Consensus Guidelines in the Treatment of Major Depressive Disorder

The number of available antidepressant medications has increased dramatically in the last 10years. Furthermore, no single medication is a panacea for all depressed patients—a fact underscoredby randomized, controlled trial evidence showing that when one medication fails, an alternative maysucceed. Thus, a key issue in the treatment of depression is how to optimally orchestrate availablemedication options to maximally benefit the greatest number of patients most rapidly. One approach isthe use of consensus guidelines or medication algorithms. This paper discusses the rationale for andcritical issues in the development of medication algorithms, and the timely use of symptom measuresto ensure proper implementation. Once developed, guidelines must be appropriately implemented byclinicians, adhered to by patients, and supported by administrators. These three stakeholder groupsoften need education, incentives, and ongoing support to implement such guidelines. Whether guidelinesactually improve outcome is largely uninvestigated, although a recent study of depressed patientsin primary care found that using guidelines did improve outcome but at an increased treatmentcost. The clinical and economic impact of guideline-driven treatment for the severe and persistentlydepressed deserves study.