Clinical tips from the American Psychiatric Association for treatment of major depressive disorder

One of the most common mental disorders in the U.S. is major depression, according to the National Institute of Mental Health. Major depression can be defined as a period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had a majority of specified symptoms, such as problems with sleep, eating, energy, concentration or self‑worth.

Blue Cross Blue Shield of Michigan and Blue Care Network are committed to helping ensure that our recommendations and policies for the treatment of behavioral health conditions follow evidence‑based guidelines. Following are several clinical tips based on current recommendations of the American Psychiatric Association that we thought you might find useful.

Begin with a thorough evaluation. Many medical problems can present with comorbid depressive symptoms. Diabetes, heart disease, chronic pain, endocrine disorders and sleep apnea are just a few of the many medical problems that share similar symptoms with major depression.

Use of the PHQ-9 screening tool provides an objective measure of severe depression symptoms and can be repeated to measure progress to remission. The pneumonic SIG E CAPS is another good tool for diagnosis. The acronym stands for S (suicidal ideation), I (lack of interest or initiative), G (excessive guilt), E (lack of energy), C (change in cognition), A (sad affect or apathy/appetite change), P (psychomotor agitation or slowing), S (somatization/sleep disturbance).

Use of the PHQ‑2 or 9 provides an objective measure of severe depression symptoms and can be repeated to measure progress to remission. Other useful tools include the Zung Depression Scale or the Beck Depression Inventory, which aren’t as commonly used.

Initiate a course of cognitive behavioral psychotherapy at the outset of treatment.  Psychotherapy (sometimes referred to as counseling, therapy or “talk therapy”) can help a patient to think through events and consequences they’ve experienced and see them in new ways. Psychotherapy can also help patients learn new responses to circumstances and change the way they think about themselves and their value to themselves and others.

Initiate an antidepressant medication. Consider prescribing a selective serotonin reuptake inhibitor, selective serotonin and norepinephrine reuptake inhibitor or an atypical (bupropion, mirtazapine), titrate the medication to full Food and Drug Administration-approved dose or highest tolerated dose for a full four weeks.

Recommend a diet and exercise regimen. Moderate exercise can help increase chemicals in your brain that are similar to the effect of certain medications. Usually, doing 30 to 45 minutes of aerobic exercise three to five times per week helps a patient to think more clearly, sleep better at night, digest their food better and helps cardiac and lung function as a side benefit.

Diet is important to create the needed building blocks of the chemicals in the brain that can improve mood. A good balanced diet is adequate but adding two fatty fish‑containing meals a week is even better. Salmon, walleye, perch, bass and tilapia are examples.

Reevaluate the patient at the four to six week interval. At this time, readminister the same objective scale along with a clinical examination. If there is no or only minimal change in depression symptoms, seriously consider increasing the dose/frequency of the current medication or consider changing to another class of antidepressant. Confirm they are taking it and participating in therapy in addition to following the recommendations for diet and exercise.

Reevaluate the patient again after four to six weeks. If there is still no improvement, you might request a psychiatric consultation for diagnostic confirmation and possible use of augmentation agents. These agents might include such medications as lithium, thyroid hormone (t3), an atypical antipsychotic agent (Seroquel or Abilify) or a psychostimulant. Each of these has literature to support their use but should be initiated by a specialist or at least in consultation with one.

Continue to reevaluate with objective scales. Doing this may help identify progress that would be missed using only subjective evaluations even by the most experienced provider.

Additional steps. There are additional steps in the algorithm that the specialist
can progress to as indicated. For people who don’t attain remission with the first few steps in treatment, a specialist can assist with more advanced interventions. These may include combinations of medications and somatic treatments, such as electroconvulsive therapy, transcranial magnetic stimulation, vagal nerve stimulation, esketamine nasal inhaled treatment and deep-brain stimulation (considered investigational).

Full remission of symptoms is the goal, and it’s very important to keep working toward that goal until it’s achieved. Once achieved, continue maintenance as decreasing or discontinuing treatment can lead to lack of response to treatment if symptoms recur.  That risk is very high as more than 50% of people will experience a lack of response. More than 70% of people with a history of multiple depressive episodes will have a recurrence if treatment is stopped.  

Educating the patient about the importance of medication adherence, diet, exercise and psychotherapy, along with spiritual resources and mindfulness practices, is an important aspect of the relationship that providers have with their patients. Providing guidance and hope can be a powerful intervention.

Note: For purposes of this article, we’ve augmented the American Psychiatric Association’s tips with information about the PHQ‑9 screening tool. This evidence-based tool is freely available and incorporated into many electronic medical records.