This Clinical Practice Guideline (Depression in Primary Care: Volume 1. Detection and Diagnosis; and Volume 2. Treatment of Major Depression) was developed with support from the Agency for Health Care Policy and Research (AHCPR) by the Depression Guideline Panel to assist primary care providers (e.g., general practitioners, family practitioners, internists, nurse practitioners, registered nurses, mental health nurse specialists, physician assistants, and others) in the diagnosis of depressive conditions and the treatment of major depressive disorder. The panel hopes that the general principles embodied in these guidelines will also provide a framework for other medical and nonmedical practitioners who assume responsibilities for the recognition and care of depressed persons. Depression was selected as a topic for guideline development because: ■ Depressive disorders are commonly encountered in primary care, as well as in other treatment settings. Most depressed patients seek care from primary care practitioners. ■ A range of effective treatments are available and commonly provided for ■There is a large body of scientific evidence on which to base these ■ Practice surveys indicate that improvements are needed in primary care These guidelines are not aimed at rendering selected procedures reimbursable or not reimbursable; that decision logically falls to third-party payors. Nor do they specify which professionals should conduct which procedures, an issue addressed by licensing/privileging bodies. Should the recommended steps in the diagnosis or treatment of depression fall outside the expertise of the practitioner, he or she should seek a consultation with, or a referral to, someone knowledgeable in these matters. The Depression Guideline Panel is composed of experts from diverse disciplines, as well as a consumer representative. The guidelines are based on systematic literature reviews commissioned by the panel and conducted by experts in numerous areas relevant to depression, with special attention to the clinical issues most pertinent to the diagnosis and treatment of depression in primary care. Guideline development also included input from a broad range of professional and consumer organizations and individuals. The guidelines have undergone peer review and field review with intended users in clinical sites to evaluate the document both conceptually and operationally. For practitioners, patients, and their families, we hope these guidelines provide a richer understanding of depression. For researchers, we hope we have identified key areas of uncertainty for further investigation. Research develops knowledge. The synthesis and specification of current knowledge do not mitigate (in fact increase) the need for careful translation and application of this knowledge. Practitioners translate and apply that knowledge. However, in many cases they have to act without sufficient scientifically based data. The panel's inferences as to what is optimal patient care are not expected to apply to all patients or situations. Knowledge developed through research can only provide a starting point for approaching a particular patient. Algorithms are not applicable in every case, and often provide only coarse road maps for managing patients. Adaptation of guidelines to particular patients requires practitioners to have skill, training, knowledge, and experience, and patients and families to have patience, understanding, trust, and knowledge. This is the first edition of the Clinical Practice Guideline. We plan to revise the guidelines based on new knowledge, empirical evaluation of their impact on patient outcome, and critiques from users. The panel welcomes comments and suggestions for use in the next edition. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Executive Office Center, Suite 401, 2101 East Jefferson Street, Rockville, MD 20852. Depression Guideline Panel Abstract Despite the high prevalence of depressive symptoms and full major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the providers most likely to see these patients initially. Primary mood disorders include both depressive (unipolar) and manic-depressive (bipolar) conditions. Major depressive disorder (sometimes called unipolar depression) is characterized by one or more episodes of mild, moderate, or severe clinical depression without episodes of mania or hypomania (i.e., low-level mania). Depression may co-occur with nonpsychiatric medical disorders or with other psychiatric disorders; it may also be brought on by the use of certain medications. Major risk factors for depression include a personal or family history of depressive disorder, prior suicide attempts, female gender, lack of social supports, stressful life events, and current substance abuse. The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments. The cost of the illness in pain, suffering, disability, and death is high. Given the strong evidence that treatments are effective, third-party coverage for the diagnosis and treatment of depression should be equal to that available for other medical disorders. This document is in the public domain and may be used and reprinted Depression Guideline Panel. Depression in Primary Care: Volume 1. Dedication Depression in Primary Care is dedicated to the memory of Gerald L. Klerman, MD, who passed away while serving as one of our scientific reviewers. Dr. Klerman, in his lifetime of research, teaching, and clinical work, and in his years of government service as the administrator of the Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service, Washington, DC (1977–80), worked diligently to develop scientifically based information to help clinicians better serve their patients. We remain indebted to him for his contribution to our panel and to the field of psychiatry in general. |