VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF MAJOR DEPRESSIVE DISORDER

Department of Veterans Affairs Department of Defense

Patient Guide

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor.

Version 3.0 – 2016

I. Major Depressive Disorder

Major depressive disorder, commonly known as depression, is a mental health condition characterized by sadness for a long duration of time and indifference or lack of interest in the normal pleasures of life. There are different kinds of depression, including persistent depressive disorder (formerly known as dysthymic disorder) which is persistent, mild symptoms of depression; seasonal affective disorder, which is depression with a seasonal component; and postpartum depression, which is depression after giving birth. Depression is a serious condition where those affected feel so sad and hopeless that they are unable to function normally. If untreated, depression results in a poor quality of life and even death by suicide. Fortunately, there are many effective treatments for depression.

A. Depression in the Military Population

Military personnel are especially prone to depression which has been associated with traumatic experiences, including witnessing combat, and with separation from family during deployment or military trainings. 1,2 Over a quarter of military servicemen and women report symptoms of depression. 1

II. What are the causes of depression?

Depressive illnesses are disorders of the brain. Most likely, depression is caused by a combination of genetic, biological, environmental, and psychological factors. Trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. However, depressive episodes may occur with or without an obvious trigger, and while depression can run in families, it also occurs in people without a family history of depression. Depression typically presents during the young adult years or between the ages of 20-40, though it can present earlier or later. 3 Depression is more common in women compared to men, but women are also more likely to seek treatment and less likely to commit suicide. 3 Frequently Asked Questions: How do I decide which treatment is best for me? Discuss medications, talk therapy, and other treatments with your provider to help you figure out which treatment might be best for you with the fewest side effects. Why do I need to see my provider so often? It may take several months and many visits to adjust your treatment to help you feel as well as possible. My depression is better. Can I stop treatment? No, depression treatment needs to continue even after you feel better. Most people are on medication for at least 6-12 months or longer or even indefinitely to prevent the depression from getting worse. Speak to your provider before discontinuing any part of your treatment.

III. How do I know if I have depression?

People don't always realize they have depression and might just think they have the blues and should be able to feel better without help. But depression is more than just feeling down for a few days. It can also appear as: 4,5

  • Lack of interest or motivation in things you typically enjoy

  • Sadness for a long time or unexplained crying

  • Eating more or less than usual

  • Poor sleep
  • Irritability and anger
  • Low energy; tiredness
  • Feelings of guilt, worthlessness
  • Inability to concentrate
  • Unexplained aches and pains
  • Recurring thoughts of death or suicide
  • Problems making decisions
  • Excessive worrying
  • Memory problems
  • Inability to function normally at home or work

IV. What can I expect from my doctor?

Your doctor will ask you a few questions to see if you might be depressed. If you might be depressed, your doctor will ask a longer set of questions as part of an interview to see if you have a more serious form of depression and might benefit from treatment. Your doctor may also do some blood or laboratory testing to see if you have other conditions that can cause or contribute to depression such as:

  • A thyroid test
  • A pregnancy test
  • A drug test

If your doctor thinks you might harm yourself or others, you will be referred for emergency treatment with a specialist.

V. How can I treat my depression?

Many people who are depressed do not seek treatment and fare poorly as a result. It is very important to seek treatment for depression and to stay engaged with care to get the help you need. Treatment typically includes medication, talk therapy, both, or other treatments.

A. Antidepressant medications

There are several different classes of medications that treat depression effectively but they have different mechanisms and side effects. Discuss medications with your doctor to find the best treatment for your particular situation. When you start treatment, you may have to see your provider often to adjust medications.

B. Psychotherapy

Psychotherapy—or talk therapy—is a form of counseling where you discuss your problems with an individual therapist or as part of a group. There are different approaches to therapy that might involve, for example, focusing on behavior change, self-awareness, or relationships.

C. Other treatments

Although your provider will probably suggest medications and/or talk therapy first, there are other treatments that can help people with depression. These include electroconvulsive treatment, transcranial magnetic stimulation, light therapy, and herbal treatments. Discuss these options with your provider to see if they might help you.

VI. What can I do to improve my health?

In addition to seeking help and sticking to treatment, there are things you can do to help yourself feel better. These include:

  • Exercise
  • Eat right
  • Practice good sleep habits
  • Bibliotherapy (reading texts for healing)
  • Eliminate use of tobacco and alcohol during an episode
  • Reach out to friends and family for support and company
  • Call your doctor or someone immediately if you are feeling worse or thinking about harming yourself.

Where Can I Find More Information?

National Institute of Mental Health: https://www.nimh.nih.gov/health/topics/depression/index.shtml

American Psychological Association: http://www.apa.org/topics/depress/

Centers for Disease Control and Prevention: http://www.cdc.gov/mentalhealth/basics/mental-illness/depression.htm

References

  1. Kerr M. Depression and the military. Healthline, March 29, 2012. Accessed on November 15, 2015. http://www.healthline.com/health/depression/military-service#1.
  2. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA Mar 1 2006; 295(9):1023-1032.
  3. Substance Abuse and Mental Health Services Administration. Results from the 2013 national survey on drug use and health: Mental health findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 14-4887.
  4. U.S. National Library of Medicine. Depression. MedlinePlus, 2015. Accessed on November 15, 2015. https://www.nlm.nih.gov/medlineplus/depression.html#cat5.
  5. Johns Hopkins Medicine. Depression: What you need to know as you age. Johns Hopkins Medicine, 2015. Accessed on November 15, 2015. http://www.hopkinsmedicine.org/health/healthy_aging/diseases_and_conditions/depression-what-you-need-

to-know-as-you-age.