What are the treatment options for depression?

Treatment Options for Depression

The American College of Physicians recommends combined therapy with second-generation antidepressants (particularly SSRIs) plus cognitive behavioral therapy as the most effective first-line treatment for depression, superior to either approach alone. 1, 2

First-Line Treatment Selection

Combination Therapy (Preferred)

• Combined psychotherapy plus medication demonstrates superior efficacy compared to monotherapy, particularly for chronic or severe depression, with effect sizes showing approximately 0.30-0.33 standardized mean difference improvement over single modalities 2, 3
• This combination approach should be the default for moderate-to-severe depression and chronic presentations 1, 2

Pharmacotherapy Options

• Second-generation antidepressants are first-line medications due to favorable safety profiles compared to older tricyclics 1
• SSRIs (sertraline, fluoxetine, escitalopram, paroxetine) and SNRIs (venlafaxine, duloxetine) all demonstrate small-to-medium effect sizes over placebo (SMD 0.23-0.48) 3, 4
• No single antidepressant shows superior efficacy—selection should be based on adverse effect profiles, cost, and patient preferences rather than effectiveness 1
• Starting dose for sertraline: 50 mg once daily for major depression, with dose range of 50-200 mg/day based on response 5
• For panic disorder, PTSD, and social anxiety disorder, start sertraline at 25 mg daily for one week, then increase to 50 mg daily 5

Psychotherapy Options

• Cognitive behavioral therapy (CBT) is the most strongly recommended psychotherapy 1, 2
• Other evidence-based options include interpersonal therapy, behavioral activation, problem-solving therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy—all showing medium-sized effects (SMD 0.50-0.73) 3

Treatment Monitoring Algorithm

Initial Phase (Weeks 1-8)

• Begin assessment within 1-2 weeks of treatment initiation 1
• Monitor closely for suicidal ideation during first 1-2 months, as SSRIs carry increased suicide attempt risk compared to placebo 1
• Use validated tools: Patient Health Questionnaire-9 (PHQ-9) or Hamilton Depression Rating Scale (HAM-D) 1, 2
• Treatment response is defined as 50% reduction in severity scores 1
• If inadequate response by 6-8 weeks, modify treatment 1

Common Pitfalls

• More than 60% of patients experience adverse effects with second-generation antidepressants, including sexual dysfunction, gastrointestinal symptoms, and sleep disturbances 2
• Sexual dysfunction rates vary by agent—consider switching if this becomes problematic 1
• Up to 70% of patients fail to achieve remission with initial treatment, requiring second-step interventions 2

Treatment Duration by Phase

Acute Phase (6-12 weeks)

• Continue current regimen if achieving response 2

Continuation Phase (4-9 months after remission)

• Minimum 4-9 months for first episode of depression 1
• Prevents relapse (symptom return during acute/continuation phases) 1

Maintenance Phase (≥1 year)

• For chronic depression or ≥2 prior episodes, continue treatment for at least 1 year 1
• Prevents recurrence (symptom return during maintenance phase) 1
• For PTSD, efficacy maintained up to 28 weeks following initial 24-week treatment 5
• For social anxiety disorder, efficacy maintained up to 24 weeks following initial 20-week treatment 5

Second-Line Strategies for Treatment-Resistant Depression

When initial antidepressant fails after adequate trial (6-8 weeks at therapeutic dose), three options have approximately equal success rates 3:

• Switch to different antidepressant class
• Add second antidepressant
• Augment with non-antidepressant medication (e.g., atypical antipsychotics) 6

Complementary Approaches

Evidence-Based Adjuncts

• Exercise (aerobic activities) demonstrates effectiveness for depression management 2
• Acupuncture, meditation, omega-3 fatty acids, and S-adenosyl-L-methionine (SAMe) show efficacy 2
• St. John's wort for mild-to-moderate depression only 2
• Anti-inflammatory drugs (NSAIDs) show moderate antidepressant effects with high response rates (OR=3.62) 4

Collaborative Care Enhancement

Systematic follow-up and outcome assessment through collaborative care programs significantly improve treatment effectiveness (SMD 0.42 over usual care), making this approach essential for optimizing outcomes 3