What is the recommended treatment for depression?

Recommended Treatment for Depression

For adults with depression, the recommended first-line treatment includes cognitive behavioral therapy (CBT) or other evidence-based psychotherapies, with selective serotonin reuptake inhibitors (SSRIs) as the preferred pharmacological option when medication is indicated. 1

Psychotherapy Options

• Cognitive behavioral therapy (CBT), behavioral activation, problem-solving therapy, interpersonal therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy all show medium-sized effects in improving depression symptoms compared to usual care 2
• For patients with both depression and anxiety symptoms, treatment of depressive symptoms should be prioritized, or a unified protocol combining CBT treatments for both conditions may be used 1
• Regular assessment of treatment response is recommended when providing psychological treatment (e.g., at pretreatment, 4 weeks, 8 weeks, and end of treatment) 1

Pharmacotherapy Options

First-line Medications

• SSRIs are recommended as first-line pharmacological treatment with modest superiority over placebo (NNT of 7-8) 1
• Fluoxetine is FDA-approved for depression in adults and adolescents, while escitalopram is approved for adults and adolescents aged 12 years and older 1
• Starting doses for SSRIs should generally be lower than maximum doses (e.g., fluoxetine 20 mg/day) 3

Medication Selection Considerations

• For treatment-naïve patients, all second-generation antidepressants are equally effective; choice should be based on patient preferences, adverse effect profiles, cost, and dosing frequency 1
• Preferred agents for older patients include citalopram, escitalopram, sertraline, mirtazapine, and venlafaxine 1
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) may be slightly more effective than SSRIs but have higher rates of adverse effects like nausea and vomiting 1

Monitoring and Dose Adjustment

• Regular monitoring is essential - patients should be assessed at 4 and 8 weeks using standardized validated instruments to evaluate symptom relief, side effects, and satisfaction 1
• If there is little improvement after 8 weeks despite good adherence, the treatment regimen should be adjusted (e.g., change medication, add psychological intervention) 1
• About 63% of patients receiving second-generation antidepressants experience at least one adverse effect during treatment 1

Combined Treatment Approach

• Combined psychotherapy and pharmacotherapy may be preferred, especially for more severe or chronic depression 2
• Combined treatment shows greater symptom improvement than either psychotherapy alone or medication alone 2

Treatment Duration

• For a first episode of major depression, treatment should continue for at least 4-9 months after symptom remission 1
• Patients with recurrent depression may benefit from prolonged treatment 1
• The treatment of depression can be characterized by 3 phases: acute (6-12 weeks), continuation (4-9 months), and maintenance (≥1 year) 1

Special Populations

Adolescents

• For adolescents with depression, fluoxetine may be considered as one possible treatment in non-specialist settings, but patients should be monitored closely for suicidal ideation/behavior 1
• For children aged 6-12 years, antidepressants should not be used for treatment of depressive episodes in non-specialist settings 1

Older Adults

• A "start low, go slow" approach is recommended for antidepressant therapy in older persons 1
• Paroxetine and fluoxetine should generally be avoided in older adults due to higher rates of adverse effects 1

Treatment Effectiveness and Considerations

• Antidepressants are most effective in patients with severe depression 1
• Collaborative care programs that include systematic follow-up and outcome assessment improve treatment effectiveness 2
• If pharmacologic treatment is used, the treating clinician should regularly assess symptom relief, side effects, and patient satisfaction 1

Common Pitfalls and Caveats

• Deliberate self-harm and suicide risk may be more likely if SSRIs are started at higher doses rather than normal starting doses 1
• Nausea and vomiting are the most common reasons for discontinuation of antidepressant therapy 1
• All SSRIs should be slowly tapered when discontinued because of risk of withdrawal effects 1
• When switching from an SSRI to a monoamine oxidase inhibitor (MAOI), at least 5 weeks should be allowed after stopping the SSRI before starting the MAOI 3