How should major depressive disorder be treated, according to the U.S. Department of Veterans Affairs and Department of Defense guidelines?
New recommendations in these guidelines include monitoring patients with depression via an ongoing measurement tool and reserving ketamine/esketamine for patients who have not responded to several adequate trials of drug therapy. The recommendations do not prioritize either psychotherapy or drug therapy but suggest choosing a single approach for uncomplicated depression. You can find the full guidelines on the U.S. Department of Veterans Affairs website.
Plan de l'etude:
The guideline working group comprised representatives from several disciplines and specialties. Patients were involved in focus groups to assess important aspects of treatment and to learn their values and preferences. There were no financial conflicts of interest. In a nod to the role of intellectual conflicts of interest, researchers were recused from discussion of evidence in the areas of their research. The recommendations were based on a systematic review of evidence. The guidelines continue to recommend screening of adults for depression and using a quantitative scale to monitor symptoms over time (both weak recommendations). These guidelines addressed uncomplicated depression, severe depression, and depression that has had a partial or limited response to initial treatment. For uncomplicated depression, the authors suggest treating with either psychotherapy or pharmacotherapy alone (weak recommendation). They do not recommend a specific type of psychotherapy or whether it should be individually or in a group (weak recommendation). They do not give a recommendation for choice of drug therapy, other than to avoid nefazodone, monoamine oxidase inhibitors, and tricyclic antidepressants. Esketamine/ketamine should be reserved for patients who have not responded to several trials of pharmacotherapy. Patients with severe symptoms or with partial or limited response to treatment should be treated with a combination of psychotherapy and drug therapy.
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine