Objectives To provide a succinct, clinically useful summary of the management of major depression, based on the 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (MDcpg2020). Methods To develop the MDcpg2020, the mood disorders committee conducted an extensive review of the available literature to develop evidence‐based recommendations (EBR) based on National Health and Medical Research Council (NHMRC) guidelines. In the MDcpg2020, these recommendations sit alongside consensus‐based recommendations (CBR) that were derived from extensive deliberations of the mood disorders committee, drawing on their expertise and clinical experience. This guideline summary is an abridged version that focuses on major depression. In collaboration with international experts in the field, it synthesises the key recommendations made in relation to the diagnosis and management of major depression. Results The depression summary provides a systematic approach to diagnosis, and a logical clinical framework for management. The latter begins with Actions, which include important strategies that should be implemented from the outset. These include lifestyle changes, psychoeducation and psychological interventions. The summary advocates the use of antidepressants in the management of depression as Choices and nominates seven medications that can be trialled as clinically indicated before moving to Alternatives for managing depression. Subsequent strategies regarding Medication include Increasing Dose, Augmenting and Switching (MIDAS). The summary also recommends the use of electroconvulsive therapy (ECT), and discusses how to approach non‐response. Conclusions The major depression summary provides up to date guidance regarding the management of major depressive disorder, as set out in the MDcpg2020. The recommendations are informed by research evidence in conjunction with clinical expertise and experience. The summary is intended for use by psychiatrists, psychologists and primary care physicians, but will be of interest to all clinicians and carers involved in the management of patients with depressive disorders.

The clinical practice guidelines for mood disorders, published under the auspices of The Royal Australian and New Zealand College of Psychiatrists (RANZCP), are somewhat unique in that they address the management of both bipolar and depressive disorders. For the treatment of acute major depression, the RANZCP guideline recommends six psychological interventions, 1 and while short-term psychodynamic therapy (STPP) features among the recommended treatments, longterm psychodynamic psychotherapy (LTPP) does not.* The reason for this is straightforward, in that there is no compelling evidence to support the use of LTPP in the treatment of acute major depression.Nevertheless, the inclusion of only STPP ignited an intense debate concerning the use of psychodynamic therapy in the management of acute depression, and the fact that LTPP is not advocated by the guideline has drawn considerable ongoing criticism.

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Depression comprises heterogeneous syndromes with multifactorial aetiology that result in varied clinical manifestations. This makes its treatment challenging (Malhi and Mann, 2018). In addition to psychological, lifestyle and social interventions, the mainstay of management involves antidepressant pharmacotherapy. Worldwide, nearly 30 antidepressant medications are available that draw on a variety of putative mechanisms of action. However, clinically, relatively modest differences in efficacy separate these agents, and hence prescription choice is usually based on tolerability and clinician experience. In addition, several psychological interventions have replicated efficacy in clinical trials but again this is insufficient to differentiate individual therapies. In practice, approximately a third of depressed patients achieve remission in response to their first antidepressant treatment, and combining, augmenting or switching to another antidepressant is usually necessary to eventually attain remission in half of the remaining patients (Rush et al., 2006). This means that, overall, at least two-thirds of patients require several antidepressant trials to achieve remission, and, even then, many will need alternative treatments, such as psychosocial interventions or electroconvulsive therapy (ECT). In other words, despite the wide range of treatments available, poor response to antidepressants is common, and is once again attracting increasing attention.