This tool is designed to support primary care providers in the treatment of adult patients (≥ 18 years) who have major depressive disorder (MDD). MDD is the most prevalent depressive disorder, and approximately 7% of Canadians meet the diagnostic criteria every year.1,2 The treatment of MDD involves psychotherapy and/or pharmacotherapy. Providers should work with patients to create a treatment plan together using providers’ clinical expertise and keeping in mind the patient’s preferences, as well as the practicality, feasibility, availability and affordability of treatment.
In case of an emergency
Advise your patient, their family, caregivers and friends to call 911 or go to the Emergency Department.
Consult the CEP’s Keeping Your Patients Safe on how to complete a Form 1, if you believe that your patient is at immediate risk of harming themselves or others.
Click on the sections below to get started:
Screen patient for MDD
It is important to provide your patient with non-judgmental care (e.g. “Being diagnosed with depression is nothing to be ashamed of, it is very common and many adults are diagnosed with it every year”).
- Don’t use clinical/psychiatric language (e.g. “mental health,” “psychiatric,” and/or “maladaptive”) unless the patient uses these terms first.
- Use understandable language for cognitive distortions (e.g. “assumption” which covers many cognitive distortions, “thought trap” instead of rumination).
- Use positive language, and maintain a focus on your patient’s strengths.
- Avoid stigmatizing labels (e.g. “abnormal”, “unusual”).
- Talk about symptoms instead of disorders/diagnoses.
Screen
If patient has suspected depression, screen the patient using the PHQ-93
Click to complete with your patientClick and drag to move around, scroll to zoom.
Quick reference: interpreting PHQ-9 results
Conduct risk assessment
Use the CEP’s Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments4 tool to assess the patient.
In case of an emergency
Advise your patient, their family, caregivers and friends to call 911 or go to the Emergency Department.
Confirm MDD diagnosis
Conduct diagnostic work-up
- Rule out causes of secondary MDD by considering testing for B-12 deficiency, CBC, folic acid deficiency, corticosteroid medication, hypothyroidism and syphilis. If necessary, treat the cause of secondary MDD and other disorders.
- Rule out comorbid alcohol5 and substance use disorder6
- Rule out bipolar disorder7
- Assess if patient has a sleeping disorder8
- Rule out other chronic diseases
Confirm the diagnosis of MDD using the DSM-V criteria
A DSM-V score of > 5 with symptoms during the same two week period that are a change from the previous functioning. Depressed Mood (Q1) and/or loss of interest/pleasure (Q2) must be present.9
Assess suicidality
Suicidal thoughts, plans, and attempts are very common among people with MDD.10 Every clinical encounter with a patient that has MDD should include an assessment of suicide risk.10
- Assess if a patient is at risk of suicide or developing suicidal thoughts by using the Columbia-Suicide Severity Rating Scale (C-SSRS).
- Use active listening: involves receiving a message, processing it, and sending it back. Remember that your patient is the expert on their own experience.
Manage suicide-related behaviour
- Schedule periodic follow-up appointments to track your patient’s progress and assess their well-being.
- Monitor the presence and strength of the patients’ protective factors.4
- Help your patient identify the nearest distress centre.11
Create a management plan
Create a safety plan with lower-risk patients
Having a safety plan in place is important for both patients and providers as it:
- facilitates honest communication between patient and provider;
- establishes a collaborative relationship between patient and provider;
- facilitate the patient’s active involvement; and
- enhances patient’s commitment to treatment.
Basic components of a safety plan:
- Work with your patient to develop a safety plan that they can use when in crisis.
- Recognize warning signs that are proximal to an impending suicidal crisis.
- Identify and employ internal coping strategies without needing to contact another person.
- Use contacts with people as a means of distraction from suicidal thoughts and urges (e.g. going to healthy social settings without discussing suicidal thoughts).
- Contact family members or friends who may help to resolve a crisis and with whom suicidality can be discussed.
- Contact mental health professionals or agencies.
- Reduce the potential use of lethal means.
- See Keeping Your Patients Safe and Portico for more information.
Establish a treatment plan
Depending on the severity of your patient’s MDD, non-pharmacological, pharmacological therapies and/or complementary and alternative medicines are available. Providers should work with patients to create a treatment plan together using providers’ clinical expertise and keeping in mind the patient’s preferences, as well as the practicality, feasibility, availability and affordability of treatment.
It is suggested to offer a combination of psychotherapy and pharmacotherapy for patients with:
- Severe (i.e. PHQ-9 >20) MDD
- Chronic (duration greater than two years) MDD
- Recurrent (with three or more episodes) MDD
For additional help, consult specialists across the province to provide the best care possible for patients with complex MDD at OTN eConsult15 and the Collaborative Mental Health Network (CMHN).16
Click below to review the psychotherapy, pharmacotherapy, complementary and alternative medicine treatments available to the patient.
Psychotherapy options
When selecting a specific type of psychotherapy consider the patient’s treatment goals and preferences (e.g. group or individual therapy), whether the patient has had a prior positive response to psychotherapy treatment and if providers skilled in the preferred psychotherapy approach are available.
Take a stepped care approach
Start with the least intrusive form of care and progress to more intensive care if needed.
Set realistic expectations when initiating treatment
- “If you stick to your treatment, you should feel better than you do now. It’s also okay if you don’t feel better right away. We can help to eventually make your life feel easier.”
- “Recovery will have its ups and downs.”
- “People who stick to their treatment plan are the ones who see the most improvement over time. So, we are going to work together to make sure that happens.”
Provide your patient with adequate support
- “Depression is a common experience, you’re not alone in this. It takes a lot of strength to seek support.”
First line pyschotherapy options
Scroll (left-right) for details
Pharmacotherapy options
Select a first-line antidepressant
The selection of a first-line antidepressant is dependent on the following considerations:
Patient
- Clinical features and dimensions
- Comorbid conditions
- Response and side effects of previous use of antidepressants
- Patient preference
Medication
- Comparative efficacy
- Comparative tolerability warnings, contraindications and precautions
- Potential interactions with other medications.
- Simplicity of use
- Cost and availability
Clinical features and dimensions
The following are treatment options available to treat the clinical specifier and dimension of a patient’s MDD. For depression with melancholic features, with atypical features and with seasonal pattern, no specific antidepressants have demonstrated superiority.
Level of evidence:
• • • • = Meta-analysis with narrow confidence intervals and/or 2 or more RCTs with adequate sample size, preferably placebo-controlled,
• • • = Meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size,
• • = Small-sample RCTs or nonrandomized, controlled prospective studies or case series or high-quality retrospective studies,
• = Expert opinion/consensus
Patients with anxious distress
Use an antidepressant with efficacy in generalized anxiety disorder (level of evidence: •)
Patients with catatonic features
Benzodiazepines (level of evidence: • •)
Patients with psychotic features
Use antipsychotic and antidepressant co-treatment (level of evidence: • • • •)
Patients with mixed features
Lurasidone (level of evidence: • • •)
Ziprasidone (level of evidence: • •)
Patients with cognitive dysfunction
Vortioxetine (level of evidence: • • • •)
Bupropion (level of evidence: • • •)
Duloxetine (level of evidence: • • •)
SSRIs (level of evidence: • • •)
Moclobemide (level of evidence: • •)
Patients with sleep disturbances
Agomelatine (level of evidence: • • • •)
Mirtazapine (level of evidence: • • •)
Quetiapine (level of evidence: • • •)
Trazodone (level of evidence: • • •)
Patients with somatic symptoms (for pain)
Duloxetine (level of evidence: • • • •)
Other SNRIs (level of evidence: • • •)
Patients with somatic symptoms (for fatigue)
Bupropion (level of evidence: • • • •)
SSRIs (level of evidence: • • •)
Patients with somatic symptoms (for energy)
Duloxetine (level of evidence: • • •)
Adapted from: the Canadian Network for Mood and Anxiety Treatments (CANMAT), 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder, Section 3: Pharmacological Treatments.
First-line antidepressant options17,19
The medications listed below are all equal in efficacy and in evidence.17,18
Scroll (left-right) for details
Complementary and alternative medicine options
Complementary and alternative medicine (CAM) treatments are a group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine.20
Patients may prefer CAM treatments due to fewer side effects, lower costs, perceived efficacy and empowerment. CAM treatments may be appropriate for patients with mild MDD while pharmacological and psychological treatments remain the first-line interventions for moderate to severe MDD.
The following is presented as guidance for clinicians when considering CAM treatments in the context of individual patients and not as standards of care.20
Scroll (left-right) for details
Adapted from: the Canadian Network for Mood and Anxiety Treatments (CANMAT), 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder, Section 5: Complementary and Alternative Medicine Treatments.20
Follow-up and monitoring
Functional outcomes of treatment
Recovery from depression includes both symptom relief and improved functioning.17 After achieving symptom remission, treatment is recommended to be maintained for 6-9 months. Use clinical expertise and consider patient’s life events before determining tapering and/or stopping treatments. Unless there are clinical reasons otherwise, it is recommended to slowly taper patients off antidepressants over several weeks to avoid discontinuation syndrome. It is helpful to explain to patients what to watch out for once they have discontinued antidepressants (e.g. flu-like symptoms, insomnia, nausea and imbalance). If symptoms persist or are worrisome the patient should contact their providers.
Inadequate treatment response pathway
In patients who have not achieved remission on the highest tolerated dose after two weeks of confirmed adherence, it is recommended to switch to another monotherapy (medication or psychotherapy) or augment with a second medication or psychotherapy. For early treatment-resistant patients, consider switching to an antidepressant with superior efficacy or use other medications adjunctively.17
Use the pathway below to determine next steps:
* For chronic (characterized as MDD with duration greater than two years)13 and resistant (treated with, but failed to respond to, at least four adequate medication and/or ECT treatment regimens)13 depressions, consider:
- a chronic disease approach, with less emphasis on symptom remission and more emphasis on improvement in functioning and quality of life; and,
- larger evaluation periods for improvement.
Switching antidepressants
Considering switching to another antidepressants when:
- It is the first antidepressant trial (in subsequent trials lack of response may not be a factor for choosing between switching and adding adjunctive medications).
- There is failure of one or more antidepressants (in this case, consider switching to a second- or third-line antidepressant).
- There are poorly tolerated side effects to the initial antidepressant. Work with your patient to see if they can try to tolerate the side effects for one to two weeks to see if they disappear or are no longer problematic before switching.
- There is more time to wait for a response (less severe, less functional impairment).
- Patient prefers to switch to another antidepressant.
Options
When considering switching to another antidepressant, there is not enough of a difference in efficacy between antidepressants to make a decision on this factor alone. When initially selecting an antidepressant base it on tolerability first but if there is no improvement, consider switching to a different antidepressant. There has been some meta-analysis on a few antidepressants that suggest there may be a very slight difference in efficacy. When switching, you may want to consider these medications with a slightly better efficacy.
Antidepressants with slightly better efficacy
Level of evidence:
• • • • = Meta-analysis with narrow confidence intervals and/or 2 or more RCTs with adequate sample size, preferably placebo-controlled,
• • • = Meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size,
• • = Small-sample RCTs or nonrandomized, controlled prospective studies or case series or high-quality retrospective studies,
• = Expert opinion/consensus
Scroll (left-right) for details
Adjunctive medications
Consider adding an adjunctive medication to your patient’s treatment when17:
- There have been two or more antidepressant trials
- The initial antidepressant is well-tolerated
- There are specific residual symptoms or side effects to the initial antidepressant that can be targeted
- There is less time to wait for a response (more severe, more functional impairment)
- Patient prefers to add on another medication
Consult with a pharmacist before initiating adjunctive medication.
First line adjunctive therapy options
Level of evidence:
• • • • = Meta-analysis with narrow confidence intervals and/or 2 or more RCTs with adequate sample size, preferably placebo-controlled,
• • • = Meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size,
• • = Small-sample RCTs or nonrandomized, controlled prospective studies or case series or high-quality retrospective studies,
• = Expert opinion/consensus
Scroll (left-right) for details
For second-line adjunctive medications, see Appendix C.
Special patient populations: pregnant and postpartum patients
Although postpartum psychosis is rare, women with this disorder may have homicidal impulses toward the newborn. Careful assessment of homicidal and suicidal ideation, as well as intention and plans are important. Postpartum psychosis must always be treated as a psychiatric emergency, with hospitalization considered for the safety of the mother and baby.14
Screen
For pregnant and postpartum patients use the Edinburgh Postnatal Depression Scale (EPDS)35 to screen for depression.
Keep in mind: Specialists are available across the province to provide the best care possible for your patients at OTN eConsult15 and the Collaborative Mental Health Network (CMHN)16
First-line treatment recommendations
- For women who wish to become pregnant, are pregnant, or are breastfeeding, depression-focused psychotherapy alone is recommended.
- Depending on the severity of symptoms, depression-focused psychotherapy should be considered as the first option.14
- Most medications can be safely used by breastfeeding mothers. Consider all risks and benefits of pharmacotherapy for both mother and baby before prescribing medication.
Mild to moderate MDD21
Psychotherapy (individual or group)
Severe MDD
- Antenatal patients: pharmacotherapy is the first-line treatment, either alone or in combination with psychotherapy.
- Postpartum patients: Pharmacotherapy should be used first-line, with or without psychotherapy.21
Electroconvulsive therapy (ECT) can be an effective treatment for severe MDD in pregnant and postpartum patients who:
- have psychotic features;
- treatment-resistant patients; and
- who elect to use this modality as a matter of preference.14,21
Weigh the risks and benefits of ECT with patients before recommending treatment.
Pyschotherapy options
Scroll (left-right) for details
Pharmacotherapy options
- Valproate and paroxetine must not be used in pregnant women13,22
- St John’s Wort must not be used in pregnant or breastfeeding women13
Scroll (left-right) for details
For second-line treatment options for antenatal and for postpartum MDD please see Appendix D.
Special patient populations: older adults
Late-life depression (LLD) can be defined as MDD occuring in adults 60 years and older. It is important to differentiate early adult-onset (MDD) depression recurring in late life from late-onset depression.21
Screen
For older adults use the Geriatric Depression Scale (GDS) to screen for depression.
Keep in mind: Specialists are available across the province to provide the best care possible for your patients at OTN eConsult15 and the Collaborative Mental Health Network (CMHN).16
First line treatment recommendations
- Check the patient’s family history, consult patient’s family or caregiver to provide input on their cognition and conduct assessments to rule out dementia.
- Use the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam (MMSE) to asses the patient. The MoCA Clinic and Institute recommends to complete the MoCA Training & Certification Program46 before providers administer, interpret and score test results to avoid misdiagnosis and liability.25
- Start at the lowest possible dose of an antidepressant and increase dose as needed.
- Monitor sodium level closely when starting or changing dosages in older adults.25
Mild to moderate MDD13, 21
Pharmacotherapy is the first-line treatment, either alone or in combination with psychotherapy.
Severe MDD21
Pharmacotherapy should be used first-line, with or without psychotherapy.
Psychotherapy options
Scroll (left-right) for details
Pharmacotherapy options
According to the 2019 American Geriatric’s Society Beers Criteria: antipsychotics, mirtazapine, SNRIs, SSRIs and TCA are to be used with caution in the older adult population because it may exacerbate or cause SIADH or hyponatremia.25
Scroll (left-right) for details
For second-line treatment options see Appendix D.
Special patient populations: patients on Tamoxifen
Patients with MDD that are being treated for breast cancer with Tamoxifen should not be prescribed antidepressants that inhibit CYP2D6 (buproprion, duloxetine, fluoxetine, paroxetine) because it will decrease the efficacy of the breast cancer treatment.26
For women already taking tamoxifen and other medications (e.g. aromatase inhibitors)27 with a known CYP2D6 inhibitor, any change in antidepressant treatment should be gradual to minimize the risks of SSRI withdrawal and adverse effects commonly seen on initiation of treatment.26
Moderate inhibitors that impart lesser degrees of inhibition and are reasonable alternatives:26,28
Scroll (left-right) for details
Resources for patients, their family, caregivers and friends
Information on depression
- Greenspace – Connects people with therapists across Ontario
- Canadian Mental Health Association brochure on depression
- Here to Help – Resource on helping patients manage their depression
- Informed Choices About Depression – Information about depression and treatments for depression
- Centre for Clinical Intervention – Resource on helping patients understand and work through their depression
Online therapy
- BounceBack Ontario – Guided self-help program grounded in cognitive behavioural therapy designed to help adults manage symptoms depression. Involves 6 telephone sessions with trained coaches who lead the patient through a series of workbooks. Cost is free. Patient is contacted within 5 business days of referral to schedule first appointment. Referral or patient self-referral is required.
- Centre for Mindfulness Studies – Provides mindfulness-based cognitive therapy (MBCT), mindfulness-based stress reduction (MBSR), mindful self-compassion (MSC) and specialized mindfulness training to the general public.
- Headspace – An online site for meditation.
- Mindshift app – This app uses scientifically proven strategies based on Cognitive Behavioural Therapy (CBT) to help you learn to relax and be mindful, develop more effective ways of thinking, and use active steps to take charge of your anxiety. Available on the App Store and Google Play .
- Moodgym – A 5-module online cognitive behavioural therapy program for depression. Cost is $39 AUD for 12 month.
Support groups and wellness services
- Canadian Mental Health Association (CMHA) – Locate your local CMHA for mental health support services and programs.
- Mood Disorders Association of Ontario – Provides free support programs to people across Ontario, and their families, who are living with depression.
- Thought Spot app – Provides a live map for easily identifying and accessing health, mental health and wellness services in the Greater Toronto Area. Available on the App Store and Google Play.
Suicide prevention
- Canadian Association for Suicide Prevention – Tips on how to identify suicidal thoughts and tips for the patient’s loved ones or caregivers.
- Distress and Crisis Ontario (DCO) – DCO have distress centres that provide a listening ear for lonely, depressed, and/or suicidal people, usually 24 hours a day, 7 days a week. Many centres also have Suicide Survivor programs, support services for youth, telephone call out programs for seniors and vulnerable people, mental health Crisis Lines services and much more.
- ReMinder Suicide Safety Plan app – Helps you to create a simple suicide safety plan, that can be accessed at any time on your phone. Available on the App Store and Google Play.
- Portico Network – This toolkit includes information, resource and tools to support clinicians in providing comprehensive care to clients and patients who demonstrate suicide-related behaviour.
Supporting materials and resources for providers
Clinical resources
- Columbia-Suicide Severity Rating Scale – Provides suggested probes to understand the presence and severity of an individual’s suicidal ideation. Ultimately, the determination of the presence of suicidal ideation or behavior depends on the judgment of the individual administering the scale.
- Centre for Effective Practice – Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments tool.
- MDCalc – Medical calculators, equations, scores, and guidelines.
- Ontario Drug Benefit formulary search
- SwitchRx – aims to provide healthcare professionals with the most current and useful information to guide their clinical practice when adjusting their patient’s psychotropic treatment regimens.
- RxFiles – antidepressant comparison chart.
Clinical supports
- Centre for Mindfulness Studies – Provides mindfulness-based cognitive therapy (MBCT), mindfulness-based stress reduction (MBSR), mindful selfcompassion (MSC) and specialized mindfulness training to the general public.
- Ontario College of Family Physician’s (OCFP) Collaborative Mental Health Network (CMHN)
- OTN eConsult
For treating antenatal and postpartum MDD patients
- e-lactancia – Is a resource to check the compatibility of medications whilst breastfeeding.
- LactMed – Is a database that contains information on drugs and other chemicals to which breastfeeding mothers may be exposed.
- Infant Risk Centre – Is a leading resource on the safety of medications during pregnancy and lactation.
- Medications and Mother’s Milk – Online reference for evaluating medication use in breastfeeding mothers. Cost is $59.99 USD for 12 month access.
- SickKids’ Motherisk Clinic – The Motherisk Clinic is a specialized referral-only service that assesses the safety of medications and/or substances consumed by pregnant or nursing women and the potential effects on their babies. Health-care providers can continue to send referrals through EpicCareLink.
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Legal
This Tool was developed as part of the Knowledge Translation in Primary Care Initiative, led by the Centre for Effective Practice in collaboration with the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario. Clinical leadership for the development of the Tool was provided by Dr. Mark Silverman CCFP and was subject to external review by health care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.
This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Health care professionals are required to exercise their own clinical judgement in using this Tool. Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in this Tool (whether specifically named or not) that are owned or operated by their parties, including any information or advice contained therein.
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