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## Complete Summary

#### GUIDELINE TITLE

Depression clinical practice guidelines.

#### BIBLIOGRAPHIC SOURCE(S)

Kaiser Permanente Care Management Institute. Depression clinical
practice guidelines. Oakland (CA): Kaiser Permanente Care Management
Institute; 2006 Mar. 196 p. \[157 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Kaiser Permanente Care
Management Institute. Adult primary care depression guidelines. Oakland
(CA): Kaiser Permanente Care Management Institute; 2004 Apr. 132 p.

To keep current with changing medical practices, all guidelines are
reviewed, and if appropriate, revised at least every two years.

### \*\* 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.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [October 25, 2006, Effexor (venlafaxine
    HCl)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Effexor):
    Published retrospective studies report that venlafaxine overdosage
    may be associated with an increased risk of fatal outcome.

-   [May 12, 2006, Paxil (paroxetine) and Paxil
    CR](http://www.fda.gov/medwatch/safety/2006/safety06.htm#paxil):
    Changes to the Clinical Worsening and Suicide Risk subsection of the
    WARNINGS section in the prescribing Information related to adult
    patients, particularly those who are younger adults.

-   [December 8, 2005, Paxil
    (paroxetine)](http://www.fda.gov/medwatch/safety/2005/safety05.htm#Paxil3):
    Pregnancy category changed from C to D and new data and
    recommendations added to the WARNINGS section of prescribing
    information.

-   [September 27, 2005, Paxil (paroxetine) and Paxil
    CR](http://www.fda.gov/medwatch/safety/2005/safety05.htm#Paxil2):
    Changes to the Pregnancy/PRECAUTIONS section of the Prescribing
    Information to describe the results of a retrospective epidemiologic
    study of major congenital malformations in infants born to women
    taking antidepressants during the first trimester of pregnancy.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Major Depressive Disorder

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nursing\
Pharmacology\
Psychiatry\
Psychology

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Nurses\
Pharmacists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations (evidence-based and consensus) on the
treatment of Major Depressive Disorder in primary care adult outpatients

#### TARGET POPULATION

Adults with Major Depressive Disorder seen in primary care outpatient
settings

*Patients younger than 18 years and pregnant women are not included.
These guidelines do not necessarily apply to adults being seen in
specialty behavioral health (inpatient or outpatient) settings.*

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment/Management/Evaluation**

1.  Antidepressant treatment

    -   Selective serotonin reuptake inhibitors (SSRIs)

    -   Tricyclic antidepressants (TCAs)

    -   Dopamine agonists (DAs)

    -   Serotonin norepinephrine reuptake inhibitors (SNRIs)

    -   Norepinephrine reuptake inhibitors (NRIs)

    -   Combinations of antidepressants

2.  Psychotherapy (interpersonal therapy, cognitive behavioral therapy,
    problem-solving therapy)

3.  Combination of antidepressants and psychotherapy

4.  Hypericum (St. John\'s Wort) (Note: Considered but not recommended)

5.  Consultation with specialists (behavioral health, psychiatrist) for
    patients expressing suicidal ideation, intent, or plan

6.  Second-line treatment for patients whose symptoms fail to remit

    -   Combining antidepressants and psychotherapy

    -   Increasing dose of antidepressant

    -   Combined treatment with SSRI and low-dose desipramine

    -   Switching to a different antidepressant

    -   Augmenting with low-dose lithium

    -   Switching from psychotherapy to antidepressants or vice versa

> **Note**: The following were considered but not recommended for
> second-line treatment: right prefrontal transcranial magnetic
> stimulation (rTMS), folate, inositol, vagus nerve stimulation,
> augmentation with atypical antipsychotic agents, augmentation with
> pindolol

7.  Consideration of appropriate length of treatment with
    antidepressants

8.  Follow-up at specified intervals, including assessment for
    adherence, side effects, suicidal ideation, and response to
    treatment

9.  Tapering or stopping antidepressant medication

10. Consideration of patient treatment preferences

11. Self-management strategies, including exercise, bibliotherapy,
    internet self-help materials, and befriending

12. Behavioral health education classes

#### MAJOR OUTCOMES CONSIDERED

-   Change in symptoms

-   Quality of life

-   Missed school/work days

-   Office/Urgent Care Center(UCC)/Emergency Room (ER) visits

-   Hospitalizations

-   Mortality

-   Adherence to treatment plan

-   Patient satisfaction

-   Relapse prevention

-   Side effects of medication or adverse effects of treatment, such as
    attempted suicide

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Guidelines are developed using an \"evidence-based methodology\" and
involve a systematic literature search, critical appraisal of the
research design and statistical results of relevant studies, and grading
of the sufficiency (quantity, quality, consistency, and relevancy) of
the evidence for drawing conclusions.

During the guideline development process, the Guideline Development Team
reviews evidence published in peer-reviewed scientific journals,
existing evidence-based guidelines, and consensus-based statements from
external professional societies and government health organizations, and
clinical expert opinion of Kaiser Permanente regional specialty groups.

For details of the literature search, including databases searched and
search terms for each clinical question, see the original guideline
document.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Refer to Table 2 in the Appendix in the original guideline document for
the system for grading the strength of a body of evidence.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Guidelines Project Management Team performed systematic reviews of
the medical literature on each of the clinical questions identified by
the workgroup.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

To develop the Depression Guideline, a multidisciplinary, Programwide
Depression Guideline Development Team (GDT) first met in August 2005 to
define the scope of the guideline. The Project Management Team then
performed systematic reviews of the medical literature on each of the
clinical questions identified by the Guideline Development Team,
assembled the evidence, and developed draft recommendations for review
by the Guideline Development Team. All of the recommendations and
supporting evidence were reviewed by the Guideline Development Team in
depth through a series of conference calls in November through December
2005. GDT recommendations and supporting documents were then reviewed by
the Quality Review Subcommittee (of evidence-based methodological
experts) of the Kaiser Permanente National Guideline Directors group.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Recommendations are classified as either \"evidence-based (A-D, I)\" or
\"consensus-based.\"

-   Evidence-based: sufficient number of high-quality studies from which
    to draw a conclusion, and the recommended practice is consistent
    with the findings of the evidence. A recommendation can also be
    considered \"evidence-based\" if there is insufficient evidence and
    no practice is recommended.

-   Consensus-based: insufficient evidence and a practice is recommended
    based on the consensus or expert opinion of the Guideline
    Development Team.

**Label and Language of Recommendations\***

  --------------------------------------------------------------------------------
  **Label**             **Evidence-Based Recommendations**
  --------------------- ----------------------------------------------------------
  **Evidence-based      **Language**: ^a^ The intervention is strongly recommended
  (A)**                 for eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on good evidence, and the Guideline
                        Development Team (GDT) concludes that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good.

  **Evidence-based      **Language**: ^a^ The intervention is recommended for
  (B)**                 eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on 1) good evidence that benefits outweigh
                        harms and costs; or 2) fair evidence that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ No recommendation for or against routine
  (C)**                 provision of the intervention. (At the discretion of the
                        GDT, the recommendation may use the language \"option,\"
                        but must list all the equivalent options.)\
                        \
                        **Evidence**: Evidence is sufficient to determine the
                        benefits, harms, and costs of an intervention, and there
                        is at least fair evidence that the intervention improves
                        important health outcomes. But the GDT concludes that the
                        balance of the benefits, harms, and costs is too close to
                        justify a general recommendation.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ Recommendation against routinely
  (D)**                 providing the intervention to eligible patients.\
                        \
                        **Evidence**: The GDT found at least fair evidence that
                        the intervention is ineffective, or that harms or costs
                        outweigh benefits.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ The evidence is insufficient to
  (I)**                 recommend for or against routinely providing the
                        intervention. (At the discretion of the GDT, the
                        recommendation may use the language \"option,\" but must
                        list all the equivalent options.)\
                        \
                        **Evidence**: Evidence that the intervention is effective
                        is lacking, of poor quality, or conflicting and the
                        balance of benefits, harms, and costs cannot be
                        determined.\
                        \
                        **Evidence Grade**: Insufficient.

  **Consensus-based**   **Language**: ^a^ The language of the recommendation is at
                        the discretion of the GDT, subject to approval by the
                        National Guideline Directors.\
                        \
                        **Evidence**: The level of evidence is assumed to be
                        \"Insufficient\" unless otherwise stated. However, do not
                        use the A, B, C, D, or I labels which are only intended to
                        be used for evidence-based recommendations. **Evidence
                        Grade**: Insufficient, unless otherwise stated.

  For the rare          
  consensus-based       
  recommendations which 
  have \"Good\" or      
  \"Fair\" evidence,    
  the evidence must     
  support a different   
  recommendation,       
  because if the        
  evidence were good or 
  fair, the             
  recommendation would  
  usually be            
  evidence-based. In    
  this kind of          
  consensus-based       
  recommendation, the   
  evidence grade should 
  point this out (e.g., 
  \"Evidence Grade:     
  Good, supporting a    
  different             
  recommendation).\"    
  --------------------------------------------------------------------------------

^\[a\]^ All statements specify the population for which the
recommendation is intended.

\*Recommendations should be labeled and given an evidence grade. The
evidence grade should appear in the rationale. Evidence is graded with
respect to the degree it supports the specific clinical recommendation.
For example, there may be good evidence that Drugs 1 and 2 are effective
for Condition A, but no evidence that Drug 1 is more effective than Drug
2. If the recommendation is to use either Drug 1 or 2, the evidence is
good. If the recommendation is to use Drug 1 in preference to Drug 2,
the evidence is insufficient.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The National Guideline Directors\' Guideline Quality Committee reviewed
and approved the guidelines in March 2006.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Recommendations are identified as either \"evidence-based (A-D, I)\" or
\"consensus-based.\" For definitions of the levels of recommendations
see the end of the \"Major Recommendations\" field.

I.  **First-Line Treatment Of Major Depressive Disorder (MDD)**

> For patients with mild to moderate Major Depressive Disorder (MDD),
> use either antidepressant medication or psychotherapy^1^ as first-line
> treatment.\
> ***Evidence-based***
>
> Given the lack of evidence on a clearly superior approach for mild to
> moderate MDD, treatment decisions should be based on patient and
> clinician preference, potential side effects, and cost.\
> ***Consensus-based***
>
> For patients with severe or chronic MDD, combined treatment with
> antidepressants and psychotherapy^1^ is recommended as first-line
> treatment.\
> ***Evidence-based***
>
> If antidepressants are to be used, any class of antidepressant
> (selective serotonin reuptake inhibitor \[SSRI\], tricyclic
> antidepressant \[TCA\], serotonin norepinephrine reuptake inhibitor
> \[SNRI\], norepinephrine reuptake inhibitor \[NRI\], or dopamine
> agonist \[DA\]) can be prescribed as first-line treatment of MDD.\
> ***Evidence-based***
>
> Given the equivalence of therapeutic effect, base the choice of
> antidepressant on patient\'s prior response, patient and clinician
> preference, potential side effects, and cost.\
> ***Consensus-based***

II. **St. John\'s Wort for MDD**

> For patients with mild to moderate Major Depression, there is
> insufficient evidence to recommend for or against hypericum as a
> treatment alternative. The evidence on hypericum (St. John\'s Wort) in
> mild to moderate Major Depression is conflicting and of questionable
> quality. The balance of benefits, harms, and costs compared with other
> treatments cannot be fully determined.\
> ***Evidence-based* (I)^2^**
>
> For patients with severe Major Depression, hypericum (St. John\'s
> Wort) is not recommended.\
> ***Evidence-based***

III. **Antidepressants In Patients With MDD Expressing Suicidal
     Ideation, Intent, Or Plan**

> For patients with Major Depression expressing suicidal intent or plan,
> consultation with specialty behavioral health is recommended.\
> ***Consensus-based***
>
> For patients with suicidal ideation or who have made previous suicide
> attempts, consult or collaborate with a psychiatrist before
> prescribing tricyclic antidepressants (TCAs) or venlafaxine.\
> ***Consensus-based***

IV. **Second-Line Treatment Of MDD**

> For patients with MDD whose symptoms fail to remit after first line
> treatment, assess adherence to the initial treatment regimen.\
> ***Consensus-based***
>
> For patients with MDD whose symptoms fail to remit after adherence to
> first-line treatment, second-line treatment options include:

-   Combining antidepressants and psychotherapy. ***Evidence-based***

-   Increasing the dose of the initial antidepressant.
    ***Consensus-based***

-   Combined treatment with selective serotonin reuptake inhibitors
    (SSRIs) and low-dose desipramine (monitoring for TCA toxicity).
    ***Consensus-based***

-   Switching to a different antidepressant of the same or different
    class. ***Consensus-based***

-   Augmenting with low dose (300 to 600 mg/day) of lithium (in
    consultation with psychiatry). ***Consensus-based***

-   Switching from psychotherapy to antidepressants or antidepressants
    to psychotherapy. ***Consensus-based***

> For patients whose MDD symptoms fail to remit after adhering to
> first-line treatment, there is insufficient evidence to recommend the
> following treatments:

-   Right prefrontal transcranial magnetic stimulation (rTMS).

-   Folate

-   Inositol

-   Vagus nerve stimulation

> ***Evidence-based* (I)**
>
> For patients with (non-psychotic) MDD whose symptoms fail to remit
> after adherence to first-line treatment, augmentation with atypical
> antipsychotic agents is not recommended.\
> ***Evidence-based***
>
> For patients with MDD whose symptoms fail to remit after adherence to
> first-line treatment, augmentation with pindolol is not recommended.\
> ***Evidence-based***

V.  **Length Of Treatment With Antidepressants In Patients With MDD**

> Patients with MDD who achieve **symptom remission** with
> antidepressants should continue antidepressants at the same dose for
> at least an additional six to 12 months.\
> ***Evidence-based***
>
> **Patients With One Lifetime Episode of MDD**
>
> Based on patient and provider preference, a trial of antidepressant
> discontinuation is optional for patients in their first lifetime
> episode of MDD, who are being treated with antidepressants, achieve
> remission, and remain asymptomatic for six to 12 months after acute
> phase treatment.\
> ***Consensus-based***
>
> **Patients with Two or More Lifetime Episodes of MDD**
>
> Patients with two or more lifetime episodes of MDD, who are being
> treated with antidepressants and remain asymptomatic after acute phase
> treatment, should be maintained on the medication and dose with which
> they achieved remission for at least an additional 15 months to five
> years after acute phase treatment.\
> ***Consensus-based***
>
> **Patients with Chronic MDD or MDD with concurrent Dysthymia**
>
> Patients with chronic MDD (continual symptoms for more than two years)
> or Double Depression (MDD and dysthymia) who improve with
> antidepressants during acute phase treatment should continue
> antidepressants for at least an additional 15 to 28 months after acute
> phase treatment.\
> ***Evidence-based***

VI. **Follow-Up For Patients In The First Three Months\
    (Acute Phase) Of Treatment For MDD**

> For patients who are starting treatment with antidepressants for Major
> Depression, the minimum recommended follow-up frequency is one patient
> contact^3^ within the first month, and at least one additional patient
> contact four to eight weeks after the first contact.\
> ***Consensus-based***
>
> Assess for adherence, side effects, suicidal ideation, and patient
> response during both these visits.\
> ***Consensus-based***
>
> **Follow-Up For Asymptomatic Patients In Continuation Phase (Months
> Four To 12) Of Treatment Of MDD**
>
> After achieving symptom remission, at least one follow-up contact^4^
> is recommended during the fifth or sixth month of treatment in
> patients with Major Depression. Assess for continuing symptom
> remission and dosage/treatment adjustment during this contact.\
> ***Consensus-based***
>
> Additional patient follow-up is recommended to consider either
> continuing treatment beyond the continuation phase, or attempting a
> trial of treatment discontinuation.\
> ***Consensus-based***

VIII. **Follow-Up For Asymptomatic Patients With Major Depression In
      Maintenance Phase (Beyond 12 Months) Of Treatment Of MDD**

> For asymptomatic patients with Major Depression who are continuing on
> antidepressants beyond 12 months, at least one annual follow-up
> contact^5^ is recommended to assess for continuing symptom remission,
> the need for ongoing treatment, and dosage/treatment adjustment.\
> ***Consensus-based***
>
> Additional follow-up for asymptomatic patients with Major Depression
> who are continuing on antidepressants beyond 12 months should be based
> on patient preference and response.\
> ***Consensus-based***

IX. **Discontinuation Of Antidepressants In Patients With MDD**

> Fluoxetine may be discontinued without tapering with a relatively low
> risk of adverse effects.\
> ***Evidence-based***
>
> Taper other antidepressants (other selective serotonin reuptake
> inhibitors, tricyclic antidepressants, serotonin norepinephrine
> reuptake inhibitors, norepinephrine reuptake inhibitors, or dopamine
> agonists) over a two to four week period.\
> ***Consensus-based***

X.  **Treatment Preferences For MDD In Different Ethnic Groups**

> Because patient preferences for treatment may vary based on their
> ethnicity and culture, asking patients from different ethnic groups
> about treatment preference is recommended when discussing treatment
> options for MDD.\
> ***Evidence-based***

XI. **Patient Self-Management Strategies For Improving Depressive
    Symptoms In MDD**

> **Exercise** is recommended as an adjunctive strategy (in addition to
> antidepressants or psychotherapy) for treating the symptoms of MDD.\
> ***Consensus-based***
>
> **Bibliotherapy** is an optional adjunct strategy (in addition to
> antidepressants or psychotherapy) for treating the symptoms of MDD.\
> ***Consensus-based***
>
> Patient self-help materials on selected **internet**-sites^6^ are an
> optional adjunct strategy (in addition to antidepressants or
> psychotherapy) for treating symptoms of MDD.\
> ***Evidence-based***
>
> **Befriending** is an optional adjunct to antidepressants or
> psychotherapy for treating the symptoms of MDD.\
> ***Consensus-based***
>
> Use of **automated telephone programs** is not recommended as
> adjunctive therapy for MDD.\
> ***Evidence-based***
>
> There is currently insufficient evidence to recommend **light
> therapy** as a primary or adjunctive treatment for non-seasonal forms
> of MDD.\
> ***Evidence-based* (I)**
>
> There is insufficient evidence to recommend for or against **music
> therapy** as an adjunct to antidepressants or psychotherapy for
> treating the symptoms of MDD.\
> ***Evidence-based* (I)**
>
> There is insufficient evidence to recommend for or against **life
> review therapy** as an optional adjunctive depression management
> strategy for depressed older adult patients who are concurrently
> receiving regular social services care.\
> ***Evidence-based* (I)**

XII. **Behavioral Health Education Classes\
     (Cognitive Behavioral Skills or Problem-Solving Classes) for Adults
     with MDD**

> For patients with mild to moderate MDD, behavioral health education
> classes are an adjunctive treatment option, but should not be used in
> lieu of either antidepressant medication or psychotherapy.\
> ***Evidence-based***

^1^ (Interpersonal Therapy, Cognitive Behavioral Therapy, and
Problem-Solving Therapy)

^2^ Please note that only recommendations approved since the adoption in
2006 of evidence grading will use letters (A, B, C, etc.) to specify the
grade of the evidence. Recommendations approved prior to 2006 will not
include a letter grade following the statement \"evidence-based.\" For
additional information on evidence grading, see Table 1 on page 181 of
the original guideline document.

^3^ Contact may include in-person visits, phone calls or email between
patient and clinician, or phone calls/email between patient and a care
manager. The use of email between patients and providers is relatively
new, and has not been a widely utilized means of communication to date.
However, it is being increasingly advocated as part of a
patient-centered, more efficient (\"less visit dependent\") model of
care. At least one member of the Guideline Development Team uses this
modality regularly and deems it effective for follow-up contacts.

^4^ Contact may include in-person visits, phone calls or email between
patient and clinician, or phone calls/email between patient and a care
manager.

^5^ Follow-up contact may include in-person visits, phone calls or email
between patient and clinician, or phone calls/email between patient and
a care manager. The use of email between patients and providers is
relatively new, and has not been a widely utilized means of
communication to date. However, it is being increasingly advocated as
part of a patient-centered, more efficient (\"less visit dependent\")
model of care. At least one member of the Guideline Development Team
uses this modality regularly and deems it effective for follow-up
contacts.

^6^ Evidence at this time is limited to the following internet sites:
Blue Pages, Mood GYM, and ODIN.

**Definitions**:

Recommendations are classified as either \"evidence-based (A-D, I)\" or
\"consensus-based.\"

-   Evidence-based: sufficient number of high-quality studies from which
    to draw a conclusion, and the recommended practice is consistent
    with the findings of the evidence. A recommendation can also be
    considered \"evidence-based\" if there is insufficient evidence and
    no practice is recommended.

-   Consensus-based: insufficient evidence and a practice is recommended
    based on the consensus or expert opinion of the Guideline
    Development Team.

**Label and Language of Recommendations\***

  --------------------------------------------------------------------------------
  **Label**             **Evidence-Based Recommendations**
  --------------------- ----------------------------------------------------------
  **Evidence-based      **Language**: ^a^ The intervention is strongly recommended
  (A)**                 for eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on good evidence, and the Guideline
                        Development Team (GDT) concludes that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good.

  **Evidence-based      **Language**: ^a^ The intervention is recommended for
  (B)**                 eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on 1) good evidence that benefits outweigh
                        harms and costs; or 2) fair evidence that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ No recommendation for or against routine
  (C)**                 provision of the intervention. (At the discretion of the
                        GDT, the recommendation may use the language \"option,\"
                        but must list all the equivalent options.)\
                        \
                        **Evidence**: Evidence is sufficient to determine the
                        benefits, harms, and costs of an intervention, and there
                        is at least fair evidence that the intervention improves
                        important health outcomes. But the GDT concludes that the
                        balance of the benefits, harms, and costs is too close to
                        justify a general recommendation.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ Recommendation against routinely
  (D)**                 providing the intervention to eligible patients.\
                        \
                        **Evidence**: The GDT found at least fair evidence that
                        the intervention is ineffective, or that harms or costs
                        outweigh benefits.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ The evidence is insufficient to
  (I)**                 recommend for or against routinely providing the
                        intervention. (At the discretion of the GDT, the
                        recommendation may use the language \"option,\" but must
                        list all the equivalent options.)\
                        \
                        **Evidence**: Evidence that the intervention is effective
                        is lacking, of poor quality, or conflicting and the
                        balance of benefits, harms, and costs cannot be
                        determined.\
                        \
                        **Evidence Grade**: Insufficient.

  **Consensus-based**   **Language**: ^a^ The language of the recommendation is at
                        the discretion of the GDT, subject to approval by the
                        National Guideline Directors.\
                        \
                        **Evidence**: The level of evidence is assumed to be
                        \"Insufficient\" unless otherwise stated. However, do not
                        use the A, B, C, D, or I labels which are only intended to
                        be used for evidence-based recommendations.\
                        \
                        **Evidence Grade**: Insufficient, unless otherwise stated.

  For the rare          
  consensus-based       
  recommendations which 
  have \"Good\" or      
  \"Fair\" evidence,    
  the evidence must     
  support a different   
  recommendation,       
  because if the        
  evidence were good or 
  fair, the             
  recommendation would  
  usually be            
  evidence-based. In    
  this kind of          
  consensus-based       
  recommendation, the   
  evidence grade should 
  point this out (e.g., 
  \"Evidence Grade:     
  Good, supporting a    
  different             
  recommendation).\"    
  --------------------------------------------------------------------------------

^\[a\]^ All statements specify the population for which the
recommendation is intended.

\*Recommendations should be labeled and given an evidence grade. The
evidence grade should appear in the rationale. Evidence is graded with
respect to the degree it supports the specific clinical recommendation.
For example, there may be good evidence that Drugs 1 and 2 are effective
for Condition A, but no evidence that Drug 1 is more effective than Drug
2. If the recommendation is to use either Drug 1 or 2, the evidence is
good. If the recommendation is to use Drug 1 in preference to Drug 2,
the evidence is insufficient.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation, but the evidence underlying the recommendations are
drawn from randomized controlled trials, meta-analyses, and existing
systematic reviews. In cases where the data was inconclusive,
inconsistent, or non-existent, recommendations were based on the
consensus opinion of the group.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate treatment and management of adult patients with Major
Depressive Disorder

#### POTENTIAL HARMS

-   Side effects of medication

-   Adverse effects of treatment, such as suicide (attempted or
    completed)

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Combining monoamine oxidase inhibitors (MAOIs) and selective serotonin
reuptake inhibitors (SSRIs) have been associated with adverse patient
outcomes and are contraindicated.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are informational only. They are not intended or
    designed as a substitute for the reasonable exercise of independent
    clinical judgment by practitioners, considering each patient\'s
    needs on an individual basis.

-   Guideline recommendations apply to populations of patients. Clinical
    judgment is necessary to design treatment plans for individual
    patients.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Kaiser Permanente Care Management Institute. Depression clinical
practice guidelines. Oakland (CA): Kaiser Permanente Care Management
Institute; 2006 Mar. 196 p. \[157 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Apr (revised 2006 Mar)

#### GUIDELINE DEVELOPER(S)

Kaiser Permanente Care Management Institute - Managed Care Organization

#### SOURCE(S) OF FUNDING

Kaiser Permanente Care Management Institute

#### GUIDELINE COMMITTEE

Kaiser Permanente Depression Guidelines Project Management Team\
Kaiser Permanente Guideline Development Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Depression Guidelines Project Management Team Members*: David Price,
MD, Clinical Lead, Care Management Institute; Patricia deSa, MS, Project
Manager, Care Management Institute; Paul Barrett, MD, Evidence-Based
Medicine Methodologist, Care Management Institute; Norma Iban, Staff
Assistant, Care Management Institute; Tabitha Pousson, Staff Assistant,
Care Management Institute

*Guideline Development Team Members*

**Colorado**

Daniel Dugan PharmD\
David Price, MD\
Jennifer Bajaj, MD

**Georgia**

Andrea Carstens\
Howard Gould, MD\
Samuel Moss, MD

**Group Health Cooperative**

Ann Lervold

**Hawaii**

David DesJarlais, MD\
Grant Okawa, MD\
Steven Orimoto, MD

**Mid-Atlantic States**

Irv Snyder\
Timothy Sitts, MD

**Northwest**

Priscilla Butler, MD\
Donna Erbs\
Keith Griffin, MD\
Michael Johnson\
Mary Lockhart, PhD\
Norman Mullenberg, RPh

**Northern California**

Andrew Bertagnolli, PhD\
Robin Dea, MD\
Julie Lenhart\
Joel Meresman, PhD\
Charles Wang, MD

**Ohio**

Kathleen Grieser, MD\
Mark Roth, MD\
Avtar Saran, MD

**Southern California**

Allison E Arch\
Misha Askren, MD\
Mark Dreskin, MD\
Debbie Kubota, PharmD\
Martha Shenkenberg\
Carol Spellen, MD\
Erin Stone, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There were no conflicts of interest by the project management team or
the guideline development team.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Kaiser Permanente Care
Management Institute. Adult primary care depression guidelines. Oakland
(CA): Kaiser Permanente Care Management Institute; 2004 Apr. 132 p.

To keep current with changing medical practices, all guidelines are
reviewed, and if appropriate, revised at least every two years.

#### GUIDELINE AVAILABILITY

Electronic and print copies: Available from Patricia deSa, Kaiser
Permanente Care Management Institute, One Kaiser Plaza, 16th Floor,
Oakland, CA 94612

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Kaiser Permanente Care Management Institute. Depression. Clinical
    practice guidelines for adult primary care. Oakland (CA): Kaiser
    Permanente Care Management Institute; 2006. 9 p.

-   Kaiser Permanente Care Management Institute. Treating depression in
    primary care. Oakland (CA): Kaiser Permanente Care Management
    Institute; 2004. 2 p.

Electronic and print copies: Available from Patricia deSa, Kaiser
Permanente Care Management Institute, One Kaiser Plaza, 16th Floor,
Oakland, CA 94612

#### PATIENT RESOURCES

The following are available:

-   Dealing with feelings of depression. Kaiser Permanente Medical Care
    Program. 2005.

-   Talking with your health care provider about your antidepressant
    medication. Kaiser Permanente Medical Care Program. 2002.

Brochure ordering information: Available from the CMI Product Line at
510-271-6426, or <CMIproducts@kp.org>.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on December 6, 2004. The
information was verified by the guideline developer on January 20, 2005.
This summary was updated by ECRI on August 15, 2005, following the U.S.
Food and Drug Administration advisory on antidepressant medications.
This NGC summary was updated by ECRI on September 28, 2006. The updated
information was verified by the guideline developer on October 3, 2006.
This summary was updated by ECRI on November 22, 2006, following the FDA
advisory on Effexor (venlafaxine HCl). This summary was updated by ECRI
Institute on November 9, 2007, following the U.S. Food and Drug
Administration advisory on Antidepressant drugs.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
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Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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Date Modified: 11/10/2008