What is the recommended treatment for depression?

Recommended Treatment for Depression

The recommended first-line treatments for depression include both psychotherapy (particularly cognitive behavioral therapy) and second-generation antidepressants, with combination therapy being preferred for moderate to severe depression or chronic cases. 1

Initial Treatment Options

Psychotherapy

• Cognitive Behavioral Therapy (CBT) has strong evidence supporting its efficacy, with effectiveness comparable to antidepressant medications 1, 2
• Other effective psychotherapies include interpersonal therapy, behavioral activation, problem-solving therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy 2
• Psychotherapy appears to have enduring effects that may reduce subsequent risk following treatment termination 3

Pharmacotherapy

• Second-generation antidepressants (SGAs) are the most commonly prescribed medications for depression 4
• These include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and other medications with related mechanisms of action 5, 4
• Antidepressants have similar efficacy but differ in side effect profiles 1
• For patients with symptoms of both depression and anxiety, treatment of depressive symptoms should be prioritized 1

Combination Therapy

• Combined treatment with psychotherapy and antidepressant medication is particularly beneficial for patients with:
  • Moderate to severe depression 2
  • Chronic depression 6, 2
  • Recurrent depression 6, 3
• Combination therapy shows greater symptom improvement than either psychotherapy alone (SMD, 0.30) or medication alone (SMD, 0.33) 2

Treatment Selection Considerations

Patient Factors to Consider

• Severity of depression (moderate to severe depression may benefit more from combination therapy) 1, 2
• Previous treatment response history 1
• Presence of psychotic features (indicates need for pharmacotherapy) 1
• Patient preference (some patients may prefer one modality over another) 1
• Comorbidities and risk of adverse effects 4

Monitoring and Follow-up

• Regular assessment of treatment response is essential:
  • For psychotherapy: assessment at pretreatment, 4 weeks, 8 weeks, and end of treatment 1
  • For pharmacotherapy: assessment at 4 and 8 weeks using standardized validated instruments 1
• If little improvement is seen after 8 weeks despite good adherence, adjust the treatment regimen 1

Second-step Treatments

For Inadequate Response to Initial Treatment

• If response to pharmacotherapy is inadequate, options include:
  • Switching to a different antidepressant 1
  • Adding a second antidepressant 1, 2
  • Augmenting with a non-antidepressant medication 1, 2
  • Adding psychotherapy to medication 1, 6
• If response to psychotherapy is inadequate, consider:
  • Switching from group to individual therapy 1
  • Adding pharmacotherapy 1, 6

Treatment Duration

• For a first episode of major depressive disorder, continue treatment for 4-9 months after a satisfactory response 1
• For patients with two or more episodes, longer duration of therapy is beneficial 1
• Patients with recurrent major depressive disorder have better long-term outcomes if an active treatment component is maintained during recovery 6

Special Considerations

Medication Selection

• No single second-generation antidepressant has been proven superior to others in terms of efficacy 1
• Selection should be based on:
  • Side effect profiles (e.g., sexual dysfunction varies among medications) 1
  • Cost considerations 1
  • Patient's previous response to specific medications 1

Treatment Delivery

• Collaborative care programs with systematic follow-up and outcome assessment improve treatment effectiveness 2
• Telemental health services are an effective modality for delivering care 1
• Cultural and linguistic appropriateness should be considered when providing information about depression and its treatment 1

Emerging Treatments

• For treatment-resistant depression, ketamine and esketamine may be considered after failure of other treatments 1
• Bright light therapy has expanded recommendations in recent guidelines 1
• Psychedelic treatments are currently recommended only in research settings 1

Remember that treatment should be regularly reassessed and adjusted based on response, and long-term treatment may be necessary, particularly for patients with recurrent depression.