Earlier this year, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of major depressive disorders (MDD). These updated guidelines are diverse, and the synopsis focuses on key recommendations with new evidence for pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telehealth, which became an important component of treatment during the COVID-19 pandemic. A summary of key recommendations is published in Annals of Internal Medicine.
In a change from the 2016 guideline, the 2022 guideline has two sections that refer to “treatment of uncomplicated MDD” and “treatment of MDD that is severe or has a partial or limited response to initial treatment” to better align with the body of evidence and clinical practice. Several interventions that did not meet inclusion criteria or had a limited recommendation in the 2016 guideline now are included or have higher-level recommendations. The VA/DoD guidelines recommend a range of psychotherapies for treatment of depression and are the only major guidelines to address the use of ketamine, esketamine, and psychedelics. The guidelines suggest use of ketamine and esketamine in patients who have not responded to other treatments and psychedelic treatments only in a research setting.
Interventional treatments, such as electroconvulsive therapy, are recommended for patients with multiple failed attempts at therapy or a need for immediate relief from symptoms.
Telemedicine, or virtual treatment, became more widely available during the COVID-19 pandemic, even for mental health issues. While limited evidence suggests some benefit to computer-guided treatment, the guideline authors found insufficient evidence overall to recommend for or against telehealth for treatment of MDD.
Depressive disorders are common and are ranked third after headaches and pain in terms of years lived with disability. Although a broad range of effective treatments are available to treat depressive disorders, most people with depression do not receive adequate care. As such, it is important for patients and providers to have knowledge of and access evidence-based interventions. The guideline work group found a broad and expanding range of treatment options for major depression and the resulting VA/DoD clinical practice guidelines are best practices for health care. (FH/NW)