What are the categories and treatment options for major depressive disorder?

Categories and Treatment Options for Major Depressive Disorder

Major Depressive Disorder (MDD) should be treated with either cognitive behavioral therapy (CBT) or second-generation antidepressants as first-line monotherapy, with combination therapy as an option for moderate to severe cases. 1, 2

Diagnostic Categories of MDD

MDD is defined as five or more of the following symptoms present for at least 2 weeks, with at least one being depressed mood or loss of interest/pleasure 3:

• Depressed mood
• Diminished interest or pleasure in activities
• Significant weight loss/gain or appetite changes
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Poor concentration or indecisiveness
• Recurrent thoughts of death or suicidal ideation

Clinical Subtypes of MDD

1. Uncomplicated MDD - Responds to initial treatment approaches 1
2. Severe MDD - Marked by more intense symptoms that significantly impair functioning 1
3. MDD with Partial/Limited Response - Cases that don't adequately respond to initial treatments 1
4. MDD with Psychotic Features - Characterized by delusions or hallucinations, affecting about 11% of MDD patients 4
   • Associated with higher suicide risk (60% vs 44%)
   • More likely to require inpatient treatment (56% vs 32%)
   • Higher treatment resistance (80% vs 36%)
   • Often requires antipsychotic augmentation

Treatment Approaches

First-Line Treatment Options

For Mild MDD:

• CBT monotherapy is suggested as initial treatment 2

For Moderate to Severe MDD:

1. Monotherapy options (strong recommendation, moderate-quality evidence) 1, 2:

   • Cognitive Behavioral Therapy (CBT)
   • Second-generation antidepressants (e.g., SSRIs)

2. Combination therapy (conditional recommendation, low-quality evidence) 2:

   • CBT plus a second-generation antidepressant

Pharmacologic Treatment

Second-Generation Antidepressants:

• SSRIs (e.g., sertraline, fluoxetine):
  • Sertraline: Start at 50 mg daily, can increase to 200 mg daily 5
  • Fluoxetine: Standard dosing for MDD 6
  • Monitor for response after 4-6 weeks 7
  • Continue treatment for 4-9 months after satisfactory response 7

Important Considerations:

• 60-70% of patients respond to antidepressant treatment 7
• Monitor closely for suicidal ideation, especially in first weeks of treatment 7
• For elderly patients, prefer sertraline, citalopram, or escitalopram due to favorable side effect profiles 7

Psychotherapy Options

1. Cognitive Behavioral Therapy (CBT) - First-line therapy with similar efficacy to antidepressants 1, 7
2. Short-term Psychodynamic Psychotherapy (STPP) - Now included in updated guidelines 1

Second-Step Treatment Options

For patients who don't respond to initial treatment after 6-8 weeks 1, 2:

1. Switch to a different second-generation antidepressant
2. Switch to or augment with CBT
3. Augment with a second medication:
   • Second-generation antipsychotics
   • Other antidepressants
   • Mood stabilizers

Advanced Treatment Options

For treatment-resistant cases 1:

1. Repetitive Transcranial Magnetic Stimulation (rTMS)
2. Electroconvulsive Therapy (ECT)
3. Ketamine or Esketamine - For severe, treatment-resistant depression

Treatment Phases

1. Acute Phase (6-12 weeks) - Focus on symptom resolution
2. Continuation Phase (4-9 months) - Prevent relapse
3. Maintenance Phase (≥1 year) - Prevent recurrence in high-risk patients 5

Monitoring and Evaluation

• Use standardized measures (e.g., PHQ-9) to assess treatment response
• Evaluate treatment efficacy at approximately 6 weeks and 12 weeks 7
• Monitor for suicidal ideation, especially in the first weeks of treatment 7

Common Pitfalls to Avoid

1. Inadequate duration of treatment - Continue antidepressants for at least 4-9 months after response 7
2. Failure to recognize psychotic features - Present in 11% of MDD patients and requires different treatment approach 4
3. Overlooking drug interactions - Particularly important in elderly patients on multiple medications 7
4. Insufficient monitoring - Regular assessment of both response and side effects is essential 7
5. Premature switching of medications - Allow 4-6 weeks for adequate trial before changing 1