NATIONAL CLINICAL PRACTICE GUIDELINE Adult Depression Clinical Practice Guideline This guideline is informational only. It is 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. Approved by the National Guideline Directors February 2012 Table of Contents Introduction................................................................................................................................... 1 Guideline Summary...................................................................................................................... 5 Rationale Statements .................................................................................................................. 12 1. First-Line Treatment of Major Depressive Disorder (MDD) .............................................. 12 2. Hypericum (St. John’s Wort) for MDD............................................................................... 38 3. Antidepressants In Patients With MDD Expressing Suicidal Ideation, Intent, Or Plan...... 44 4. Second-Line Treatment Of MDD ........................................................................................ 48 5. Length Of Treatment With Antidepressants In Patients With MDD................................... 63 6. Follow-Up For Patients In The Acute Phase of Treatment For MDD................................. 70 7. Follow-Up For Patients In The Continuation Phase of Treatment of MDD........................ 72 8. Follow-Up For Patients In Maintenance Phase of Treatment of MDD............................... 74 9. Discontinuation of Antidepressants in Patients with MDD................................................. 75 10. Treatment Preferences For MDD In Different Ethnic Groups ............................................ 77 11. Patient Self-Management Strategies for Improving Symptoms of MDD............................ 80 12. Behavioral Health Education Classes For Adults With MDD............................................. 95 13. Antidepressants To Avoid During Pregnancy or Breastfeeding.......................................... 98 Appendix A: Criteria for Grading the Evidence ................................................................... 108 Appendix B: Supporting Documentation ............................................................................... 110 1. First-Line Treatment of Major Depressive Disorder (MDD) ............................................ 110 Problem Formulation 1 ......................................................................................................... 110 Search Strategy ..................................................................................................................... 111 Evidence Tables.................................................................................................................... 114 2. Hypericum (St. John’s Wort) For Treatment of MDD ...................................................... 196 Problem Formulation 2 ......................................................................................................... 196 Search Strategy ..................................................................................................................... 197 Evidence Tables.................................................................................................................... 200 3. Antidepressants In Patients With MDD Expressing Suicidal Ideation, Intent, or Plan..... 207 Problem Formulation 3 ......................................................................................................... 207 Search Strategy ..................................................................................................................... 208 Evidence Tables.................................................................................................................... 210 4. Second-Line Treatement of MDD ..................................................................................... 214 Problem Formulation 4 ......................................................................................................... 214 Search Strategy ..................................................................................................................... 215 Evidence Tables.................................................................................................................... 218 © 2012 Kaiser Permanente Medical Care Program For use within Kaiser Permanente only. 02/12 i National Adult Depression Clincial Practice Guideline 5. Length of Treatment With Antidepressants In Patients With MDD.................................. 228 Problem Formulation 5 ......................................................................................................... 228 Search Strategy ..................................................................................................................... 229 Evidence Tables.................................................................................................................... 232 6. Follow-Up For Patients In The Acute Phase of Treatment For MDD............................... 239 Problem Formulation 6 ......................................................................................................... 239 Search Strategy ..................................................................................................................... 240 Evidence Table...................................................................................................................... 242 7. Follow-Up For Patients In The Continuation Phase of Treatment For MDD ................... 243 Problem Formulation 7 ......................................................................................................... 243 Search Strategy ..................................................................................................................... 244 Evidence Table...................................................................................................................... 246 8. Follow-Up For Patients In Maintenance Phase Treatment Of MDD ................................ 247 Problem Formulation 8 ......................................................................................................... 247 Search Strategy ..................................................................................................................... 248 Evidence Table...................................................................................................................... 249 9. Discontinuation of Antidepressants In Patients With MDD.............................................. 250 Problem Formulation 9 ......................................................................................................... 250 Search Strategy ..................................................................................................................... 251 Evidence Tables.................................................................................................................... 253 10. Treatment Preferences For MDD In Different Ethnic Groups .......................................... 255 Problem Formulation 10 ....................................................................................................... 255 Search Strategy ..................................................................................................................... 256 Evidence Table...................................................................................................................... 258 11. Patient Self-Management Strategies For Improving Symptoms of MDD......................... 259 Problem Formulation 11 ....................................................................................................... 259 Search Strategy ..................................................................................................................... 260 Evidence Tables.................................................................................................................... 262 12. Behavioral Health Education Classes For Adults With MDD........................................... 276 Problem Formulation 12 ....................................................................................................... 276 Search Strategy ..................................................................................................................... 277 Evidence Tables.................................................................................................................... 279 13. Antidepressants To Avoid During Pregnancy or Breastfeeding........................................ 283 Problem Formulation 13 ....................................................................................................... 283 Search Strategy ..................................................................................................................... 284 Evidence Tables.................................................................................................................... 285 References.................................................................................................................................. 298 © 2012 Kaiser Permanente Medical Care Program For use within Kaiser Permanente only. 02/12