What is the recommended management for depression?

Management of Depression

For depression management, second-generation antidepressants (particularly SSRIs) are recommended as first-line pharmacological treatment, along with evidence-based psychotherapies such as cognitive behavioral therapy (CBT) or interpersonal therapy (IPT-A). 1

Treatment Approach

Initial Treatment Options

1. Psychotherapy Options:

   • Cognitive Behavioral Therapy (CBT): Targets negative thoughts and behaviors to improve mood
   • Interpersonal Therapy (IPT-A): Focuses on interpersonal problems that may cause or exacerbate depression
   • Both therapies have strong evidence for effectiveness in depression 2, 1

2. Pharmacotherapy Options:

   • First-line: SSRIs due to favorable side effect profiles and safety

     • Sertraline (25-50 mg daily, max 200 mg)
     • Citalopram (10 mg daily, max 40 mg; 20 mg max in elderly)
     • Escitalopram (10 mg daily, max 20 mg)
     • Fluoxetine (20 mg daily, typically sufficient for most cases) 1, 3

   • Alternative options for specific patient needs:

     • Mirtazapine: Beneficial for patients with insomnia, poor appetite, or weight loss
     • Bupropion: Useful for patients with apathy or concerns about sexual dysfunction
     • Venlafaxine: Consider for treatment-resistant depression 1

Treatment Based on Depression Severity

1. Mild Depression:

   • Psychotherapy alone or SSRI monotherapy
   • Starting with lower doses of medication (e.g., fluoxetine 10 mg or sertraline 25 mg)

2. Moderate to Severe Depression:

   • Combination of psychotherapy and medication
   • Standard dosing of SSRIs (e.g., fluoxetine 20 mg daily) 1, 3

3. Severe Depression with Suicidal Ideation or Psychotic Features:

   • Immediate psychiatric consultation
   • Consider hospitalization
   • Combination treatment with close monitoring
   • Consider electroconvulsive therapy for treatment-resistant cases 1

Medication Management

Dosing and Administration

• Starting doses:

  • Start with lower doses in elderly patients (approximately 50% of adult starting dose)
  • Fluoxetine: 20 mg daily for adults; 10 mg daily for children/adolescents 3
  • Sertraline: 50 mg daily is optimal for most patients 4

• Dose adjustments:

  • Increase gradually (every 5-7 days)
  • Allow 4-8 weeks for full therapeutic effect
  • Maximum fluoxetine dose should not exceed 80 mg/day 1, 3

Monitoring and Duration

• Assess response within 1-2 weeks of starting treatment
• Monitor for therapeutic response, side effects, and emergence of suicidal thoughts
• Continue treatment for at least 4-9 months after achieving remission for first episode
• For recurrent depression, maintain treatment for at least 1 year 1

Common Side Effects and Management

• Common SSRI side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction
• Medication-specific considerations:
  • Fluoxetine: May cause insomnia and nervousness at initiation 5
  • Paroxetine: More anticholinergic effects than other SSRIs
  • Mirtazapine: May cause sedation and weight gain
  • Bupropion: Contraindicated in seizure disorders 1

Special Populations

Children and Adolescents

• Start with psychotherapy (CBT or IPT-A)
• For medication, fluoxetine is FDA-approved for children and adolescents
• Start with 10 mg/day in lower-weight children, may increase to 20 mg/day after 1 week if needed 2, 3

Elderly Patients

• SSRIs are preferred due to favorable side effect profiles
• Start with approximately 50% of adult starting dose
• Avoid tricyclic antidepressants due to anticholinergic effects and cardiotoxicity 1

Patients with Comorbidities

• Bipolar disorder: Avoid SSRI monotherapy due to risk of triggering mania 1, 6
• Anxiety disorders: SSRIs are effective for both depression and anxiety
• Pain syndromes: Consider SNRIs (venlafaxine, duloxetine)
• Insomnia: Consider mirtazapine 1

Treatment-Resistant Depression

For patients who don't respond to initial treatment:

1. Optimize current medication dose
2. Switch to another antidepressant class
3. Consider augmentation strategies (adding second medication)
4. Evaluate for electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS) 1

Important Caveats

• Suicide risk: Close monitoring is essential, especially in young adults (18-24)
• Discontinuation: Taper medications gradually over 10-14 days to minimize withdrawal symptoms
• Drug interactions: Be aware of potential interactions, particularly with SSRIs
• Bipolar depression: Screen for bipolar disorder before initiating antidepressants to avoid triggering mania 1