Treatments recommended as most effective by the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD) PDF include:

Acceptance and Commitment Therapy (ACT)

• For mild to moderate depression
• Manualized psychotherapy intervention derived from relational frame theory that emphasizes acceptance of emotional distress and engagement in goal-directed behaviors
• Key feature is acceptance rather than avoidance of emotional pain, which is thought to reduce affective symptom severity
• To facilitate behavior change, ACT emphasizes identification of personal values and learning to act based on those values in spite of inevitable distress as opposed to having behaviors be focused on avoiding pain and adversity

Behavior Therapy (BT)/Behavioral Activation (BA)

• For mild to moderate depression; typically 8–15 sessions
• Interventions that treat MDD by teaching patients to increase rewarding activities
• Patients learn to track their activities and identify the affective and behavioral consequences of those activities
• Emphasizes training patients to monitor their symptoms and behaviors to identify the relationships between them
• Primary therapeutic techniques include collaborative empiricism (the therapist and patient working together to increase rewarding behaviors), functional analysis of obstacles to activities, structured practice outside of the session, including scheduled activities, mood tracking and interpersonal skills practice
• Behavioral activation targets the link between avoidant behavior and depression

Cognitive Behavioral Therapy (CBT)

• For moderate to major depression; typically 16–20 sessions
• Interventions that treat MDD by teaching patients to modify both thinking and behavior
• Patients learn to track thinking and activities and identify the affective and behavioral consequences of those thoughts and activities
• Patients learn techniques to change thinking that contributes to depression and schedule activities to improve mood
• Primary therapeutic techniques include education about the treatment model, collaboration between patient and therapist to choose goals, identifying unhelpful thoughts and developing experiments to test the accuracy of such thoughts, and guided discovery
• Treatment incorporates structured practice outside of the session, including scheduled activities, mood tracking, recording and challenging thoughts, and interpersonal skills practice

Interpersonal Psychotherapy (IPT)

• For mild to moderate depression; typically 16–20 sessions
• Derived from attachment theory and treats MDD by focusing on improving interpersonal functioning and exploring relationship-based difficulties
• Addresses the connection between patients’ feelings and current difficulties in their relationships with people in their life by targeting four primary areas: interpersonal loss, role conflict, role change, and interpersonal skills

Mindfulness-based Cognitive Therapy (MBCT)

• For mild to moderate depression; typically 8–16 sessions
• Integrates traditional CBT interventions with mindfulness-based skills, including mindfulness meditation, imagery, experiential exercises, and other techniques that aid patients in experiencing affect without necessarily attempting to change it
• MBCT does not so much seek to modify or eliminate dysfunctional thoughts as to become more detached and able to observe thoughts as objects

Problem Solving Therapy (PST)

• For mild to moderate depression; typically 6 sessions, delivered over 3 months
• A discrete, time-limited, structured psychological intervention that focuses on learning to cope with specific problem areas
• Therapist and patient work collaboratively to identify and prioritize key problem areas; to break problems down into specific, manageable tasks; to problem solve; and to develop appropriate coping behaviors for problems
• Can be delivered effectively in primary care settings by general practitioners or nurses

Medications can help to treat symptoms of depression. According to the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD), anti-depressant medications (ADMs) are thought to correct chemical imbalances in the brain that occur when an individual is depressed.

• Many types of anti-depressants are 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 the treatment of depression as they are effective in relieving symptoms and have few side effects
• Mirtazapine and bupropion are additional medications also noted as evidence-based pharmacotherapy options in the treatment of MDD
• Though anti-depressant medications are not addictive, they should not be stopped suddenly to prevent unpleasant side effects such as headaches and nausea
• Individuals prescribed ADMs should take them for a minimum trial of four to six weeks prior to switching to another monotherapy or augmenting with another medication
• Medications should be taken for at least six months after resolution of depression to decrease risk of relapse

Psychoeducation should be provided to all patients on the nature of depression, including its course and various treatment alternatives, adherence-enhancement strategies, and other self-management strategies.

According to the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD) PDF, it is important to educate patients during the acute phase of treatment regarding:

• Common symptoms and relapsing nature of MDD
• Early signs and symptoms of relapse or recurrence, along with encouragement to seek treatment early in the event these signs or symptoms occur
• Side effects of potential medications, which can precede therapeutic benefit, but may recede over time and can be addressed if the prescriber is informed
• Need to take any prescribed medication daily or as directed, noting that usually takes four to six weeks before improvements are seen
• Reminder not to discontinue taking medications without first discussing with provider
• Need to continue to take medication even after feeling better, as most need to be on medication for at least 6-12 months after adequate response to prevent relapse
• Medication and/or dosage adjustments in order to maximize response while minimizing side effects are to be expected
• The potential for a slight increase in suicidal ideation in the first month to occur and importance of contacting their provider should this occur