Management of Major Depressive Disorder

Publication Date: April 26, 2022

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the Department of Veterans Affairs, the Department of Defense, for major depressive disorder. This patient summary is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Major Depressive Disorder is described in the DSM-5 as “… persistent feelings of sadness, hopelessness, and [loss of] interest in people and … surroundings.”
- MDD is commonly referred to as “depression.”
We will use the abbreviation MDD throughout this summary to refer to major depressive disorder.
Depression is typically caused by grievous life events, such as bereavement, in susceptible individuals.
Other causes of MDD include hypothyroidism, vitamin B-12 deficiency, syphilis, pain, chronic disease and certain drugs.
This patient summary focuses on the management of MDD.

Screening and Diagnosis

The VA encourages everyone to be screened for depression.
Diagnosis should include a measure of the severity of the depression.

Treatment

The VA recommends treatment by more than a single therapist.
Treatment should be either by medications or psychotherapy.
- Psychotherapy options (either group or individual) — preferred for the elderly and during pregnancy and breastfeeding:
  - Acceptance and commitment therapy
  - Behavioral therapy/behavioral activation
  - Cognitive behavioral therapy (CBT)
  - Interpersonal therapy
  - Mindfulness-based cognitive therapy
  - Problem-solving therapy
  - Short-term psychodynamic psychotherapy
  - 2nd choice: CBT-based bibliotherapy
  - 2nd choice: non-directive support
- Medication options: (If successful, continue for at least 6 months)
  - Bupropion
  - Mirtazapine
  - A serotonin-norepinephrine reuptake inhibitor
  - Trazodone, vilazodone, or vortioxetine
  - A selective serotonin reuptake inhibitor
  - For mild MDD (and neither pregnant nor breastfeeding): St, John’s wort
The VA suggests a combination of both medications and psychotherapy for patients with severe, persistent, or recurring MDD.
For inadequate response, the VA suggests:
- Changing treatment
- Adding a second-generation antipsychotic
- Adding ketamine or esketamine
- Repetitive transcranial magnetic stimulation
Electroconvulsive therapy (ECT) is recommended for Severe MDD plus:
- Catatonia or
- Psychotic depression or
- Severe suicidality or
- A history of a good response to ECT or
- Need for rapid, definitive treatment response or
- A history of a poor response or intolerable side effects to multiple antidepressants
For a high risk of relapse, consider adding:
- Cognitive behavioral therapy
- Interpersonal therapy
- Mindfulness-based cognitive therapy
For significant relational distress, offer couples-focused therapy
Consider light therapy
Consider adding yoga, tai chi, qi gong, resistance, and aerobics

Abbreviations

CBT: Cognitive Behavioral Therapy
DSM-5: Diagnostic And Statistical Manual Of Mental Disorders, 5th Edition
ECT: Electroconvulsive Therapy
MDD: Major Depressive Disorder
VA: Veterans Administration

Source Citation

McQuaid JR, Buelt A, Capaldi V, Fuller M, Issa F, Lang AE, Hoge C, Oslin DW, Sall J, Wiechers IR, Williams S. The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2022 Oct;175(10):1440-1451. doi: 10.7326/M22-1603. Epub 2022 Sep 20. PMID: 36122380.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.