What is the first line of treatment for depression?

First-Line Treatment for Depression

The first-line treatment for depression should include both psychotherapy (particularly cognitive behavioral therapy) and second-generation antidepressants (SGAs), with either option being effective as monotherapy for mild to moderate depression and combination therapy showing superior outcomes for moderate to severe depression. 1

Evidence-Based Treatment Options

Psychotherapy Options

• Cognitive Behavioral Therapy (CBT)
• Interpersonal therapy
• Psychodynamic therapies

Pharmacological Options (Second-Generation Antidepressants)

• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Other newer antidepressants

Treatment Algorithm Based on Depression Severity

Mild to Moderate Depression

• First option: Either psychotherapy (particularly CBT) OR a second-generation antidepressant
• Moderate-quality evidence shows no difference in response rates between SGAs and CBT 2
• Low-quality evidence shows no difference in remission rates between SGAs and interpersonal or psychodynamic therapies 2

Moderate to Severe Depression

• First option: Combination of psychotherapy and pharmacotherapy
• The combination has shown superior outcomes compared to either treatment alone 1

Pharmacotherapy Selection and Dosing

When selecting an SGA:

• Start with an SSRI (e.g., sertraline) at the lower range of the licensed dose
• Sertraline starting dose: 50 mg once daily 3
• The optimal balance between efficacy, tolerability, and acceptability is achieved in the lower range of licensed doses 4

Monitoring and Adjustment

• Assess response within 1-2 weeks of starting treatment 1
• Monitor for side effects and emergence of suicidal thoughts
• If inadequate response after 6-8 weeks, consider:
  1. Dose adjustment
  2. Switching to a different antidepressant
  3. Adding psychotherapy if on medication alone
  4. Adding medication if on psychotherapy alone

Duration of Treatment

• For first episode: Continue treatment for 4-9 months after achieving remission 1
• For recurrent depression: Consider maintenance treatment for 1+ years 1

Important Considerations and Caveats

Side Effects

• Approximately 63% of patients experience at least one adverse effect with SGAs 1
• Common side effects include diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain
• SSRIs are associated with increased risk for suicide attempts compared to placebo, particularly in adults 18-24 years old 1

Special Populations

• For patients with panic disorder in addition to depression, starting at lower doses may be beneficial 5
• For elderly patients, no dose adjustment is needed for sertraline 6

Discontinuation

• Slowly taper SGAs when discontinuing to avoid withdrawal effects 1
• Withdrawal symptoms can occur with abrupt discontinuation, particularly with shorter-acting agents 1

The evidence strongly supports that both psychotherapy and SGAs are effective first-line treatments for depression, with the choice between them depending on depression severity, patient preference, and availability of resources.