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Department of Veterans Affairs
Veterans Health Administration
Office of Quality & Performance

Title:  Management of Major Depressive Disorder in Adults
Citation
   Management of Major Depressive Disorder in Adults in the Primary Care Setting. Washington, DC: VA/DoD Evidence Based Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs , and Health Affairs, Department of Defense, May 2000. . Office of Quality and Performance publication 10Q-CPG/MDD-00
Completion Date:
   February 2000
Release Date:
  May 2000
Source(s):
  The Major Depressive Disorder (MDD) Guideline was developed and written for clinicians by the Department of Veterans Affairs (VA) and the Department of Defense (DoD).
Adaptation:
  The guideline draws heavily from APA (American Psychiatric Association) and AHCPR Clinical Practice Guideline No.5 Depression in Primary Care, Volume 1 Detection and Diagnosis and Volume 2 Treatment of Major Depression. This guideline also integrates recommendations for pharmacological management of patients with major depression developed by VA Medical Advisor’s Panel (MAP) to the Pharmacy  Benefits Management Strategic Health Care Group and DoD’s Pharmacoeconomic Center.
Guideline Status:
  This is a current release of the guideline.  An update is targeted for late 2002.
Developer(s):
  Veterans Health Administration (VA), Department of Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [US]
Funding Source:
  U.S. Government
Committee:
  The Management of Major Depressive Disorder Working Group
Group Composition:
  The list of contributors to the guideline includes internists, family practitioners, psychiatrists, psychologists, psychiatric nurses social workers, and chaplains, from a wide-variety of specialty and primary care settings, diverse geographic regions, and both VA and DoD health care systems, civilian practitioners, and policy-makers.
Disease/Condition:
  Major Depressive Disorder
Category:
  Screening, Diagnosis, Treatment, and Management
Intended Users:
  Module A - Clinicians in the primary care setting and outpatient mental health specialty clinics
Module B - Clinicians in an outpatient mental health setting
Module C - Clinicians in the inpatient mental health setting
Target Population:
  Persons eligible for care in the VA or DoD health care delivery system.
Contact Person(s):
 

VA:
Laurent S. Lehman, MD
Acting Chief Consultant for Mental Health
VA Headquarters
810 Vermont Avenue, NW (116)
Washington, DC  20420
Phone: (202) 273-8434
Email:larry.lehmann@mail.va.gov

DoD:
Charles C. Engel, MD, MPH, LTC, MC, USA
Chief, Deployment Health Clinical Center
Assistant Professor Psychiatry
Uniformed Services University of the Health Services
4301 Jones Bridge Road
Bethesda, Maryland 20814-4799
Phone: (202) 782-8064
Email: cengel@usuhs.mil

Molly J. Hall, COL, MC, USAF
Chief, Clinical Quality Management Division
Air Force Measures of Effectiveness (AFMOE)/SGOC
110 Luke Avenue, Room 405
Bolling Air Force Base
Washington, DC  20332
Phone: (202) 767-4048
Email:molly.hall@usafsg.bolling.af.mil

Morgan Sammons LCDR, MSC, USN
Clinical Psychologist
US Naval Academy
Annapolis, Maryland
Phone: (410) 293-1343
Email:mtsammons@US.med.navy.mil

GOALS/OBJECTIVES
  • Identify the critical decision points in management of patients with depressive conditions, such as assessment (including assessment of unstable and high-risk conditions), empirically supported psycho therapies and pharmacological therapies, non-MDD conditions deserving consultation, patient education, and follow-up treatment.


  • Accommodate local policies or procedures, such as those regarding referrals to or consultation with mental health personnel.


  • Motivate administrators at each of the Federal agencies and care access sites to develop innovative plans to break down barriers that may prevent patients from having prompt access to preventive care.
INTERVENTIONS AND PRACTICES

The Guideline consists of three modules addressing Management of MDD in the primary care setting, inpatient mental health settings, and outpatient mental health settings. The guideline also contains the following appendices that provide screening instruments and more detailed information about a condition or treatment option to inform the provider of the spectrum of treatment options.
  • Appendix 1: Assessment Instruments


  • Appendix 2: Unstable and High Risk Conditions


  • Appendix 3: Suicidality


  • Appendix 4: Empirically Supported Psychotherapies of MDD


  • Appendix 5: Pharmacological Therapy of MDD


  • Appendix 6: Non-MDD Conditions Deserving Consultation


  • Appendix 7: Patient Education


  • Appendix 8: Electro-convulsive Therapy (ECT)
OUTCOMES CONSIDERED

Early diagnosis and treatment of MDD resulting in remission and full functional ability.

MAJOR RECOMMENDATIONS

The Major Depressive Disorder (MDD) is presented in an algorithmic format that allows the practitioner to follow in the recognition and treatment of MDD.  Recommendations are made with regard to establishing diagnosis, treatment and follow-up treatment.

CLINICAL ALGORITHM(S) ARE PROVIDED FOR:
TYPE OF EVIDENCE

The annotations that accompany the algorithms in the guideline indicate whether each recommendation is based on scientific data or expert opinion.  Where existing literature is ambiguous or conflicting, or where scientific data are lacking on an issue, recommendations are based on the expert panel’s opinion and clinical experience.  The guideline contains a bibliography and discussion of the evidence supporting each recommendation.

DESCRIPTION OF METHODS TO COLLECT EVIDENCE

The algorithm and annotations were based on an exhaustive review of the literature.  The goal of the literature review was to provide a systematic basis for the development of an evidence-based guideline.  The inclusion criteria for the literature search were related to the population being studied (adult) and the treatment setting (primary care).

The Medical Subject Headings (MeSH) terms used for the search included key therapies in hypertension, study characteristics, and study design.  In this search, “study characteristics” were those of analytic studies, case-control studies, retrospective studies, cohort studies, longitudinal studies, follow-up studies, prospective studies, cross-sectional studies, clinical protocols, controlled clinical trials, RCTs, intervention studies, and sampling studies.   Study design included crossover studies, double-blind studies, matched pair analysis, meta-analysis, random allocation, reproducibility of results, and sample size.

See Guideline Introduction page iv & v

METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

The literature search was followed by critical analysis of the literature, primarily by the clinical experts. To promote the evidence-based approach, the quality of evidence was rated using a hierarchical rating scheme.  The value of a hierarchical rating scheme is that it provides a systematic means for evaluating the scientific basis for health care services   The rating scheme used for this guideline is based on a system used by the U.S> Preventive Services Task Force (USPSTF 1996).  Decision points in the algorithm are annotated, and the primary source documents for the annotation are graded.

See Guideline Introduction page iii

The Grading Scheme Used for the Guideline

Quality of Evidence (QE)
Grade Description
I Evidence is obtained from at least one properly randomized controlled trial.
II-1 Evidence is obtained from well-designed controlled trials without randomization.
II-2 Evidence is obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3 Evidence is obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.
III Opinions of respected authorities are based on clinical experience, descriptive studies in case reports, or reports of expert committees.
 
Strength of Recommendation (SR)
Grade Description
A There is good evidence to support the recommendation that the condition be specifically considered.
B There is fair evidence to support the recommendation that the condition be specifically considered
C There is insufficient evidence to recommend for or against the inclusion of the condition, but a recommendation may be based on other grounds.
D There is fair evidence to support the recommendation that the condition be excluded from consideration
E There is good evidence to support the recommendation that the condition be excluded from consideration


REVIEW METHODS

Peer Review

QUALIFYING STATEMENTS

Clinical practice guidelines, which are increasingly being used in health care, are seen by many as a potential solution to inefficiency and inappropriate variations in care. Guidelines should be evidenced-based as well as based upon explicit criteria to ensure consensus regarding their internal validity. However, it must be remembered that the use of guidelines must always be in the context of a health care provider's clinical judgment in the care of a particular patient. For that reason, the guidelines may be viewed as an educational tool analogous to textbooks and journals, but in a more user-friendly format.

GUIDELINE AVAILABILITY

Electronic copies available from:
The Office of Quality and Performance web site.

Print copies available from:
The Office of Quality and Performance (10Q)
Veterans Health Administration, Department of Veterans Affairs
810 Vermont, NW
Washington, DC 20420
Copy Statement: No copyright restrictions apply