Clinical Practice Guideline: The Diagnosis and Treatment of Unipolar Depression—National Disease Management Guideline

Abstract

Background: Depression is one of the most common mental disorders worldwide. The German National Disease Management Guideline on Unipolar Depression (NDGM), (Nationale Versorgungsleitlinie, NVL), updated in 2022, contains recommendations on the diagnosis and treatment of acute and chronic depressive disorders.

Methods: The update was based on the findings of a systematic review of the evidence (2013-2022) and was issued by a multidisciplinary panel after a formalized consensus process.

Results: The structure of the guideline was fundamentally revised and is now based on the phases of depression and/or its treatment, as well as on the severity of the disease. There is newly added material with recommendations on Internet- and mobile-device based treatments, esketamine, repetitive magnetic stimulation, psychosocial therapies, rehabilitation, social participation, and complex forms of care. The guideline also emphasizes better coordination of all services in the care of patients with depression. This article covers the most important changes and additions among the 156 recommendations in the guideline. More information and accompanying materials are available at www.leitlinien.de/depression.

Conclusion: There are effective treatments for depression and a variety of supportive measures that can be applied with great benefit by primary care physicians, psychiatrists, psychotherapists, and complementary care providers. The updated guideline aims to further improve the early detection, definitive diagnosis, treatment, and interdisciplinary care of people with depression.

Figure 1

The diagnostic process for depressive disorders (11)

Figure 2

Acute treatment of mild depressive disorders (11) *¹ For example previous moderate/severe episodes; psychosocial risk factors; comorbidity *² Guided self-help, basic (psychosomatic) management by primary care physicians, or basic psychiatric, psychosomatic, or psychotherapeutic treatment (talk-based services beyond genuine psychotherapies, which have to be applied for with the health insurance fund) *³ Internet- and mobile device-based interventions (IMI) should be offered in mild depressive episodes, embedded in an overall therapeutic concept. ↑↑ Recommended; ↑ should be considered; ↔ may be considered; shared decision-making

Figure 3

Acute treatment of moderate and severe depressive disorders (11) *Internet- and mobile device-based interventions: – May be offered to patients with moderate depressive episodes in addition to treatment with antidepressants or psychotherapy, embedded in an overall therapeutic concept. – Should be offered as an alternative treatment option to patients with moderate depressive episodes who refuse both psychotherapy and antidepressants. – May be offered to patients with severe depressive episodes in addition to treatment with antidepressants and/or psychotherapy. ↑↑ Recommended; ↑ should be considered; ↔ may be considered; shared decision-making

Figure 4

Procedure in the event of non-response to drug treatment (11) *¹ If discontinuation does not come into question because a coexisting illness requires priority treatment, consider switching to an antidepressant from a non-interacting class of substances *² Combination of SSRI or SNRI or TCA with mianserin, mirtazapine, or trazodone *³ No more than one change to an antidepressant with the same mechanism of action within the same episode of depression *⁴ In the case of repeated non-response, i.e., failure to respond to the initial monotherapy and at least one further treatment strategy, the same six options as before can be considered again (but avoiding a second change of antidepressant), together with three further options. *⁵ The number of treatment lines before this option can vary widely among individual cases. In treatment according to the guidelines, all other strategies in the case of non-response can be tried but do not have to be, including augmentation with lithium and antipsychotics. ↑↑ Recommended; ↑ should be considered; ↔ may be considered; shared decision-making ECT, electroconvulsive therapy; rTMS, repetitive transcranial magnetic stimulation; SSRI, selective serotonin reuptake inhibitors; SNRI, serotonin and norepinephrine reuptake inhibitors; TCA, tricyclic antidepressants

eFigure 1

eFigure 2

Procedure in the event of non-response to psychotherapy * If alternative medication is possible and/or a coexisting illness does not take priority ↑↑ Recommended; ↑ should be considered; ↔ may be considered