Clinical Practice Guideline Brief Summary For Major Depressive

Clinical Practice Guideline Brief Summary For Major Depressive Disorder in Adults Depression is a serious disorder that interferes more with social and physical functioning than do such chronic physical illnesses as hypertension, diabetes, arthritis, and back pain. It is associated with significant morbidity and a 15% mortality rate from suicide. Those who suffer from the disorder often find it to be a chronic and recurrent condition. The lifetime risk for females is 20-26%; and for males is 3-12%; with a 3-5% prevalence in the United States. Within 5 years of recovering from an episode of major depression, more than 60% of the patients will have a recurrence; a relapse within the first 6 months after recovery places patients at high risk for chronicity. Individuals who have had two episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. Current literature suggests lifetime maintenance on antidepressant following 3 distinct episodes of depression. DISEASE/CONDITION(S) GUIDELINE CATEGORY CLINICAL SPECIALTY INTENDED USERS GUIDELINE OBJECTIVE(S) Major Depressive Disorder Management Treatment Neurology Psychiatry Physicians 1. To assist the physician faced with the task of implementing specific antidepressant treatment(s) for an adult patient diagnosed as suffering from major depression according to the criteria for this disorder defined in DSM-IV (*see latest criteria DSM-IV-R per CompCare). 2. To summarize the specific forms of somatic, psychotherapeutic, psychosocial, and educational treatments that have been developed to deal with major depressive disorder and its various subtypes. Adults (over the age of 18) suspected of having major depressive disorder TARGET POPULATION INTERVENTIONS AND PRACTICES CONSIDERED The various interventions considered for treatment of a major depressive episode may be used alone or in combination. Furthermore, the psychiatrist must decide whether to conduct treatment on an outpatient, partial hospitalization, or inpatient basis. Psychotherapeutic Interventions  Psychotherapeutic management  Behavior therapy  Psychodynamic psychotherapy and psychoanalysis  Cognitive behavior therapy  Brief psychodynamic psychotherapy  Marital therapy and family therapy  Interpersonal therapy  Group therapy Somatic Interventions  Antidepressant medications including: 1. Cyclic antidepressants, which include the tricyclic antidepressants as well as the tetracyclic antidepressant medication Maprotiline 2. Selective serotonin-reuptake inhibiting antidepressants, which currently include fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, and escitalopram (Lexapro). 3. Monoamine oxidase (MAO) inhibitors, which include the commonly used phenelzine, Emsam patch, and tranylcypromine 4. Other antidepressant medications, including bupropion, nefazodone, trazodone, venlafaxine, mirtazapine, and reboxetine.  Electroconvulsive therapy  Light therapy  *VNS per CompCare. See important information regarding use of this guideline on the last page of this document. Confidential & Proprietary to CompCare Approved Quality Advisory Council 082407 Page 1 Clinical Practice Guideline Brief Summary For Major Depressive Disorder in Adults MAJOR OUTCOMES CONSIDERED  Control of depressive symptoms  Rate of remission, relapse and recurrence of major depression  Morbidity and mortality due to major depression *REGULATORY ALERT: FDA WARNING/REGULATORY ALERT: Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.  On May 12, 2006, GlaxoSmithKline (GSK) and the U.S. Food and Drug Administration (FDA) notified healthcare professionals of changes to the Clinical Worsening and Suicide Risk subsection of the WARNINGS section in the prescribing Information for Paxil and Paxil CR. These labeling changes relate to adult patients, particularly those who are younger adults. A recent meta-analysis conducted of suicidal behavior and ideation in placebo-controlled clinical trials of paroxetine in adult patients with psychiatric disorders including Major Depressive Disorder (MDD), other depression and non-depression disorders. Results of this analysis showed a higher frequency of suicidal behavior in young adults treated with paroxetine compared with placebo. Further, in the analysis of adults with MDD (all ages), the frequency of suicidal behavior was higher in patients treated with paroxetine compared with placebo. This difference was statistically significant; however, as the absolute number and incidence of events are small, these data should be interpreted with caution. All of the reported events of suicidal behavior in the adult patients with MDD were non-fatal suicide attempts, and the majority of these attempts (8 of 11) were in younger adults aged 18-30. These MDD data suggest that the higher frequency observed in the younger adult population across psychiatric disorders may extend beyond the age of 24. It is important that all patients, especially young adults and those who are improving, receive careful monitoring during paroxetine therapy regardless of the condition being treated. See the FDA Web site for more information. IMPORTANT NOTE TO PRACTITIONER: 1. This guideline is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and patterns evolve. These parameters of practice should be considered guidelines only. 2. This clinical practice guideline has been adopted from a nationally recognized source and is provided in a brief summary for ease of presentation. CompCare does not endorse use of this guideline based solely on this condensed version, but recommends a practitioner review the guideline in its entirety. To obtain the guideline in full, visit the American Psychiatric Association’s website at www.psych.org. To obtain a copy of this guideline as published by the federal government’s National Guideline Clearing House visit guidelines.gov or visit our website at www.compcare.com. 3. In a review of current literature and community practices, information may have been added to this guideline. The added information and reference source is indicated with an * asterisk. See important information regarding use of this guideline on the last page of this document. Confidential & Proprietary to CompCare Approved Quality Advisory Council 082407 Page 2