What are the treatment options for feeling low?

Treatment for Feeling Low (Depression)

First-Line Treatment Approach

Start with either an SSRI antidepressant (fluoxetine 20mg or sertraline 50mg daily) or evidence-based psychotherapy (cognitive behavioral therapy, behavioral activation, or interpersonal therapy), with combination treatment preferred for moderate-to-severe symptoms. 1

Medication Options

SSRIs and SNRIs are first-line pharmacological treatments, with all 21 studied antidepressants showing small-to-medium effect sizes over placebo (standardized mean difference 0.23-0.48). 1

• Fluoxetine: Start 20mg daily in the morning, may increase after several weeks if insufficient response, maximum 80mg/day. 2
• Sertraline: Effective for depression with comorbid anxiety or panic symptoms. 3
• Full therapeutic effect may require 4+ weeks of treatment. 2

Psychotherapy Options

Six psychotherapy modalities have medium-to-large effect sizes (standardized mean difference 0.50-0.73 over usual care): 1

• Cognitive behavioral therapy
• Behavioral activation
• Problem-solving therapy
• Interpersonal therapy
• Brief psychodynamic therapy
• Mindfulness-based psychotherapy

Combination Treatment

Combine antidepressant medication with psychotherapy for moderate-to-severe depression, as combination treatment shows superior outcomes compared to either modality alone (standardized mean difference 0.30 over psychotherapy alone, 0.33 over medication alone). 1

Assessment Requirements Before Treatment

Screen using a validated tool with established cutoffs, such as the PHQ-9 with a cutoff score ≥8 for depression. 4

Evaluate these specific factors before initiating treatment: 4

• Suicidal ideation or self-harm risk
• History of bipolar disorder (antidepressant monotherapy contraindicated)
• Psychotic symptoms
• Substance use disorders
• Comorbid anxiety (present in 85% of depression cases)
• Medical comorbidities and current medications

Treatment Monitoring

Implement systematic follow-up with outcome assessment every 2-4 weeks initially, as collaborative care programs with regular monitoring significantly improve treatment effectiveness (standardized mean difference 0.42 over usual care). 1, 4

Reassess at 4 weeks and 8 weeks using standardized instruments. 4

• If minimal improvement after 8 weeks with good adherence, add psychotherapy to medication or switch treatment strategy. 4
• Consider switching from group to individual therapy if insufficient response. 4

Second-Line Strategies for Treatment-Resistant Depression

If initial antidepressant fails, three options have approximately equal likelihood of success: 1

1. Switch to a different antidepressant
2. Add a second antidepressant
3. Augment with a non-antidepressant medication (such as atypical antipsychotics)

Special Populations

Comorbid Anxiety

When depression and anxiety coexist (occurs in 85-90% of cases), prioritize treating depressive symptoms first, as this often improves anxiety concurrently. 5, 6

• SSRIs and SNRIs treat both conditions effectively. 7, 6
• Benzodiazepines may help insomnia and anxiety but do not treat depression and carry dependency risks. 6

Post-Stroke Depression

Use SSRIs or tricyclic antidepressants for post-stroke depression, with pharmacotherapy having Grade A evidence. 4

• Antidepressants also effectively treat emotional lability post-stroke. 4
• Patient and family education is essential, as emotional symptoms are often mistaken for depression. 4

Cancer Survivors

Screen at initial diagnosis, during treatment transitions, and at regular intervals. 4

• Low-intensity interventions include psychosocial support groups and individual psychological therapy. 4
• Pharmacologic treatment with antidepressants should be monitored regularly for adherence and side effects. 4

Maintenance Treatment

Continue antidepressant treatment for several months minimum after remission, as discontinuation increases relapse risk compared to continued use. 7

• Gradually taper dosage while providing concurrent cognitive behavioral therapy to decrease relapse risk. 7
• Few studies examine safety beyond 2 years, though many patients use antidepressants indefinitely. 7

Critical Pitfalls to Avoid

• Never use antidepressant monotherapy in bipolar disorder - this can trigger mania or rapid cycling. 5
• Do not expect immediate results - full therapeutic effect requires 4+ weeks. 2
• Avoid premature discontinuation - inadequate treatment duration leads to high relapse rates. 5
• Do not overlook comorbid anxiety - present in 85% of depression cases and requires concurrent treatment. 6
• Failure to monitor systematically - collaborative care with regular follow-up significantly improves outcomes. 1