What are the recommended antidepressants for treating depression?

Recommended Antidepressants for Treating Depression

Escitalopram and sertraline are the recommended first-line antidepressants for treating depression due to their favorable efficacy and side effect profiles. 1

First-Line Treatment Options

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Escitalopram (Lexapro)

  • Initial dose: 10 mg daily
  • Maximum dose: 20 mg daily
  • Particularly favorable side effect profile among SSRIs 1
  • Preferred for geriatric patients (start at 5 mg/day) 1

• Sertraline (Zoloft)

  • Initial dose: 25-50 mg daily
  • Maximum dose: 200 mg daily
  • Particularly effective for depression with anxiety symptoms 1
  • Superior efficacy profile compared to fluoxetine 2

• Other SSRIs

  • Citalopram (Celexa): 10 mg daily, maximum 40 mg daily (20 mg maximum in elderly due to QT prolongation risk) 1
  • Fluoxetine (Prozac): 10 mg daily, maximum 60 mg daily 1
  • Paroxetine: Note that it has more anticholinergic effects than other SSRIs 1

Second-Line Treatment Options

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Venlafaxine

  • More effective than fluoxetine in multiple studies 2
  • Caution: May increase blood pressure at higher doses 3

• Other SNRIs

  • Duloxetine: More balanced serotonin and norepinephrine reuptake inhibition 3
  • Milnacipran (not approved for depression in the USA) 3
  • Levomilnacipran 3

Other Antidepressant Classes

• Mirtazapine

  • More effective than fluoxetine in some studies 2
  • Side effects include sedation and weight gain 1

• Tricyclic Antidepressants (TCAs)

  • Use with caution due to more anticholinergic effects 1
  • Avoid in elderly patients with dementia 1

Special Considerations

Monitoring and Follow-up

• Assess response within 1-2 weeks of starting treatment 1
• Continue treatment for at least 4-9 months after achieving remission for first episode 1
• Continue for at least 1 year for recurrent depression 1
• Monitor for:
  • Suicidal thoughts (particularly in young adults 18-24) 1, 4
  • Hyponatremia
  • Changes in appetite and weight
  • Sexual dysfunction (common with SSRIs) 1

Important Precautions

• Screen for bipolar disorder before starting antidepressants 1, 4

  • Antidepressants can trigger manic episodes in undiagnosed bipolar disorder 1
  • MAOIs and other antidepressants should never be used together due to risk of serotonin syndrome 4

• Drug interactions

  • SSRIs may inhibit CYP2D6, affecting metabolism of other medications 5
  • Sertraline has favorable drug interaction profile compared to some other antidepressants 5
  • Avoid combining serotonergic medications due to risk of serotonin syndrome 5, 4

Common Pitfalls to Avoid

1. Failing to screen for bipolar disorder before initiating antidepressants 1
2. Overlooking medication interactions, especially with serotonergic agents 1
3. Inadequate monitoring for suicidal thoughts, particularly in young adults 1
4. Stopping treatment too soon after symptom improvement 1
5. Not accounting for side effect profiles when selecting an antidepressant 1

Augmentation for Treatment-Resistant Depression

For patients who don't respond to first-line treatments:

• Consider atypical antipsychotics (aripiprazole, brexpiprazole, cariprazine, quetiapine extended-release) 6
• Weigh benefits against potential adverse events (weight gain, akathisia, tardive dyskinesia) 6