The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Detection and Diagnosis
Assess if Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for major depression are met [A]:
Must have a total of five symptoms for at least two weeks. One of the symptoms must be depressed mood or loss of interest:
- Depressed mood
- Markedly diminished interest or pleasure in all or almost all activities
- Significant weight loss or gain (>5% body weight), or increase or decrease in appetite
- Insomnia/hypersomnia
- Psychomotor agitation or retardation
- Fatigue/loss of energy
- Feeling of worthlessness or inappropriate guilt
- Diminished concentration or indecisiveness
- Recurrent thoughts of death or suicide (Recognition may be increased with the use of a validated screening tool, e.g., Patient Health Questionnaire [PHQ-9], Harvard Department of Psychiatry National Depression Screening Day Scale [HANDS], Center for Epidemiologic Studies - Depression Scale [CES-D] Revised, Zung [see "Availability of Companion Documents" field], Primary Care Evaluation of Mental Disorders [PRIME-MD])
Assess whether patients have symptoms suggesting bipolar disorder [C]
Eligible Population
Adults 18 years or older with high risk for major depressive disorder including prenatal and postpartum populations
Frequency
- At each evaluation where the patient's high-risk status, symptoms, or signs raise suspicion of current or uncontrolled depression
- At the first prenatal care visit through end of first post-partum year
Screening for Suicide Risk
Assess risk of suicide by direct questioning about suicidal ideation and, if present, suicidal planning, potential means, and personal/family history of suicidal attempts. [D]
Eligible Population
Individuals diagnosed with significant mood symptoms, particularly those meeting criteria for major depression
Frequency
At each encounter addressing depression until patient is treated to remission, is stable and has not expressed suicidal thinking in previous visits.
Management of Patients Who Are Prescribed Antidepressant Medication
- Initiate antidepressant medication following manufacturer's recommended doses. [A]
- Referral to, and coordination with, Behavioral Health Specialist when [D]:
- Identified or suspected risk of suicide
- Additional counseling as desired
- Primary physician not comfortable managing patient's depression
- Diagnosis is uncertain or complicated by other psychiatric factors
- Complex social situation
- Management is complex, response to medication at therapeutic dosage is not optimal, or considering prescribing multiple agents
- Psychotherapy and/or hospitalization required
- Monitor medication frequently and adjust to a therapeutic level as assessed by clinical data not to exceed the highest recommended dose. [D] Medication should not be abruptly discontinued.
- If no response after 2 to 3 weeks on therapeutic dosage increase dosage as tolerated and begin new observation period. If no response after 2 to 3 weeks on maximal dosage then switch antidepressant. If partial response after 2 to 3 weeks on maximal dosage then switch antidepressant or augment with additional agent.
- For patients with recurrent major depression, continue medication for at least one year or longer at effective dosage. [B]
Eligible Population
Individuals diagnosed with significant mood symptoms, particularly those meeting criteria for major depression
Frequency
Medications for at least 9 to 12 months after acute symptoms resolve [A]
Schedule at least 3 follow-up visits in first 12 weeks, one of which can be telephonic [D]
Definitions:
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
