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APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder (2nd Ed)

APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder (2nd Ed)

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1
PRACTICE GUIDELINE FOR THE
 Treatment of Patients WithMajor Depressive Disorder
Second Edition
WORK GROUP ON MAJOR DEPRESSIVE DISORDER
T. Byram Karasu, M.D., Chair Alan Gelenberg, M.D. Arnold Merriam, M.D.Philip Wang, M.D., Dr.P.H. (Consultant)
Originally published in April 2000. This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance withnational standards, including those of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse (http://www.guideline.gov/), this guideline can no longer be assumed to be current. A third edition of this guideline is in development; publication is expected in December 2009. The September 2005 Guideline Watch associated with this  guideline provides additional information that has become available since publication of the  guideline, but it is not a formal update of the guideline.
 
2
APA Practice Guidelines 
AMERICAN PSYCHIATRIC ASSOCIATIONSTEERING COMMITTEE ON PRACTICE GUIDELINES
 John S. McIntyre, M.D.,
Chair 
Sara C. Charles, M.D.,
Vice-Chair 
Daniel J. Anzia, M.D.Ian A. Cook, M.D.Molly T. Finnerty, M.D.Bradley R. Johnson, M.D. James E. Nininger, M.D.Paul Summergrad, M.D.Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D.
AREA AND COMPONENT LIAISONS
Robert Pyles, M.D. (Area I)C. Deborah Cross, M.D. (Area II)Roger Peele, M.D. (Area III)Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V)Lawrence Lurie, M.D. (Area VI)R. Dale Walker, M.D. (Area VII)Mary Ann Barnovitz, M.D.Sheila Hafter Gray, M.D.Sunil Saxena, M.D.Tina Tonnu, M.D.
STAFF
Robert Kunkle, M.A.,
Senior Program Manager 
 Amy B. Albert, B.A.,
 Assistant Project Manager 
Laura J. Fochtmann, M.D.,
 Medical Editor 
Claudia Hart,
Director, Department of Quality Improvement and Psychiatric Services 
Darrel A. Regier, M.D., M.P.H.,
Director, Division of Research
 
Treatment of Patients With Major Depressive Disorder 
3
CONTENTS
Statement of Intent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Guide to Using This Practice Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Part A: Treatment Recommendations for Patients With Major Depressive Disorder
. . . . . . 9I.Summary of Treatment Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9A.Psychiatric Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9B.Acute Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10C.Continuation Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15D.Maintenance Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15E.Discontinuation of Active Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16II.Formulation and Implementation of a Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16A.Psychiatric Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17B.Acute Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19C.Continuation Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25D.Maintenance Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25E.Discontinuation of Active Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26III.Specific Clinical Features Influencing the Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26A.Psychiatric Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26B.Demographic and Psychosocial Variables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30C.Treatment Implications of Concurrent General Medical Disorders . . . . . . . . . . . . . . . . . . . . 35
Part B: Background Information and Review of Available Evidence
. . . . . . . . . . . . . . . . . . . 37IV.Disease Definition, Epidemiology, Natural History, and Course . . . . . . . . . . . . . . . . . . . . . . . . . . 37A.Specific Features of Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38B.Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38C.Natural History and Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40V.Review and Synthesis of Available Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41A.Acute Phase Somatic Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41B.Acute Phase Psychosocial Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53C.Psychotherapy Combined With Pharmacotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58D.Continuation Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58E.Maintenance Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

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