What are the recommended treatments for depression?

Recommended Treatments for Depression

Both psychotherapy (particularly cognitive behavioral therapy) and second-generation antidepressants are equally effective first-line treatments for depression, and the choice should be based on patient preferences, adverse effect profiles, and cost considerations. 1

First-Line Treatment Options

Psychotherapy

• Cognitive Behavioral Therapy (CBT) has shown similar efficacy to antidepressants for the treatment of major depressive disorder, with response rates comparable to medication 1
• Other effective psychological interventions include behavioral activation, problem-solving therapy, interpersonal therapy, and psychodynamic therapies 1, 2
• For patients with symptoms of both depression and anxiety, treatment of depressive symptoms should be prioritized or a unified protocol combining treatments for both conditions may be used 1

Pharmacotherapy

• Second-generation antidepressants are considered first-line pharmacologic treatment for depression 1, 3
• Selective Serotonin Reuptake Inhibitors (SSRIs) are typically the initial medication choice due to their favorable side effect profile compared to older antidepressants 1, 4
• For treatment-naïve patients, all second-generation antidepressants have similar efficacy 1
• The initial recommended dose for fluoxetine is 20 mg/day administered in the morning, with potential dose increases after several weeks if clinical improvement is insufficient 4
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) may be slightly more effective than SSRIs but are associated with higher rates of adverse effects such as nausea and vomiting 1

Combined Approach

• The combination of psychotherapy and antidepressant medication may be preferred for patients with severe or chronic depression 2
• Combined treatment shows greater symptom improvement than either psychotherapy alone or medication alone 2

Monitoring and Treatment Duration

• Clinicians should monitor patients on antidepressant therapy regularly, beginning within 1-2 weeks of initiation 1
• Treatment should be modified if the patient does not have an adequate response to pharmacotherapy within 6-8 weeks 1
• Regular assessment of treatment response is recommended (e.g., at 4 weeks, 8 weeks, and end of treatment) 1
• For a first episode of major depression, treatment should continue for 4-9 months after a satisfactory response 1
• For patients who have had two or more episodes of depression, a longer duration of therapy may be beneficial 1

Second-Step Treatment Options

• If initial treatment is ineffective despite good adherence after 8 weeks, treatment should be adjusted 1
• Second-line options include:
  • Changing to a different antidepressant 1
  • Adding a second antidepressant 1
  • Augmenting with a non-antidepressant medication 1
  • Adding psychological therapy to pharmacotherapy (or vice versa) 1

Special Populations

Older Adults

• Preferred agents for older patients include citalopram, escitalopram, sertraline, mirtazapine, venlafaxine, and bupropion 1
• Paroxetine and fluoxetine should generally be avoided in older adults due to higher rates of adverse effects 1
• A "start low, go slow" approach is recommended for antidepressant therapy in older persons 1

Common Adverse Effects and Considerations

• About 63% of patients receiving second-generation antidepressants experience at least one adverse effect 1
• Common side effects include diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain 1
• Nausea and vomiting are the most common reasons for discontinuation of therapy 1
• Antidepressants are most effective in patients with severe depression 1

Implementation Considerations

• Collaborative care programs that include systematic follow-up and outcome assessment improve treatment effectiveness 2
• Regular assessment using standardized validated instruments helps evaluate symptom relief, side effects, and patient satisfaction 1
• Most patients with mild to moderate depression can be effectively managed by their primary care physician 5

Remember that depression is considered a chronic disease, and the likelihood of recurrence increases with the number of episodes, often necessitating prolonged maintenance medication 5.