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Evidence to Improve Care

Major Depression

Care for Adults and Adolescents

Click below to see a list of brief quality statements and scroll down for more information.

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment
People suspected to have major depression have timely access to a comprehensive assessment.

Quality Statement 2: Suicide Risk Assessment and Intervention
People with major depression who are at considerable risk to themselves or others, or who show psychotic symptoms, receive immediate access to suicide risk assessment and preventive intervention.

Quality Statement 3: Shared Decision-Making
People with major depression jointly decide with clinicians on the most appropriate treatment for them, based on their values, preferences, and goals for recovery. They have access to a decision aid in a language they understand that provides information on the expected treatment effects, side effects, risks, costs, and anticipated waiting times for treatment options.

Quality Statement 4: Treatment After Initial Diagnosis
People with major depression have timely access to either antidepressant medication or evidence-based psychotherapy, based on their preference. People with severe or persistent depression are offered a combination of both treatments.

Quality Statement 5: Adjunct Therapies and Self-Management
People with major depression are advised about adjunctive therapies and self-management strategies that can complement antidepressant medication or psychotherapy

Quality Statement 6: Monitoring for Treatment Adherence and Response
People with major depression are monitored for the onset of, or an increase in, suicidal thinking following initiation of any treatment. People with major depression have a follow-up appointment with their health care provider at least every 2 weeks for at least 6 weeks or until treatment adherence and response have been achieved. After this, they have a follow-up appointment at least every 4 weeks until they enter remission.

Quality Statement 7: Optimizing, Switching, or Adding Therapies
People with major depression who are prescribed antidepressant medication are monitored for 2 weeks for the onset of effects; after this time, dosage adjustment or switching medications may be considered. People with major depression who do not respond to their antidepressant medication after 8 weeks are offered a different or additional antidepressant, psychotherapy, or a combination of antidepressants and psychotherapy.

Quality Statement 8: Continuation of Antidepressant Medication
People taking antidepressant medication who enter into remission from their first episode of major depression are advised to continue their medication for at least 6 months after remission. People with recurrent episodes of major depression who are taking antidepressant medication and enter into remission are advised to continue their medication for at least 2 years after remission.

Quality Statement 9: Electroconvulsive Therapy
People with severe or treatment-resistant major depression have access to electroconvulsive therapy.

Quality Statement 10: Assessment and Treatment for Recurrent Episodes
People with major depression who have reached full remission but are experiencing symptoms of relapse have timely access to reassessment and treatment.

Quality Statement 11: Education and Support
People with major depression and their families and caregivers are offered education on major depression and information regarding community supports and crisis services.

Quality Statement 12: Transitions in Care
People with major depression who transition from one care provider to another have a documented care plan that is made available to them and their receiving provider within 7 days of the transition, with a specific timeline for follow-up. People with major depression who are discharged from acute care have a scheduled follow-up appointment with a health care provider within 7 days.


This quality standard addresses care for people who have major depression. The quality standard applies to adults and adolescents who have suspected major depression, and it considers all care settings. It does not apply to women with postpartum depression or to young children.

This quality standard includes 12 quality statements addressing areas that were identified by Health Quality Ontario’s Major Depression Quality Standard Advisory Committee as having high potential for quality improvement. It focuses on adults and adolescents 13 years of age or older receiving care for major depression in all settings by a number of providers. This quality standard does not apply to women with postpartum depression or to children under 13 years of age.

This quality standard focuses on unipolar major depression. Some statements refer specifically to people with major depression that is classified as mild, moderate, or severe. There is a range of scientifically validated measurement scales that enable clinicians to determine this classification based on factors such as the number, duration, and intensity of symptoms; the presence or absence of psychotic symptoms; and the person’s degree of functional impairment.

Major depression is one of the most common mental illnesses, imposing a huge human and economic burden on people and society. Each year, about 7% of people meet the diagnostic criteria for major depression, and about 13% to 15% of these people will experience major depression for the rest of their lives.

Major depression affects people of all ages, including the elderly, although it is most common in people who are in their early 20s to early 30s. Studies show higher rates of depression in women than in men. People with major depression may feel persistently sad and irritable, and may lose interest in pleasurable activities. They may also exhibit changes in sleeping patterns and eating habits and have difficulty concentrating or thinking clearly. These symptoms often have a negative impact on personal relationships as well as work performance and attendance. People with major depression often feel guilty and suffer from significant distress, potentially leading them to think about suicide or self-harm.

There are significant gaps in the quality of care that people with major depression receive in Ontario: for example, only one in three people discharged from hospital for a primary diagnosis of depression or other mood disorders receives the recommended follow-up visit with a physician within 7 days. There are also inequities in the care people receive for major depression: for example, although hospitalization rates for major depression are significantly higher for people living in lower-income areas than in higher-income areas, people in lower-income areas starting antidepressant medication are less likely to receive the recommended three or more physician follow-up visits within 12 weeks of starting their medication.

This quality standard is underpinned by the principles of respect and recovery, as described in the Mental Health Strategy for Canada.

People with major depression should receive services that are respectful of their rights and dignity and that promote self-determination. Each person is unique and has the right to determine their path toward mental health and well-being.

People with major depression are capable of leading meaningful lives. They have a right to services provided in an environment that promotes hope, empowerment, and optimism, and that are consistent with the values and practices of recovery-oriented care.

People with major depression should receive services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, or religious background), or disability. There are “many intersecting factors (biological, psychological, social, economic, cultural, and spiritual)” that may have an impact on mental health and well-being.

Care for people with major depression should also incorporate what is referred to as recovery. As described in the Mental Health Strategy for Canada, “recovery—a process in which people living with mental health problems and mental illnesses are actively engaged in their own journey of wellbeing—is possible for everyone. Recovery journeys build on individual, family, cultural, and community strengths and can be supported by many types of services, supports, and treatments.”

Early in the development of each quality standard, a small number of health outcomes are chosen as the most important measures of success of the entire standard. The outcomes are mapped to indicators that reflect the goals of the standard. These outcomes and the associated indicators guide the development of the quality standard so that every statement within the standard aids in achieving the chosen outcomes. Each statement is accompanied by process, structure, and/or outcome indicators that measure the successful implementation of the statement.

The following set of outcome indicators has been selected to measure the impact of the major depression quality standard as a whole

  • Number of inpatient deaths by suicide among people with a primary diagnosis of major depression

  • Percentage of people with major depression discharged from a hospital inpatient stay who die by suicide within 30 days, 3 months, 6 months, and 1 year of discharge

  • Percentage of emergency department visits for major depression that are a person’s first contact with health care services for a diagnosis of major depression

  • Overall rating of services received by people with major depression

  • Percentage of people with major depression who rate the care they receive in the hospital as excellent, very good, or good

  • Percentage of people with major depression who show a decrease in their unmet needs over time

  • Percentage of people with major depression who show an improvement in depressive symptoms during an inpatient stay

  • Readmission to any hospital within 7 days and 30 days of discharge from an inpatient hospital stay, stratified by the reason for readmission:

    • Any reason

    • A reason related to mental health and addictions

    • Major depression

  • Unscheduled emergency department visit within 7 days and 30 days after hospital inpatient discharge, stratified by the reason for the visit:

    • Any reason

    • A reason related to mental health and addictions

    • Major depression

    • Self-harm

In Ontario, major depression is the most common mental illness. According to HQO’s “Taking Stock” report (2015), almost 5% of Ontarians aged 15 and older reported symptoms of this condition in the past year (p.17). Data also suggests that between 2006 and 2014, no improvement has been achieved in the quality of care received by Ontarians living with major depression.

For example, data indicates that between 2006 and 2014 the proportion of patients who revisited the emergency department for a mental health or addictions condition within 30 days of a previous emergency department visit for major depression fluctuated between 9.7% (minimum value) and 11.3% (maximum value)1. (Figure 1).

Figure 1


To learn more about why this standard is needed, please review the Information and Data Brief for this standard.

1Quality Standards, Major Depression - Care for Adults and Adolescents (slide 12). Data sources: National Ambulatory Care Reporting System, Registered Persons Database, provided by the Institute for Clinical Evaluative Sciences. Crude rates.

"One of the turning points in my own journey was realizing that in order to be well and stay well, I needed to be a partner in my own care. This meant learning about treatment options that are available, and advocating (or asking someone to advocate) for the most appropriate option. When patients and healthcare professionals partner to achieve a common goal, the relationship contributes to one’s wellness. One cannot underestimate the knowledge and experience that a person with lived experience brings to their own health care; drawing on that wisdom demonstrates a respect for the individual, which builds trust and rapport, and may lead to better health outcomes as well."

- Rachel Cooper, expert panel member

"Implementing the major depression quality standard represents an opportunity to advance quality in a way that we have never had before and that no other province in Canada has had. Implementing the quality standards will represent a paradigm change. The biggest change relies on replacing non-evidence based interventions with evidence based interventions. With a spirit of innovation and a willingness to engage in partnerships, and at times a little more or less runway, this is absolutely doable. [This paradigm shift] is going to provide better service user experience, a different lens that is more aligned with recovery and better clinical outcomes for the patient. I hope organizations are going to embrace the opportunity to reduce the gap between the emergence of evidence and the delivery of best practices to their patients. And if patients and family members have these statements in front of them they will be more informed about the best evidence-based treatments, they will request and ask the right questions to make sure they get the best evidence based treatments."

- Dr. Phil Klassen, expert panel member

This quality standard was completed in October 2016.

Updated: February 2017

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