Pharmacologic Treatment of Acute Major Depression and Dysthymia: Clinical Guideline, Part 1

• Depression
• Antidepressive agents, second-generation
• Antidepressive agents, tricyclic
• Serotonin uptake inhibitors
• Monoamine oxidase inhibitors

The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper, “A Systematic Review of Newer Pharmacotherapies for Depression in Adults: Evidence Report Summary,” which is part 2 of this guideline (see pages743-756).

Major depression and dysthymia are two of the most common and debilitating illnesses. The World Health Organization estimates that worldwide, major depression is the fourth leading cause of loss of disability-adjusted life-years. Major depression is a clinical syndrome lasting at least 2 weeks, during which the patient experiences either depressed mood or anhedonia plus at least five of the following symptoms: depressed mood most of the day, nearly every day; markedly diminished interest or pleasure in most activities most of the day; significant weight loss or gain or appetite disturbance; insomnia or hypersomnia; psychomotor agitation or retardation; inappropriate guilt; diminished ability to think or concentrate, or indecisiveness; or recurring thoughts of death, including suicidal ideation. Dysthymia, by contrast, is a chronic but mild depressive disorder found in approximately 3% of community populations. It also causes significant impairment and is characterized by depressed mood, less severe than that in major depression, that is present on more days than not for 2 years. During this period, two of the following symptoms must also be present: appetite disturbance, insomnia or hypersomnia, decreased energy or fatigue, low self-esteem, decreased concentration or difficulty making decisions, or feelings of hopelessness.

This guideline is based on an evidence report on pharmacotherapies for depression from the San Antonio Evidence-based Practice Center that was commissioned by the Agency for Healthcare Research and Quality (1). It answers the following questions: What is the evidence supporting the benefits of pharmacologic treatment? What are the data on the efficacy and side effect profiles of “newer” compared with “older” pharmacotherapies? How can …