What are the treatment options for major depressive disorder (MDD)?

From the Guidelines

Depression treatment typically involves a combination of medication, psychotherapy, and lifestyle changes, with selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) being viable first-line options. For medication, SSRIs like fluoxetine (Prozac, 20-80mg daily), sertraline (Zoloft, 50-200mg daily), or escitalopram (Lexapro, 10-20mg daily) are often first-line treatments, usually taken for at least 6-12 months after symptom improvement 1. Psychotherapy, particularly CBT or interpersonal therapy (IPT), typically involves weekly sessions for 12-16 weeks. Lifestyle modifications include regular exercise (30 minutes of moderate activity most days), maintaining a consistent sleep schedule, reducing alcohol consumption, and building social connections.

Some key points to consider in treatment include:

• The phases of treatment: acute (6 to 12 weeks), continuation (4 to 9 months), and maintenance (≥1 year) 1
• The importance of personalized treatment based on symptom severity, previous treatment response, and individual preferences
• The potential benefits of combining medication and therapy for severe depression
• The need for gradual improvement over several weeks rather than immediate relief

It's also important to note that:

• Second-generation antidepressants have lower toxicity in overdose than first-generation antidepressants and similar efficacy 1
• Psychological interventions, complementary and alternative medicine (CAM) options, exercise, or a combination of these treatments can be efficacious for MDD compared with placebo or other inactive interventions 1
• High dropout rates, dosing inequalities, small sample sizes, and poor assessment of adverse events can limit confidence in the evidence 1

From the FDA Drug Label

The efficacy of the immediate-release formulation of bupropion was established in two 4-week controlled inpatient trials and one 6-week controlled outpatient trial of adult patients with MDD The recommended starting dose for MDD is 150 mg once daily in the morning. After 4 days of dosing, the dose may be increased to the target dose of 300 mg once daily in the morning. In controlled trials used to support the efficacy of fluoxetine, patients were administered morning doses ranging from 20 to 80 mg/day. A dose of 20 mg/day, administered in the morning, is recommended as the initial dose. A dose increase may be considered after several weeks if insufficient clinical improvement is observed.

Treatment Options for Major Depressive Disorder (MDD):

• Bupropion: The recommended starting dose is 150 mg once daily, which may be increased to 300 mg once daily after 4 days of dosing 2.
• Fluoxetine: The recommended initial dose is 20 mg/day, administered in the morning, with possible dose increases after several weeks if insufficient clinical improvement is observed 3. Key points to consider:
• The dose needed for maintenance treatment may be different from the dose that provided an initial response.
• Treatment should be individualized based on the patient's historical pattern of MDD episodes.
• The full therapeutic effect may be delayed until 4 weeks of treatment or longer.

From the Research

Treatment Options for Major Depressive Disorder (MDD)

• The treatment of MDD can involve various approaches, including the use of selective serotonin reuptake inhibitors (SSRIs) 4, 5, switching to a different class of antidepressants 6, or combination therapy with multiple medications 7.
• SSRIs are commonly used as a first-line treatment, but the optimal starting dose is still a topic of debate, with some studies suggesting that higher starting doses may be more effective but also increase the risk of adverse events 5.
• For patients who do not respond to SSRIs, switching to a non-SSRI antidepressant may be a more effective strategy than switching to a different SSRI 6.
• Combination therapy with multiple medications, such as mirtazapine and fluoxetine, may also be an effective approach, with some studies showing higher remission rates compared to monotherapy 7.
• In addition to medication, cognitive behavioral therapy (CBT) is also a commonly used treatment for MDD, and may be used in conjunction with antidepressant medication (ADM) 8.
• The choice of treatment approach may depend on various factors, including the severity of symptoms, patient history, and individual response to treatment, with some studies suggesting that CBT and ADM may have different effects depending on early traumatic experiences, cognitive and genetic variables, and other epigenetic factors 8.