responding to psychotherapy by 6 weeks will do so by 12 weeks (Elkin, Shea, Watkins, et al., 1989).

If the initial acute treatment is combined treatment (antidepressant medication administered optimally and formal psychotherapy) and it produces no response by 6 weeks, switching to another medication is a strong consideration. For some patients, especially those who have had previous medication trials, medication augmentation may be preferable to switching. For partial responders to the combination at week 12, no clear-cut data for the next best step are available, although logic and efficacy data indicate that augmenting or switching medication are reasonable options (Depression Guideline Panel, forthcoming).

Guideline: Strategic Planning

3 for Acute Phase Treatment

Objectives of Acute Phase Treatment

Guideline: The objectives of acute phase treatment with medication, psychotherapy, the combination, or ECT are, in order of priority, (1) reduction and, wherever possible, removal of all signs and symptoms of the depressive syndrome, and (2) restoration of occupational and other psychosocial functioning to that of the asymptomatic state. (Strength of Evidence = A.)

A secondary, hoped-for consequence of acute treatment is prevention of relapse and recurrence. Table 1 shows the four most common acute phase treatment options and the suspected mechanisms by which each treatment is thought to achieve its objectives. Relapse/recurrence may occur once medication is discontinued. Theoretically, psychotherapy may prevent relapse/recurrence if patients have learned new skills or if situations have been modified. This latter notion is not fully tested or supported with evidence to date in those with recurrent major depressive disorders. One study (Frank, Kupfer, Perel, et al., 1990) indicates that recurrence may be delayed, but not prevented, with psychotherapy.

Indications for Acute Phase Treatment

Guideline: The practitioner must distinguish between major

depression, which is sufficiently severe to require intervention, and the sadness or distress that is a normal part of the human experience. If a formal mood syndrome is present, treatment is indicated. (Strength of Evidence A.)

Effective treatment rests on accurate diagnosis. The practitioner must first determine whether the patient has a clinical depression or is simply suffering normal sadness and distress. This distinction is analogous to others made in general medicine. When the patient's condition is primarily sadness, supportive discussions and/or the passage of time may be all that is necessary to resolve the symptoms. On the other hand, if a formal mood syndrome is present, specific treatments are usually indicated because there is clear evidence for their efficacy, because untreated major depressive episodes exact a high cost in pain and disability, and because the long-term prognosis for untreated major depressive disorder is poor (NIMH, 1985; Prien and Kupfer, 1986).

For patients who have very mild cases of major depression or whose diagnosis is unclear (e.g., major depression versus adjustment reaction with depressed mood) and who are not in immediate danger or are not suffering significant functional impairment, the practitioner may want to schedule one to two additional weekly evaluation visits to determine whether symptoms will abate without formal treatment or to discuss treatment options with the patient. There is evidence that clinical management leads to remission in 20 to 30 percent of cases (Elkin, Shea, Watkins, et al., 1989). However, several cautions are in order regarding extended evaluations:

If the patient has a history of previous major depressive episodes, early intervention is recommended to prevent pain and suffering, once the presence of an episode has been clearly established (NIMH, 1985; Prien and Kupfer, 1986).

■ Extended evaluations are not recommended for moderate, severe, or psychotic patients or for those with significant functional impairment. ■ Although a reduction in symptoms often occurs with extended

evaluation, this does not indicate that no treatment is needed. A full remission is the objective of both nonspecific and formal treatments. ■ All patients who remit completely with clinical management (extended evaluation) alone should be followed up carefully (roughly two to three visits over the next 6 to 12 months), as evidence suggests that a large percentage may suffer a recurrence (Shea, Elkin, Imber, et al., 1992).

Given the evidence to date, it is appropriate to treat patients with moderate to severe major depressive disorder with medication whether or not formal psychotherapy is also used. For milder cases of major depressive disorder, there is some (albeit less clear-cut) evidence for the

efficacy of medication versus placebo. Medication is administered in dosages shown to alleviate symptoms. The specific medication choice is based on side-effect profiles, history of prior response, family history of response, and type of depression. Typically, no one antidepressant medication exceeds the others in efficacy; some patients respond well to one, while others respond to a different treatment.

In general, the objectives of the formal psychotherapies in the treatment of major depressive disorder are similar to those of medication: symptom remission, improved psychosocial functioning, and prevention of relapse/recurrence. Most of the limited available data (see Table 12, page 76) have established that formal psychotherapy as the sole acute treatment for major depressive disorder is more effective than a wait-list control in outpatients with mild to moderate, nonpsychotic major depressive episodes.

Most psychotherapy efficacy studies have focused on symptom amelioration either by direct, time-limited, symptom-targeted psychological treatments, such as cognitive or behavioral therapy, or by time-limited treatments targeted at resolution of current interpersonal difficulties (interpersonal psychotherapy) or psychological conflicts (brief dynamic psychotherapy) assumed to act as vulnerability or precipitating factors or to maintain the syndrome once it has been established.

Preferred psychotherapeutic approaches are those shown to benefit patients in research trials, such as interpersonal, cognitive, behavioral, brief dynamic, and marital therapies. Because untested therapies are not, by definition, known empirically to be either effective or ineffective, these guidelines recommend choosing tested therapies over untested therapies, when available. The therapy should be limited to 20 sessions, since efficacy research on longer forms of therapy is not available and since strong evidence for the efficacy of medication with clinical management is available.

A second objective of formal psychotherapies is to address the patient's associated psychosocial problems, even if symptom control is largely accomplished with medication. In these patients, it is important to identify the objectives of therapy before selecting the specific treatment. Often, these associated problems are consequences of the depressive episode itself. If the depressive episode is effectively relieved with medication alone, the associated psychosocial problems often abate without additional psychotherapy (Mintz, Mintz, Arruda, et al., 1992). Thus, a reassessment of the patient's condition is advisable once symptom relief has been obtained with medication. The continued presence of associated psychosocial problems provides a reasonably strong rationale for augmenting treatment with formal psychotherapy aimed at the residual problems, even though sequential, randomized trials to support this stepwise approach are largely lacking to date.