Note: This content is derived from the 2022 VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder. For the latest clinical practice guideline for this condition, visit https://www.healthquality.va.gov/guidelines/MH/.

Depressive disorders are common, yet underdiagnosed and undertreated, mental health conditions characterized by a sad, low, or irritable mood that affects an individual’s capacity to function. Depression is frequently a recurrent disorder and individuals with depression are at increased risk of suicide. Service members returning from combat deployments are at increased risk for developing depression. 

Depressive disorders are diagnosed when a persistent low mood and an absence of positive affect are accompanied by a range of symptoms, such as:

• Loss of interest in most activities
• Fatigue or loss of energy
• Significant change in weight or appetite
• Insomnia or hypersomnia
• Decreased concentration
• Inappropriate guilt or feelings of worthlessness
• Psychomotor agitation or retardation
• Suicidal ideation   

Major depression is diagnosed based on the number of symptoms a person experiences and the length of time symptoms persist. Women are diagnosed with depression more often than men.

The VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder provides guidance relating to screening for depressive disorders and recommended treatment options. Providers should also stay apprised of the latest DOW policy guidance on depression. PHCoE has created depression clinical support tools for providers, patients, and families based on the guidance in the clinical practice guideline.

Screening for Depression

The VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder recommends annual screening for depression, with more frequent screening for several high-risk populations, such as those with congestive heart failure, significant losses, chronic medical illness, or pregnant and postpartum women.

Patient Health Questionnaire

The Patient Health Questionnaire tools are designed to facilitate recognition and diagnosis of depression in primary care patients. The PHQ-2 is the recommended screening tool by the VA and DOW. Patients who screen positive on the PHQ-2 should be assessed further for symptoms and risk level. Providers should complete assessment for acute safety risks (e.g., harm to self or others, psychotic features) for all patients with suspected depression.

Screening for Depression in Pregnancy and in the Postpartum Period

Women who are pregnant or postpartum are at elevated risk for depression and if untreated, depression can have adverse impacts on mother and child. The VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder recommends screening for depression at first contact with a health care provider in the antenatal and postnatal periods, as well as at 4-6 weeks and then at 3-4 months in the postpartum period using the PHQ-2 or the Edinburgh Postnatal Depression Scale. It should also be noted that the VA/DOD Clinical Practice Guideline for the Management of Pregnancy, released in 2023, can also assist health care providers in the evaluation, treatment, and management of pregnant patients, which includes recommendations for screening for depression.

Co-occurring Disorders with Depression

The diagnostic work-up for depression should include an evaluation for existing or emerging psychological and medical conditions that may exacerbate the depressive symptoms. Psychological conditions that may complicate treatment or put an individual at increased risk for adverse outcomes are anxiety, PTSD, and substance-related disorder. Medical conditions that also co-occur with major depressive disorder may include diabetes, hypertension, pulmonary disorders, traumatic brain injury, chronic pain, and congestive heart failure.

Treatment for Depression

There are many treatment options for depression, depending on:

• Severity factors (intensity and duration of symptoms)
• Individual factors (level of motivation, treatment adherence, psychological-mindedness, resilience, etc.)
• Contextual factors (deployment status, operational demands, proximity and availability to consistently participate in care, concurrent treatment for other health conditions, etc.).

Treatment options include psychoeducation and self-management, monotherapy (psychotherapy or pharmacotherapy), combination psychotherapy and antidepressants, somatic treatment, inpatient and residential treatment. A good reference for assessment, treatment, and health care management of depression according to the clinical practice guideline is the VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder Pocket Card.

Psychotherapy for Depression

Treatments recommended as most effective by the VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder are summarized in the Clinical Support Tool on Effective Psychotherapies for the Treatment of Major Depressive Disorder.

Pharmacotherapy for Depression

Medications recommended as most effective by the VA/DOD Clinical Practice Guideline for the Management of Major Depressive Disorder are summarized in the Clinical Support Tool on Effective Pharmacotherapies for the Treatment of Major Depressive Disorder.

Psychoeducation for Depression

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, it is important to educate patients during the acute phase of treatment and the following tools may be helpful.

Patient Tools

• Understanding Depression: A Resource for Providers and Patients (2022) - Booklet with information on treatment, medications, tips on talking to family and friends about MDD and patient worksheets on how to improve sleep and manage symptoms
• Patient Self-Management for Depression (2022) - Worksheet for patients with several things they can do to help themselves feel better, even when they’re not at their best
• Talking to Family and Friends about Depression (2022) - Worksheet to help patients plan a discussion about their depression symptoms with family and friends

Family Tool

• Depression: Facts for Families (2022) - Brochure with facts on depression symptoms, causes, and effective treatments

DOW Policy Guidance on Depression

Military Standards

• DODI 6130.03 Medical Standards for Appointment, Enlistment, or Induction in the Military Services - Establishes medical standards, which, if not met, are grounds for rejection for military service, to include depression
• DODI 6490.07 Deployment-Limiting Medical Conditions for Service Members and DOD Civilian Employees in new window - Establishes policy to ensure that service members and DoD civilian employees deployed and deploying on contingency deployments are medically able to accomplish their duties in deployed environments and includes specific information on mental health disorders and treatment

Screening

• DODI 6490.15 Integration of Behavioral Health Personnel Services into Patient-Centered Medical Home Primary Care and Other Primary Care Service Settings - Provides that screening for major depressive disorder will use evidence-based screening instruments and when screening is mandated — annually, for all new patients, and in patients at higher risk for depression based on medical illness
• Military Treatment Facility Mental Health Clinical Outcomes Guidance - Provides guidance for measurement and documentation of clinical outcomes, to include use of the Patient Health Questionnaire to screen for depression

Service-specific Guidance

• Navy Leader’s Guide to Managing Sailors in Distress - A site to help leaders recognize distress related behaviors, provide support to sailors within the unit, and collaborate with Navy helping agencies to meet the needs of distressed individuals; includes a specific page related to depression
• OPNAVINST 3591.1G Small Arms Training and Qualification - Navy policy that notes that weapons and/or ammunition shall not be issued to any individual with a psychiatric diagnosis for which medication is necessary, unless recommended for a waiver and reflects that psychiatric conditions requiring medications with a Selective Serotonin Reuptake Inhibitor (SSRI) that are determined to be stable shall normally be recommended for a waiver