From the Guidelines
The first-line treatment for major depressive disorder (MDD) should be either cognitive behavioral therapy (CBT) or second-generation antidepressants, selected after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. This recommendation is based on moderate-quality evidence from the American College of Physicians, which suggests that CBT and antidepressants have similar efficacy in treating MDD 1.
For psychotherapy, CBT is often recommended, with sessions occurring weekly for 12-16 weeks initially. CBT helps patients identify and change negative thought patterns and behaviors.
- CBT has been shown to be effective in reducing symptoms of depression and improving quality of life 2.
- It is a non-pharmacologic treatment option that can be used alone or in combination with medication.
For medication, second-generation antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed.
- SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), or escitalopram (Lexapro) are effective in treating MDD 3, 4.
- A typical starting dose for fluoxetine is 20 mg daily, taken in the morning, and the dose may be adjusted after 4-6 weeks based on response and side effects.
It is essential to continue treatment for at least 4-9 months after symptom improvement to prevent relapse, as recommended by the American College of Physicians 3, 4. Patients should be monitored regularly for side effects and treatment efficacy. This combination approach is recommended because it addresses both the psychological and biological aspects of depression. SSRIs work by increasing serotonin levels in the brain, which helps regulate mood, while CBT provides tools to manage negative thoughts and behaviors associated with depression.
In terms of treatment duration, the American College of Physicians recommends that clinicians continue treatment for 4 to 9 months after a satisfactory response in patients with a first episode of major depressive disorder, and for patients who have had 2 or more episodes of depression, an even longer duration of therapy may be beneficial 3, 4.
From the FDA Drug Label
Sertraline treatment should be administered at a dose of 50 mg once daily. While a relationship between dose and effect has not been established for major depressive disorder, OCD, panic disorder, PTSD or social anxiety disorder, patients were dosed in a range of 50 to 200 mg/day in the clinical trials demonstrating the effectiveness of sertraline for the treatment of these indications Consequently, a dose of 50 mg, administered once daily, is recommended as the initial therapeutic dose.
The first-line treatment for Major Depressive Disorder (MDD) is sertraline at an initial dose of 50 mg once daily 5.
- The dose may be increased up to a maximum of 200 mg/day if the patient does not respond to the initial dose.
- Dose changes should not occur at intervals of less than 1 week due to the 24-hour elimination half-life of sertraline.
From the Research
First-Line Treatment for Major Depressive Disorder (MDD)
The first-line treatment for MDD includes:
- Second-generation antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants 6, 7, 8, 9
- Psychotherapy, including cognitive behavior therapy and other types of individual and group therapy 8
Characteristics of First-Line Treatments
Key characteristics of first-line treatments for MDD include:
- Efficacy in reducing symptoms of depression
- Tolerability and safety profile
- Acceptability to patients
- Optimal dosing to achieve balance between efficacy and tolerability 6, 10
Examples of First-Line Medications
Examples of first-line medications for MDD include:
- SSRIs, such as fluoxetine, paroxetine, and sertraline 6, 7, 10
- Serotonin-norepinephrine reuptake inhibitors, such as venlafaxine 6
- Mirtazapine 6
Considerations for Choosing a First-Line Treatment
When choosing a first-line treatment for MDD, considerations include: