Assault  1/3 have attempted suicide.  Have you ever been forced to have sex and PTSD are best.
 1/3 have post-traumatic stress disorder. against your will?  Pelvic exams will need to be conducted more carefully
 1/8 adult women are sexually assaulted in their  As a child or as an adult, did anyone touch or avoided. Refer for gynecological care as well as
lifetime; 60% of these assaults occur before you inappropriately sexually? care for depression.
age 18.
Pre-  Depression is common. Discuss prior/current  Severity of depression  Discontinuing or decreasing meds prior to or early in
Conceptual mental health issues.  Number/frequency of episodes pregnancy may increase risk of relapse
Counseling  Women are twice as likely to experience Response history (relapses tend to become  If you do decrease meds, taper (i.e. 25% every 1-2
depression as men. progressively harder to treat) weeks)
 Highest rate is in women ages 22 to 44.  If patient is getting a good response from current meds,
best to continue same (unless contraindicated in
pregnancy)
Pregnancy  Women currently on medications have a 43%  History of depression ante-or post-partum;  Initiate systematic screening in 1st,2nd, 3rd trimester and
chance of relapse during pregnancy: family history postpartum,*as many symptoms of pregnancy are
 68% when meds discontinued  Decreasing or discontinuing medications similar to those of depression
 25% when continued  Psychosocial factors: ETOH, drugs,  For mild to moderate depression, consider
 intermediate risk for dose change  Poor social support, marital instability psychotherapy
 Previous pregnancy loss, sleep deprivation  For moderate to severe or suicidal ideation, consider
 Pain antidepressants
 Depression in the year prior to and the year - See medication chart for pregnancy classification
after delivery - SSRIs first line choice
- Decision to use an anti depressant at any point in
pregnancy depends more on the severity of the
depression and response to meds than the specific
pharmacological risks.
- A single agent at a higher dose is preferable to
multiple agents to reduce exposure risk
• Consider non pharmacological treatments such as
(Table 8 continues on next page) exercise, light therapy and ECT (with appropriate fetal
monitoring)

Table 8. Special Issues for Women (continued)
Postpartum Depression is about 15% post partum but  Mood episodes similar to depressive episodes  Specific screens for PP period recommended
increases about 3x in women w/ prior history of prior to pregnancy, but onset is within 4 weeks  Post partum” blues” are transient, occur in the
PP depression of birth first few weeks, but remit spontaneously
 Increase risk with history of major depressive  Breast feeding may disrupt sleep and increase
disorder, alcohol / drug dependence, or mania, depression
which can cause depressive symptoms  If patient is breast feeding, may be on a mini-pill
 greatest period of risk for major depression is (progesterone only), which may increase
first 9 weeks after delivery depression
 Consider IUD or barrier method
Hormonal  May be associated with depression.  More common in progesterone contraception:  Mini-pill used frequently in breast-feeding
Contraceptives depo provera, mini-pill (progesterone only) mother. Consider IUD or barrier method
 Mirena IUD (progesterone implanted, but little
systemic effect)
 Paraguard copper T IUD
 Consider trial of mini pill prior to long term
contraception (Depoprovera shots)
 Symptoms of hormonal contraception (lower
mood, libido) may be confused with depression
Post and Peri-  Hot flashes/sweats may disrupt sleep and  Insomnia, fatigue, worries associated with  Screen for depression separately.
menopausal trigger depression health, dependence of old age  Consider Rx with hormone replacement, Effexor,
Exogenous clonidine for autonomic symptoms
Hormone  See Late-life Depression section
Replacement
Therapy

Figure 3. STAR*D
Study Design and Remission Results at Each Level
References:
http://www.nimh.nih.gov/trials/practical/stard/index.shtml
http://ajp.psychiatryonline.org/cgi/content/full/164/2/201
http://ajp.psychiatryonline.org/cgi/reprint/163/11/1905
http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=318293&Ausgabe=254424&ProduktNr=223864&filename=3182
93.pdf
21 UMHS Depression Guideline, August 2011

Patient Health Questionnaire (PHQ-9)
Patient Name: _________________________________________ Date: ___________________
Not at all Several days More than Nearly every

half the days day
1. Over the last 2 weeks, how often have you been bothered
by any of the following problems?
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling/staying asleep, sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself or that you are a failure or

have let yourself or your family down
g. Trouble concentrating on things, such as reading the

newspaper or watching television.
h. Moving or speaking so slowly that other people could

have noticed. Or the opposite; being so fidgety or restless
that you have been moving around a lot more than usual.
i. Thoughts that you would be better off dead or of hurting

yourself in some way.
2. If you checked off any problem on this questionnaire so Not difficult Somewhat Very Extremely
far, how difficult have these problems made it for you to at all difficult difficult difficult
do your work, take care of things at home, or get along
with other people?

PHQ-9* Questionnaire for Depression Scoring and Interpretation Guide
For physician use only

Scoring:
Count the number (#) of boxes checked in a column. Multiply that number by the value indicated below, then add the subtotal
to produce a total score. The possible range is 0-27. Use the table below to interpret the PHQ-9 score.
Not at all (#) _____ x 0 = _____

Several days (#) _____ x 1 = _____
More than half the days (#) _____ x 2 = _____
Nearly every day (#) _____ x 3 = _____
Total score: _____
Interpreting PHQ-9 Scores
Diagnosis Total Score For Score Action

Minimal depression 0-4 ≤ 4 The score suggests the patient may not need depression
treatment
Mild depression 5-9 5 - 14 Physician uses clinical judgment about treatment, based on
Moderate depression 10-14 patient's duration of symptoms and functional impairment
Moderately severe depression 15-19 > 14 Warrants treatment for depression, using antidepressant,
Severe depression 20-27 psychotherapy and/or a combination of treatment.
* The PHQ-9 is described in more detail at the Pfizer website: http://www.phqscreeners.com/

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Guidelines for Clinical Care

* Levels of evidence for the most significant recommendations:

Table 2. Depressive Symptoms and Diagnostic Criteria for Depressive Disorders

Core Depressive Symptoms

 Depressed mood  Diminished ability to concentrate, or indecisiveness

Diagnostic Category by Symptom Grouping

Diagnostic Category Number of Symptoms Duration

Major Depression > 5 depressive symptoms, one of which is > 2 weeks

Source: DSM-IV-TR American Psychiatric Association, 2000

3 UMHS Depression Guideline Update, August 2011

If the patient's response to both questions is "no", the screen is negative.

Figure 2. Phases of Treatment for Major Depression

Table 4. Information the Patient Needs to Know

Clearly communicate the following with patients:

4 UMHS Depression Guideline Update, August 2011

5 UMHS Depression Guideline Update, August 2011

Mechanisms of action Serotonin Selective Reuptake Inhibitorsa

6 UMHS Depression Guideline Update, August 2011

Mechanisms of Action Serotonin/Norepinephrine Reuptake Inhibitor

7 UMHS Depression Guideline Update, August 2011

8 UMHS Depression Guideline Update, August 2011

Bereavement. Grieving is a “normal” reaction to a major

Pharmacotherapy principles. Table 5 provides practical

13 UMHS Depression Guideline Update, August 2011

15 UMHS Depression Guideline Update, August 2011

The Management of MDD Working Group. VA/DoD

16 UMHS Depression Guideline Update, August 2011

Psychotherapy Brief Description Evidence of Effectiveness

Evidence for increased efficacy in combination

* Levels of evidence for the most significant recommendations:

17 UMHS Depression Guideline Update, August 2011

Co-Morbid Epidemiology Diagnosing Co-Morbid Conditions Special Rx Considerations

* AUDIT-C Questions and Scoring

18 UMHS Depression Guideline Update, Month 2011

Issues Epidemiology Diagnostic Considerations Treatment considerations

19 UMHS Depression Guideline Update, August 2011

20 UMHS Depression Guideline Update, August 2011

21 UMHS Depression Guideline, August 2011

Patient Name: _________________________________________ Date: ___________________

Not at all Several days More than Nearly every

b. Feeling down, depressed, or hopeless

c. Trouble falling/staying asleep, sleeping too much

d. Feeling tired or having little energy

e. Poor appetite or overeating

f. Feeling bad about yourself or that you are a failure or

g. Trouble concentrating on things, such as reading the

h. Moving or speaking so slowly that other people could

i. Thoughts that you would be better off dead or of hurting

22 UMHS Depression Guideline, August 2011

For physician use only

Not at all (#) _____ x 0 = _____

Total score: _____

Interpreting PHQ-9 Scores

Diagnosis Total Score For Score Action

* The PHQ-9 is described in more detail at the Pfizer website: http://www.phqscreeners.com/

23 UMHS Depression Guideline, August 2011

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Patient Name: _______________________ Date: _

Not at all (#) _ x 0 = _