What is the recommended treatment for patients with depression?

Recommended Treatment for Depression

For patients with major depressive disorder, either cognitive behavioral therapy (CBT) or second-generation antidepressants are strongly recommended as first-line treatments after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. 1

First-Line Treatment Options

Psychotherapy

• Cognitive Behavioral Therapy (CBT) is a strongly recommended first-line treatment with moderate-quality evidence supporting its efficacy 1
• Benefits include:
  • No medication-related side effects
  • Provides skills that may prevent future episodes
  • May be preferred by patients concerned about medication side effects

Pharmacotherapy

• Second-generation antidepressants (SGAs) are equally strongly recommended as first-line treatment 1
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
  • Selective Serotonin Norepinephrine Reuptake Inhibitors (SSNRIs)

Medication Selection and Dosing

SSRIs (Most commonly prescribed)

1. Sertraline (Zoloft)

   • Starting dose: 50 mg daily (optimal dose for most patients) 2
   • Can increase by 50 mg increments at weekly intervals if needed
   • Maximum dose: 200 mg daily
   • Advantages: Good efficacy for anxiety with depression 3

2. Fluoxetine (Prozac)

   • Starting dose: 20 mg daily in the morning 4
   • Can increase after several weeks if insufficient improvement
   • Maximum dose: 80 mg daily
   • Note: Full effect may be delayed until 4 weeks of treatment or longer 4
   • Some patients may respond to lower doses (5-10 mg) 5

3. Escitalopram (Lexapro)

   • Starting dose: 10 mg daily
   • Maximum dose: 20 mg daily
   • Advantages: More favorable side effect profile among SSRIs 3

SNRIs

• Venlafaxine

  • Has an ascending dose-response curve (unlike SSRIs)
  • Low doses act primarily on serotonin, higher doses affect norepinephrine 6
  • Monitor blood pressure at higher doses

• Duloxetine

  • More balanced serotonin and norepinephrine reuptake inhibition
  • Useful for patients with comorbid pain conditions 6

Treatment Course and Monitoring

Acute Phase (6-12 weeks)

• Evaluate response after 1-2 weeks of treatment initiation 3
• Adjust medication based on response and tolerability
• Monitor for side effects, particularly in the first weeks

Continuation Phase (4-9 months)

• Continue treatment to prevent relapse
• Maintain effective dose

Maintenance Phase (≥1 year)

• For recurrent depression, maintain treatment for at least 1 year 3
• For first episode, treatment should continue for at least 4-9 months after achieving remission

Important Monitoring Considerations

Side Effects

• Approximately 63% of patients experience at least one adverse effect from SSRIs 3
• Common side effects include:
  • Nausea, diarrhea
  • Insomnia, anxiety
  • Sexual dysfunction
  • Headache, dizziness
  • Weight changes

Special Precautions

1. Suicidality Risk

   • Monitor closely, especially in young adults (18-24)
   • Risk is highest in initial weeks of treatment 4

2. Bipolar Disorder Screening

   • Screen all patients for bipolar disorder before initiating antidepressants
   • Antidepressants can trigger manic episodes in undiagnosed bipolar disorder 3, 4

3. Discontinuation

   • Taper medication gradually to avoid discontinuation syndrome
   • Do not abruptly stop treatment

Second-Step Treatments

If first-line treatment is ineffective or poorly tolerated:

• Switch to a different antidepressant class
• Augment with another medication
• Switch to or add psychotherapy
• Different switching and augmentation strategies provide similar symptomatic relief 1

Common Pitfalls to Avoid

1. Failing to screen for bipolar disorder before starting antidepressants
2. Not monitoring for suicidal thoughts, particularly in young adults
3. Discontinuing medication too soon after symptom improvement
4. Overlooking medication interactions (e.g., risk of serotonin syndrome)
5. Not recognizing that full therapeutic effect may take 4-5 weeks or longer