What is the recommended treatment for patients presenting with depression?

Treatment of Depression: Cognitive Behavioral Therapy and Second-Generation Antidepressants

Clinicians should select between either cognitive behavioral therapy (CBT) or second-generation antidepressants (SGAs) as first-line treatment for patients with major depressive disorder, after discussing treatment effects, adverse effect profiles, cost, accessibility, and patient preferences. 1

First-Line Treatment Options

Cognitive Behavioral Therapy (CBT)

• Moderate-quality evidence shows CBT is as effective as SGAs for treating major depressive disorder 1
• CBT has fewer adverse effects than SGAs 1
• Lower relapse rates reported with CBT compared to SGAs 1
• Should be strongly considered as an alternative to medication where available 1

Second-Generation Antidepressants (SGAs)

• Includes selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and others 1
• Moderate-quality evidence supports similar efficacy to CBT 1
• Common options include:
  • Sertraline (Zoloft): Initial dose 25-50 mg daily, maximum 200 mg daily 2
  • Fluoxetine (Prozac): Initial dose 20 mg/day in the morning 3
  • Citalopram (Celexa): Initial dose 10 mg daily, maximum 40 mg daily (20 mg maximum in elderly due to QT prolongation risk) 2
  • Escitalopram (Lexapro): Initial dose 10 mg daily, maximum 20 mg daily 2

Medication Selection Considerations

Patient-Specific Factors

• Energy levels: Bupropion has activating effects that can improve energy, but should be avoided in patients with seizure disorders 2
• Sleep disturbances: Mirtazapine promotes sleep, appetite, and weight gain 2
• Anxiety: Sertraline has demonstrated efficacy in treating both depression and anxiety symptoms 2

Adverse Effect Profiles

• Common SSRI side effects include diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain 2
• Approximately 63% of patients experience at least one adverse effect with SGAs 2
• Bupropion has lower rates of sexual dysfunction than fluoxetine and sertraline 1
• Paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, and sertraline 1

Treatment Monitoring and Duration

1. Full therapeutic effect may be delayed until 4 weeks of treatment or longer 3
2. Assess response within 1-2 weeks of starting treatment 2
3. Continue treatment for at least 4-9 months after achieving remission for first episode 2
4. For recurrent depression, continue treatment for at least 1 year 2

Special Considerations

• Elderly patients: Consider lower or less frequent dosing 3
• Hepatic impairment: Use lower or less frequent dosing 3
• Bipolar disorder risk: Screen for bipolar disorder before initiating antidepressants to avoid triggering manic episodes 2
• Drug interactions: Be aware of potential interactions, particularly with other serotonergic agents 2
• Suicidality: Monitor closely for suicidal thoughts, particularly in young adults 2

Treatment Algorithm

1. Initial assessment: Determine depression severity and presence of comorbidities
2. First-line treatment decision:
   • If CBT is available and acceptable to patient: Begin CBT
   • If medication is preferred: Select an SGA based on symptom profile and potential side effects
3. Medication initiation:
   • Start with recommended initial dose (e.g., fluoxetine 20 mg/day or sertraline 25-50 mg/day)
   • For elderly or those with hepatic impairment: Start with lower doses
4. Follow-up assessment: Evaluate response within 1-2 weeks
5. Dose adjustment: Consider dose increase after several weeks if insufficient clinical improvement is observed
6. Maintenance: Continue treatment for 4-9 months after remission (first episode) or at least 1 year (recurrent depression)

Common Pitfalls to Avoid

• Failing to screen for bipolar disorder before initiating antidepressants
• Discontinuing treatment too early (before full therapeutic effect or adequate maintenance period)
• Overlooking medication interactions, particularly the risk of serotonin syndrome
• Not discussing potential side effects with patients before initiating treatment
• Ignoring patient preferences in treatment selection