Summary of recommendations
| Screening and suicide risk factors in major depression of adults | √ | Screening of depression is not generally recommended, given that there are reasonable doubts about its effectiveness for modifying the course of the illness if it is not accompanied by follow-up measures. |
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| √ | The possibility of a depressive pathology in persons with risk factors must be taken into account. |
| B | The questionnaires to be used should include at least two questions referring to the person’s mood and ability to enjoy. |
| √ | In any patient with a major depressive disorder, it is advisable to explore ideas of death and intent to inflict self-harm. |
| √ | The clinical history of a patient with major depression must always include previous attempts to inflict self-harm. |
| √ | In patients with a high risk of suicide, it is advisable to seek frequent, additional support and to assess sending them urgently to a mental health specialist. |
| √ | Hospitalisation should be considered for patients with a high risk of suicide. |
| Pharmacological treatment of depression | A | Antidepressant drugs represent a first line of treatment for moderate or severe depression. |
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| √ | For mild depression, other therapeutic strategies can be considered before antidepressant drugs. |
| D | The use of drugs is recommended for those patients with mild depression and a history of moderate or severe episodes of depression. |
| D | The use of drugs is recommended for mild depression when other medical illnesses or associated comorbidity may be present. |
| √ | It is advisable to set up an appointment within 15 days for any patient with depression who does not receive pharmacological treatment. |
| A | SSRIs are recommended as drugs of first choice in the treatment of major depression. |
| B | In the event that an SSRI drug is not well-tolerated due to the appearance of adverse effects, it should be switched to another drug of the same group. |
| A | An SSRI should be prescribed for patients who may receive treatment with any tricyclic antidepressant and who do not tolerate it. |
| √ | TCAs are an alternative to SSRIs if a patient has not tolerated at least two drugs from this group or is allergic to them. |
| √ | New drugs could be used in the event of intolerance to SSRIs, thereby using the profile of their adverse effects as a guide. |
| B | Specific patient profiles could warrant different drugs, thereby using the adverse effects rather than their efficacy as a guide. |
| A | Venlafaxine should be considered as a second line of treatment in patients with major depression. |
| √ | Before starting antidepression treatment, a healthcare professional should adequately inform the patient about the expected benefits; the frequent, infrequent and patient-specific side effects that could arise, in both the short and the long-term; and especially about the duration of the treatment. |
| √ | It is especially advisable to inform about a possible delay in the therapeutic effect of antidepressants. |
| √ | Patients receiving antidepressant drug treatment must be closely monitored, at least during the first 4 weeks. |
| √ | All patients who show moderate major depression and who are treated with antidepressant drugs must be assessed again before 15 days after initiating treatment. |
| √ | All patients who show severe major depression and who receive outpatient treatment with antidepressant drugs must be assessed again before 8 days after initiating treatment. |
| A | Pharmacological treatment must be maintained in all patients for at least 6 months after remission. |
| B | In patients with any previous episode or the presence of residual symptoms, the treatment must be maintained for at least 12 months after remission. |
| √ | In patients with more than 2 previous episodes, the treatment must be maintained for at least 24 months after remission. |
| B | The dose of the drug used during the maintenance phase must be similar to the dose used to achieve remission. |
| √ | In patients with a partial response at the third or fourth week of treatment, it is advisable: - To wait for the clinical evolution until week eight. - To increase the dose of the drug up to the maximum therapeutic dose. |
| √ | For a patient who does not improve with the initial drug treatment for depression, it is advisable: - To revise the diagnosis of depressive disorder. - To verify that the treatment is being followed. - To confirm that the antidepressant is being taken at the right time and dose. |
| B | If the patient does not improve at the third or fourth week, any of the following strategies could be followed: - Switching from an antidepressant to any family, including another serotonergic. - Combining antidepressants. - Augmenting the initiated treatment with lithium or triiodothyronine. |
| B | It is not advisable to increase the SSRI dose if there is no response after 3 weeks of treatment. |
| C | The association of SSRI with mirtazapine or mianserin could also be a recommendable option, but thereby taking into account the possibility of greater adverse effects. |
| B | There is insufficient information available to recommend an increase in the dose of tricyclic antidepressants in non-responders. |
| √ | In the event of resistance to various treatments according to the aforementioned guidelines, assess the use of MAOIs. |
| √ | There is insufficient data for recommending augmentation with valproate, carbamazepine, lamotrigine, gabapentin or topiramate, pindolol, benzodiazepines, buspirone, methylphenidate or atypical antipsychotics. |
| Psychotherapy | |
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| √ | Psychological interventions should be provided by professionals who have experience at managing depression and who are experts in the applied therapy. This is especially important in the most severe cases. |
| B | In mild and moderate depression, specific and brief psychological treatment (such as problem-solving therapy, cognitive behavioural therapy or counselling) in 6 to 8 sessions during 10-12 weeks should be considered. |
| B | The preferred psychological treatment for moderate, severe or resistant depression is cognitive behavioural therapy. Interpersonal therapy can be considered as a reasonable alternative. |
| B | For moderate and severe depression, suitable psychological treatment should include 16 to 20 sessions during at least five months. |
| B | For moderate depression, either antidepressant drug treatment or suitable psychological intervention can be recommended. |
| B | Cognitive behavioural therapy should be offered to patients with moderate or severe depression who reject drug treatment or for whom avoiding the secondary effects of antidepressants is a clinical priority or who express that personal preference. |
| B | Couples therapy should be considered, if applicable, in the event that a suitable response is not obtained with previous individual intervention. |
| B | Cognitive behavioural therapy should be considered for patients who have not had a suitable response to other interventions or who may have a prior history of relapses or residual symptoms, despite treatment. |
| B | Cognitive behavioural therapy should be considered for patients who have recurrent depression and who have relapsed despite antidepressant treatment or who express a preference for psychological treatment. |
| A | For patients whose depression is resistant to pharmacological treatment and/or who have multiple episodes of recurrence, a combination of antidepressants and cognitive behavioural therapy should be offered. |
| A | A combination of cognitive behavioural therapy and antidepressant medication should be offered to patients with chronic depression. |
| C | Whenever cognitive behavioural therapy is applied to more severe patients, the techniques based on behavioural activation should be given priority. |
| C | Psychological interventions other than the aforementioned could be useful for dealing with comorbidity or the complexity of the family relationships frequently associated with the depressive disorder. |
| Other treatments | |
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| A | Electroconvulsive therapy should be considered as a therapeutic alternative in adults with severe major depression. |
| √ | ECT is especially indicated for patients with severe major depression (with a high risk of suicide or severe physical impairment) in resistant depression and by informed choice of the patient. |
| √ | In general, guided self-help is not recommended for patients with severe major depression. |
| B | However, for patients with mild or moderate depression, professionals could consider recommending guided self-help programmes based on cognitive behavioural therapy. |
| √ | Participation in support groups is not considered an effective treatment measure in patients with the major depression disorder, either alone or combined with other therapeutic measures. |
| C | Programmes of structured and supervised exercise of moderate intensity, with a frequency of 2-3 times per week, with a duration of 40-45 minutes and for a period of 10 to 12 weeks should be recommended to patients with mild-moderate depression. |
| √ | The existing scientific evidence does not allow recommending the use of acupuncture as a treatment for major depression. |
| B | The use of St John’s Wort is not recommended as a treatment option for patients with major depression. |
| √ | Health professionals should inform patients who consume it about the possible risks and benefits. |
| Quality indicators | |
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| √ | Quality indicators: - Underdiagnosis of major depression. - Follow-up on treatment with antidepressants. - Maintenance of treatment with antidepressants. - Efficient use of antidepressant drugs. - Psychotherapeutic treatment in severe major depression. - Psychotherapeutic treatment in mild major depression. |
Latest update: May 2009
