What are the guidelines for managing depression?

Guidelines for Managing Depression

The management of depression should include both pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) as first-line medication and evidence-based psychotherapy, with treatment selection based on depression severity, patient characteristics, and treatment availability. 1

Initial Assessment and Diagnosis

• Depression diagnosis requires at least 5 symptoms present for at least 2 weeks, including depressed mood or anhedonia

• Severity classification 1:

  • Mild: 5-6 symptoms with mild severity and minimal functional impairment
  • Moderate: Between mild and severe presentations
  • Severe: All DSM-5 symptoms or severe functional impairment, suicide plan/intent, psychotic features

• Screen for bipolar disorder before initiating antidepressants, as antidepressants may precipitate manic episodes 2

First-Line Treatment Options

Pharmacotherapy

1. SSRIs are recommended as first-line pharmacological treatment due to favorable side effect profiles and safety 1:

   • Sertraline (Zoloft): 25-50 mg daily initially, maximum 200 mg daily 1, 3
   • Citalopram (Celexa): 10 mg daily initially, maximum 40 mg daily (20 mg maximum in elderly due to QT prolongation risk) 1
   • Escitalopram (Lexapro): 10 mg daily initially, maximum 20 mg daily 1
   • Fluoxetine (Prozac): 10 mg daily initially, maximum 60 mg daily 1

2. Other pharmacotherapy options for specific situations:

   • Venlafaxine (SNRI): 37.5 mg daily initially, maximum 225 mg daily - particularly effective for patients with depression and anxiety 1
   • Mirtazapine: 7.5 mg at bedtime initially, maximum 30 mg - useful for patients with insomnia or appetite issues 1, 4
   • Bupropion: 37.5 mg every morning initially, maximum 150 mg twice daily - beneficial for patients concerned about sexual side effects 1

Psychotherapy

1. Cognitive Behavioral Therapy (CBT) is equally effective as medication for depression and should be strongly considered as first-line or adjunctive treatment 5, 1

2. Interpersonal Psychotherapy (IPT) focuses on interpersonal problems and has strong evidence for effectiveness 1

Special Populations

Adolescents

• Fluoxetine is FDA-approved for adolescents, starting at 10 mg/day, potentially increasing to 20 mg/day after 1 week 5, 1
• Psychotherapy (CBT or IPT-A) is recommended as first-line treatment for adolescents 5
• Systematic follow-up is essential due to FDA black-box warnings regarding adverse events 5

Elderly Patients

• Start with approximately 50% of adult starting dose 1
• SSRIs are preferred due to favorable side effect profiles 1
• Avoid tricyclics in patients with dementia due to anticholinergic effects 1

Pregnant/Breastfeeding Women

• Carefully weigh risks and benefits of antidepressant treatment 1
• Sertraline and paroxetine transfer to breast milk in lower concentrations 1

Monitoring and Follow-up

• Assess for response within 1-2 weeks of starting treatment 1

• Monitor closely for suicidality, particularly in young adults (18-24) who have a higher risk of suicidal thoughts (5 additional cases per 1000 patients treated) 2, 4

• Common side effects to monitor include:

  • Gastrointestinal issues (diarrhea, nausea)
  • Sexual dysfunction
  • Headache
  • Insomnia or sedation (depending on medication)
  • Dizziness 1, 2

• Watch for serotonin syndrome, especially when combining serotonergic medications 2, 4, 6

Treatment Duration and Maintenance

• Continue treatment for at least 4-9 months after achieving remission for first episode 1
• For recurrent depression, continue treatment for at least 1 year 1
• Approximately 38% of patients do not achieve treatment response during 6-12 weeks of initial treatment 1

Management of Partial Response or Treatment Resistance

1. For partial response to an SSRI at maximum tolerated dose:

   • Add evidence-based psychotherapy if not previously initiated 5
   • Consider augmentation with bupropion 1
   • Explore causes of partial response (poor adherence, comorbid disorders, ongoing conflicts) 5

2. For treatment-resistant depression:

   • Consider switching to a different class of antidepressant
   • Consider ketamine or esketamine for patients who have not responded to other treatments 5
   • Electroconvulsive therapy may be appropriate for multiple prior treatment failures or when rapid improvement is needed 5

Common Pitfalls to Avoid

• Failing to screen for bipolar disorder before initiating antidepressants 2
• Inadequate dosing or premature discontinuation of medication
• Overlooking medication interactions that could lead to serotonin syndrome 2, 4
• Neglecting systematic follow-up, especially for adolescents and young adults 5
• Abrupt discontinuation of antidepressants, which can lead to withdrawal symptoms 2

The VA/DoD and other major guidelines agree on the effectiveness of both pharmacotherapy and psychotherapy for depression, though there are some differences in specific recommendations based on the recency of evidence reviews 5.