Treatment Options

Treatment Options
.

There are many treatments options for depression, depending on severity factors (e.g., intensity and duration of symptoms), individual factors (e.g., level of motivation, treatment adherence, psychological-mindedness, resilience, etc.), and contextual factors (e.g., deployment status, operational demands, proximity and availability to consistently participate in care, concurrent treatment for other health conditions, etc.). These include: psychoeducation and self-management, monotherapy (psychotherapy or pharmacotherapy), combination psychotherapy and antidepressants, somatic treatment, inpatient and residential treatment.

Psychoeducation should be provided to all patients on the nature of depression, including its course and various treatment alternatives, education focused on adherence-enhancement strategies, and education focused on other self-management strategies. Evidence, as noted in the VA/DoD Clinical Practice Guideline Management of Major Depressive Disorder suggests that the use of psychoeducation and self-management strategies leads to improvements in patient active involvement and adherence to treatment. In treating patients, providers in the DoD should adhere to related policy as well as VA/DoD clinical practice guidelines. 

VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder

Note: The VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder was recently updated in 2016. Content revisions to this section to reflect these updates will be forthcoming.

In the interim, please refer to the VA/DoD Clinical Practice Guidelines page for Management of Major Depressive Disorder for the latest treatment guidelines.

Policy

In September 2013, the Assistant Secretary of Defense for Health Affairs issued a memorandum that provided guidance regarding measurements and documentation of clinical outcomes in mental health treatment in Military Treatment Facilities (MTFs). Pertaining to depression, this memo specifies that for patients diagnosed with depression, the PHQ-8[1] will be used during initial evaluation and periodically until termination of treatment in mental health treatment settings to help assess a patient’s treatment progress or changes to clinical presentation.

VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder

In 2000, the Department of Veterans Affairs (VA) and the DoD developed the VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder (VA/DoD CPG for MDD), a clinical practice guideline designed to reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes, provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with major depressive disorder, and identify outcome measures to support the development of practice-based evidence. The most recent version of the guideline was released in 2009; however, this guideline is currently being revised[2]. The guideline describes the critical decision points in the management of major depressive disorder and provides clear and comprehensive evidence based recommendations incorporating current information and practices for providers throughout the DoD and VA health care systems.

Based on this clinical practice guideline, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) in concert with the VA developed clinical support tools to assist providers align their practices with the guideline. These tools bring together important resources for providers, patients and family members which support comprehensive, evidence-based treatment. The below table depicts initial treatment strategies dependent upon severity and complexity of depression.

Treatment Strategies

Level PHQ-9 Total Score Functional Impairment Initial Treatment Strategies
Severity Mild 5-14 Mild Watchful waiting, supportive counseling; if no improvement after one or more months, consider use of an antidepressant or brief psychological counseling
Moderate 15-19 Moderate Start with monotherapy, or a combination psychotherapy and antidepressants
Severe > 20 Severe May start with monotherapy but should emphasize combination or combination of multiple drug therapy
Modifiers Complicated Co-occurring PTSD, SUD, mania, or significant social stressors Start with combination of medications and somatic interventions
Chronicity > 2 years of symptomatology despite treatment

For mild-start with monotherapy, or a combination of psychotherapy and antidepressants
For mod/severe-combination or multiple drug therapy

Psychotherapy for Depression

The table below lists information regarding treatments recommended as most effective by the VA/DoD CPG for MDD.

Evidence-based Treatments

Type Description Typical Treatment Course
Cognitive Behavioral Therapy (CBT) a structured, short-term therapy based on the theory that depression is caused by certain patterns of thinking and behaviors
  • helps individuals recognize unhealthy thinking patterns and change them in a structured way, through cognitive restructuring.
  • may also involve teaching relaxation techniques, ways to increase engagement in previously enjoyed activities, and other skills to help cope with negative feelings
  • homework assignments given at each session to increase activity levels, monitor thoughts and mood, and practice interpersonal skills
Course of CBT for depression lasts 16-20 sessions or less, depending on severity
Interpersonal Therapy (IPT) a short-term therapy based on the premise that some individuals experience depression because of problematic relationships
  • goal of IPT is to help identify and solve current interpersonal problems, such as relationships with family, friends and/or co-workers
  • helps improve an individual’s communication and problem solving skills as well as ability to respond to situations that tend to result in feelings of depression
  • by improving communication skills, an individual can better resolve conflicts and improve relationships
Course of IPT lasts 16-20 sessions
Problem Solving Therapy (PST) a newer approach to treating depression, based on the theory that depression can be caused in part by problems in an individual’s life stacking up, leading to feeling overwhelmed

  • individuals work through a step-by-step process to define what problems they are currently facing and learn to apply structured problem-solving techniques to gain a sense of control over the problems and see a decrease in levels of depression
  • individuals gain the tools necessary to problem solve independently
Course of PST lasts about 4-6 sessions, usually delivered in three months

Pharmacological Treatment Options

Medications can help depression symptoms. Below are the pharmacological treatment recommendations according to the VA/DoD CPG for MDD.

Evidence-based Treatments

Type Description Typical Treatment Course
Anti-depressant Medications (ADM) thought to correct chemical imbalances in the brain that occur when an individual is depressed
  • Many types of anti-depressants shown to improve symptoms of depression, with Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) recommended as first-line medications for treatment of depression
  • SSRIs and SNRIs are popular in treatment of depression as they are effective in relieving symptoms and have few side effects
  • though anti-depressant medications are not addictive, they should not be stopped suddenly to prevent unpleasant side effects such as headaches and nausea
Requires 2-4 weeks to take effect and should be taken for 4-9 months after resolution of depression

References

[1] The PHQ-8 is an eight-item patient health questionnaire, identical to the PHQ-9, except that it does not include the question assessing thoughts of suicide and self-harm.

[2] This guideline references a drug(s) for which important revised regulatory and/or warning information has been released since completion of the CPG. Corrected information, including errata sheets, is available on the VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder website.