What are the recommended treatments for mental disorders?

Recommended Treatments for Mental Disorders

For depression, cognitive behavioral therapy (CBT) or interpersonal therapy should be the initial treatment for mild cases, while moderate-to-severe depression warrants either psychological interventions or second-generation antidepressants based on patient preference, with combined treatment reserved for complex presentations. 1, 2

Depression Treatment Algorithm

Mild Depression

• Start with psychological interventions, NOT antidepressants 2
• First-line options include:
  • Cognitive behavioral therapy (CBT) including behavioral activation 1, 2
  • Interpersonal therapy 1, 2
  • Problem-solving treatment 1, 2
• Adjunctive options: physical activity and relaxation training 1, 2
• Antidepressants should be avoided as drug-placebo differences are virtually nonexistent in mild depression 2

Moderate-to-Severe Depression

• Either psychological interventions OR second-generation antidepressants are appropriate first-line treatments 1
• The 2023 American College of Physicians guideline found similar symptomatic relief across different first-step treatments, though certainty of evidence is low for most comparisons 1
• Problem-solving treatment should be used as adjunct (not monotherapy) in moderate-severe cases 1
• If antidepressants are initiated, continue for 9-12 months after recovery before considering discontinuation 1, 2

Treatment-Resistant Depression (Second-Step)

• Combined psychotherapy plus antidepressant produces moderately larger effects (effect size 0.43) than medication alone, with a number needed to treat of 4.20 3
• Switching antidepressants or augmentation strategies provide similar symptomatic relief 1
• The effects of combined treatment are approximately twice as large as pharmacotherapy alone compared to placebo 3

Psychotic Disorders (Schizophrenia Spectrum)

Acute Treatment

• Haloperidol or chlorpromazine should be routinely offered as first-line antipsychotics 1
• Second-generation antipsychotics may be alternatives if cost is not a constraint 1
• Clozapine is reserved for treatment-resistant cases and requires routine laboratory monitoring 1

Maintenance and Duration

• Continue antipsychotic treatment for at least 12 months after remission begins 1
• Use monotherapy routinely; combination antipsychotics only for non-responders with close monitoring 1
• Do NOT routinely use anticholinergics for extrapyramidal side effects; reserve for acute/severe cases when dose reduction fails 1

Psychosocial Interventions

• Psychoeducation should be routinely offered to patients and families 1
• CBT and family interventions are options if trained professionals are available 1
• Social skills training and supported employment should be facilitated 1

Bipolar Disorder

Acute Mania

• Haloperidol, lithium, valproate, or carbamazepine should be offered 1
• Lithium requires settings with close clinical and laboratory monitoring capabilities 1
• Second-generation antipsychotics are alternatives if availability and cost permit 1

Bipolar Depression

• Antidepressants must ALWAYS be combined with a mood stabilizer (lithium or valproate) 1
• Prefer SSRIs (fluoxetine) over tricyclic antidepressants 1
• Antidepressants as monotherapy are not recommended 4

Maintenance Treatment

• Lithium or valproate for at least 2 years after the last episode 1
• Decisions to continue beyond 2 years should involve a mental health specialist 1
• Long-term treatment with mood stabilizers (lithium, valproate, lamotrigine) and atypical antipsychotics (quetiapine, aripiprazole, lurasidone, cariprazine) are first-line 4

Anxiety Disorders

Panic Disorder

• Psychological treatment based on CBT principles should be offered 1
• Combined psychotherapy plus medication is superior to medication alone 3

Post-Traumatic Stress Disorder (PTSD)

• Graded self-exposure based on CBT principles for adults with PTSD symptoms who can be followed longitudinally 1
• Psychological first aid for acute distress following recent trauma 1
• Do NOT use psychological debriefing for recent traumatic events—it does not reduce PTSD, anxiety, or depressive symptoms 1, 2

Obsessive-Compulsive Disorder (OCD)

• Combined treatment is superior to medication alone 3
• Behavior therapy and CBT are effective as primary treatments 5

Critical Pitfalls to Avoid

• Never prescribe antidepressants for mild depression as initial treatment despite their widespread use—the evidence shows minimal benefit over placebo 2
• Never use antidepressants or benzodiazepines for subthreshold depressive symptoms that don't meet criteria for a depressive episode 1, 2
• Never stop antidepressants before 9-12 months after recovery—premature discontinuation increases relapse risk 1, 2
• Never prescribe antidepressants as monotherapy in bipolar disorder—always combine with mood stabilizers 1, 4
• Never routinely prescribe anticholinergics prophylactically with antipsychotics—use only when extrapyramidal symptoms are significant and other strategies have failed 1
• Never use psychological debriefing after trauma—it may be harmful 1, 2

Evidence Quality Considerations

The 2023 American College of Physicians systematic review found that certainty of evidence is low for most treatment comparisons, with effect sizes generally small across disorders and treatments (SMD 0.34 for psychotherapies, 0.36 for pharmacotherapies) 1, 6. This suggests clinicians should focus on options with the most reliable evidence, consider adverse event profiles carefully, and incorporate patient preferences into shared decision-making 1.