What is the recommended treatment for depression and stress?

Treatment Recommendations for Depression and Stress

For depression treatment, a stepped-care approach using cognitive behavioral therapy (CBT) as first-line for mild depression and adding antidepressants (preferably SSRIs like sertraline) for moderate to severe depression is strongly recommended. 1

Assessment and Treatment Algorithm

Mild Depression

1. First-line: Non-pharmacological interventions

   • Cognitive Behavioral Therapy (CBT) 1
   • Problem-solving treatment 1
   • Interpersonal therapy 1
   • Regular physical activity/exercise 1
   • Relaxation training 1

2. Avoid medications for initial treatment

   • Antidepressants should NOT be used for initial treatment of mild depression 1
   • Neither antidepressants nor benzodiazepines should be used for depressive symptoms without a diagnosed depressive disorder 1

Moderate to Severe Depression

1. First-line pharmacotherapy: SSRIs

   • Sertraline: Start at 50mg once daily (25mg if elderly or anxious) 2
   • Can be titrated up to 200mg daily if needed 2, 3
   • Monitor response at 4 and 8 weeks 1

2. Combine with psychological interventions

   • CBT should be offered alongside medication 1
   • Problem-solving treatment as adjunct therapy 1
   • Relaxation training and physical activity as adjunct treatments 1

3. If inadequate response after 8 weeks

   • Consider switching medication or adding psychological intervention 1
   • Continuing at 100mg sertraline may be more effective than increasing to 200mg 4

Special Considerations

For Anxiety with Depression

• Prioritize treatment of depressive symptoms when both anxiety and depression are present 1
• Consider unified protocol combining CBT for both depression and anxiety 1
• SSRIs like sertraline are effective for both conditions 2

For Stress Without Clinical Depression

• Problem-solving approach for those with stress/distress without clinical depression 1
• Avoid psychological debriefing for recent traumatic events 1
• Consider psychological first aid principles for acute distress after trauma 1

Duration of Treatment

• Continue antidepressant treatment for 9-12 months after recovery 1
• Regular assessment of treatment response is essential (at 4 weeks, 8 weeks, and end of treatment) 1

Alternative Medication Options

If SSRIs are not suitable, consider:

• SNRIs (venlafaxine, duloxetine) - particularly helpful for pain syndromes 5, 6
• Mirtazapine (7.5-15mg at bedtime) - helpful for insomnia and appetite issues 5
• Bupropion - avoid in patients with seizure disorders 5

Common Pitfalls to Avoid

1. Premature discontinuation of treatment

   • Antidepressants should not be stopped before 9-12 months after recovery 1
   • Early discontinuation increases relapse risk

2. Inadequate dosing or duration

   • Approximately 38% of patients do not achieve response during 6-12 weeks of treatment 1
   • Ensure adequate trial period before changing strategy

3. Ignoring side effects

   • About 63% of patients experience at least one adverse effect 5
   • Regular monitoring for side effects and suicidality is essential 1, 5

4. Missing comorbidities

   • Depression often co-occurs with anxiety and physical health problems
   • Treatment should address all conditions

5. Overuse of benzodiazepines

   • Benzodiazepines should not be used for initial treatment of depression 1

Remember that depression is a common, potentially life-disrupting, and sometimes lethal illness that is often underdiagnosed and undertreated 7. Proper treatment significantly improves quality of life and reduces mortality risk.