Treatment Options for Depression
For treating depression, clinicians should select between either cognitive behavioral therapy or second-generation antidepressants after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. 1
Understanding Depression
Depression is a serious neuropsychiatric disorder characterized by:
- Persistent feelings of sadness
- Loss of interest or pleasure in activities
- Changes in weight or appetite
- Sleep disturbances (insomnia or hypersomnia)
- Fatigue or energy loss
- Feelings of worthlessness or guilt
- Difficulty concentrating
- Recurrent thoughts of death or suicide
Major depressive disorder (MDD) has a lifetime prevalence of approximately 16% in the United States 1, making it one of the foremost causes of disability worldwide.
Treatment Algorithm
First-Line Options (Choose One)
Cognitive Behavioral Therapy (CBT)
- Structured psychological intervention focusing on identifying and changing negative thought patterns
- Typically delivered in 12-16 weekly sessions
- Equally effective as medication for most forms of depression 1
- Advantages: No physical side effects, provides skills for preventing relapse
- Disadvantages: Requires patient engagement, may take longer to see effects, accessibility issues
Second-Generation Antidepressants (SGAs)
- Selective Serotonin Reuptake Inhibitors (SSRIs) are typically first choice:
- Advantages: Relatively quick onset (2-4 weeks), convenient daily dosing
- Disadvantages: Side effects including sexual dysfunction, GI disturbances, potential for suicidal ideation especially in young adults 4
Treatment Phases
Depression treatment occurs in three phases 1:
- Acute phase (6-12 weeks): Goal is symptom reduction
- Continuation phase (4-9 months): Prevents relapse
- Maintenance phase (≥1 year): Prevents recurrence, especially important for recurrent depression
Monitoring Response
- Use validated tools like Patient Health Questionnaire-9 (PHQ-9) or Hamilton Depression Rating Scale (HAM-D) to quantify response
- Response is typically defined as ≥50% reduction in measured severity 1
- Assess for response within 1-2 weeks of starting treatment
- Continue treatment for at least 4-9 months after achieving remission for first episode, and at least 1 year for recurrent depression 3
Special Considerations
Medication Side Effects
- Monitor for common SSRI side effects: nausea, diarrhea, headache, insomnia, sexual dysfunction
- Approximately 63% of patients experience at least one adverse effect 3
- Monitor closely for suicidal thoughts, particularly in young adults (18-24) 3, 4
Important Cautions
- Screen for bipolar disorder before initiating antidepressants, as they can trigger manic episodes 3
- Be aware of potential drug interactions, particularly risk of serotonin syndrome when combining serotonergic agents 3
Complementary Approaches
These can be used alongside first-line treatments:
Exercise
- Recommended 3-5 times weekly at medium to high intensity 5
- Impacts neurobiological mechanisms including brain-derived neurotrophic factors
Self-help interventions with evidence of efficacy 6:
- Bibliotherapy (self-help books)
- Relaxation training
- Pleasant activities scheduling
- Light therapy (especially for seasonal depression)
When to Refer to Mental Health Specialist
Referral is appropriate when 7:
- Diagnosis of depression is unclear
- Depression is severe
- Patient doesn't respond to initial treatment
- Complicating factors affect treatment choice (e.g., comorbidities, pregnancy)
Common Pitfalls to Avoid
- Failing to screen for bipolar disorder before starting antidepressants
- Not monitoring young adults closely for increased suicidality
- Stopping treatment too soon after symptom improvement
- Overlooking medication interactions
- Neglecting to address physical symptoms like pain that may contribute to depression