Treatment Guidelines for Major Depressive Disorder (MDD)

Diagnostic Criteria

The American College of Physicians defines MDD as depressed mood or loss of pleasure/interest along with other symptoms that last for at least 2 weeks and affect normal functioning 1, 2
Diagnosis requires at least 5 symptoms during a 2-week period, including depressed mood, anhedonia, sleep disturbances, psychomotor changes, fatigue, feelings of worthlessness, concentration difficulties, or suicidal thoughts 3, 2
Assessment tools include the Patient Health Questionnaire-9 (PHQ-9) and Hamilton Depression Rating Scale (HAM-D) to measure severity and monitor treatment response 4, 2

The American Psychiatric Association recommends an acute phase (6-12 weeks) focusing on symptom reduction 3, 2
The American Psychiatric Association recommends a continuation phase (4-9 months) to prevent relapse 3, 2
The American Psychiatric Association recommends a maintenance phase (≥1 year) to prevent recurrence, especially important for patients with multiple episodes 3, 2

The American College of Physicians recommends starting with an SSRI (sertraline, escitalopram, fluoxetine, paroxetine, citalopram) or SNRI as first-line pharmacotherapy 1, 5
Cognitive Behavioral Therapy (CBT) has moderate-quality evidence supporting its effectiveness as equivalent to SGAs 1, 5
Other effective options include interpersonal therapy and psychodynamic therapies 5, 6

Low-quality evidence shows no significant difference in response or remission rates between SGA monotherapy and combination therapy with SGA plus CBT 5, 7
One trial showed improved work functioning with combination therapy compared to SGA monotherapy 5, 7

St. John's Wort: Low-quality evidence from 9 trials showed no difference in response or remission compared to SGAs 7, 8
Acupuncture: Low-quality evidence shows combination therapy of SGAs with acupuncture improved treatment response compared to SGA monotherapy 7, 8

Initial Assessment: Determine severity using validated tools (PHQ-9, HAM-D) 4, 2
First-line Treatment: Choose between SGA (SSRI preferred) or CBT, considering patient preference, previous treatment response, side effect profile, and comorbidities 1, 5, 2

SGAs have lower toxicity in overdose compared to first-generation antidepressants (tricyclics, MAOIs) 4, 2
Response to treatment is typically defined as ≥50% reduction in measured severity using validated tools 4, 2
Treatment-resistant depression (failure to respond to two or more adequate antidepressant trials) requires specialized approaches 2