What is the best medication for treating depression?

Best Medication for Depression

Second-generation antidepressants (SGAs) are the recommended first-line treatment for depression, with specific medication selection based on adverse effect profiles, cost, and patient preferences. 1

Medication Selection Considerations

• All second-generation antidepressants have similar efficacy for treating depression, so selection should be based on side effect profiles, cost, and patient preferences 1
• Antidepressants demonstrate modest superiority over placebo in primary care populations, with a number needed to treat of 7-8 for SSRIs and 7-16 for tricyclic antidepressants 1
• Antidepressants show greater benefit in patients with severe depression compared to those with mild to moderate depression 1

Preferred First-Line Options

• Preferred agents include citalopram, escitalopram, sertraline, bupropion, mirtazapine, and venlafaxine due to their favorable adverse effect profiles 1
• SSRIs are generally considered first-line due to their tolerability, though SNRIs may provide slightly better remission rates (49% vs. 42%) 1
• Sertraline is often preferred for breastfeeding mothers as it transfers to breast milk in lower concentrations than other antidepressants 1

Adverse Effects and Considerations

• About 63% of patients receiving second-generation antidepressants experience at least one adverse effect during treatment 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
• Bupropion is associated with lower rates of sexual dysfunction compared to fluoxetine or sertraline 1
• Paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline 1
• Paroxetine and fluoxetine should generally be avoided in older adults due to higher rates of adverse effects 1

Treatment Monitoring and Duration

• Regular monitoring of treatment response should begin within 1-2 weeks of starting therapy 1
• Treatment should be modified if there is inadequate response within 6-8 weeks 1
• For a first episode of major depression, treatment should continue for 4-9 months after a satisfactory response 1
• Patients with recurrent depression (2 or more episodes) may benefit from longer treatment duration 1

Special Populations

• For older adults, a "start low, go slow" approach is recommended, with preferred medications including citalopram, escitalopram, sertraline, mirtazapine, and venlafaxine 1
• Patients with comorbid pain disorders may benefit more from SNRIs than SSRIs 1
• Close monitoring for suicidality is essential, particularly in the first 1-2 months of treatment, with increased risk noted especially in adults 18-24 years of age 1

Common Pitfalls to Avoid

• Stopping treatment too early (before 4-9 months after remission) increases risk of relapse 1
• Failing to monitor for treatment response and side effects, especially within the first 1-2 weeks 1
• Not adjusting treatment when there is inadequate response after 6-8 weeks 1
• Overlooking the increased risk of suicidality, particularly in younger adults during the first 1-2 months of treatment 1