What is the recommended management for depression?

Management of Depression: Evidence-Based Approach

For depression management, second-generation antidepressants (particularly SSRIs) are recommended as first-line pharmacotherapy, while cognitive behavioral therapy (CBT) and other evidence-based psychotherapies are equally effective first-line options, with combination therapy showing superior outcomes for moderate to severe depression. 1, 2

First-Line Treatment Options

Psychotherapy

• Cognitive Behavioral Therapy (CBT) - Highly effective for mild to moderate depression
• Behavioral Activation (BA) - Focuses on increasing engagement in positive activities
• Interpersonal Therapy - Addresses interpersonal relationships and social functioning
• Psychodynamic Therapy - Effective option focusing on unconscious processes

Pharmacotherapy

• SSRIs (Selective Serotonin Reuptake Inhibitors):

  • First-line medication choice for most patients
  • Initial options include:
    • Sertraline (50-200 mg daily) 1, 3
    • Citalopram (10-60 mg daily) 1
    • Escitalopram (10-20 mg daily) 1
    • Fluoxetine (20-80 mg daily) 4

• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

  • Slightly more effective than SSRIs but with higher rates of adverse effects 1
  • Options include venlafaxine (37.5-225 mg daily)

• Other options:

  • Bupropion - Lower rates of sexual side effects 2
  • Mirtazapine - Helpful for patients with insomnia or appetite issues 1

Treatment Selection Algorithm

1. For mild to moderate depression:

   • Start with either psychotherapy (CBT preferred) or an SSRI
   • Base choice on patient preference, availability, and cost

2. For moderate to severe depression:

   • Consider combination therapy (medication + psychotherapy) 2
   • If using medication alone, start with an SSRI at the lower end of therapeutic range

3. Medication selection factors:

   • Side effect profile (63% experience at least one side effect) 1
   • Cost considerations
   • Patient preferences
   • Comorbidities (e.g., SNRIs for pain disorders)

Dosing and Monitoring

Initial Dosing

• Start at lower end of therapeutic range ("start low, go slow") 1, 2
• For fluoxetine: 20 mg/day is sufficient for most cases 4
• For sertraline: 50 mg/day is the optimal starting dose 3
• For older adults: Use approximately 50% of standard adult starting dose 1

Monitoring Schedule

• Assess response within 1-2 weeks of starting treatment 2
• Formal assessment at 4 weeks and 8 weeks using standardized instruments 1
• Monitor for:
  • Therapeutic response
  • Side effects (especially nausea/vomiting - most common reason for discontinuation)
  • Suicidal thoughts (highest risk in first 1-2 months of treatment)
  • Unusual changes in behavior, agitation, or irritability 2

Treatment Adjustment

• If little improvement after 6-8 weeks despite good adherence: 1

  • Adjust medication dosage
  • Switch to a different antidepressant
  • Add psychotherapy if on medication alone
  • Consider mental health consultation

• Common pitfalls to avoid:

  • Inadequate trial duration (switching too early)
  • Overlooking drug interactions (especially with fluoxetine and paroxetine)
  • Failing to monitor for side effects
  • Not addressing comorbid conditions

Treatment Duration

• First episode of depression: Continue treatment for 4-12 months after remission 1, 2
• Recurrent depression: Consider maintenance treatment for 1+ years 1, 2
• Monitor monthly for 6-12 months after full resolution of symptoms 1
• For multiple recurrences: Consider monitoring for up to 2 years 1

Special Populations

Older Adults

• Preferred agents: citalopram, escitalopram, sertraline, mirtazapine, venlafaxine, bupropion 1
• Avoid paroxetine and fluoxetine due to higher rates of adverse effects 1
• Use lower starting doses (approximately 50% of standard adult dose) 1

Adolescents

• Fluoxetine is FDA-approved for depression in children and adolescents 1
• Escitalopram is approved for adolescents 12 years and older 1
• Starting doses are generally lower than for adults 1
• Close monitoring for suicidality is essential, especially in first weeks of treatment 1

Side Effects Management

• Common side effects include diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain 1
• Nausea and vomiting are most common reasons for discontinuation 1
• SSRIs should be slowly tapered when discontinued to avoid withdrawal effects 1

By following this evidence-based approach to depression management, clinicians can optimize outcomes while minimizing adverse effects and addressing the individual needs of patients with depression.