What is the recommended treatment plan for a patient with depression?

Recommended Treatment Plan for Depression

For adults with moderate to severe depression, initiate either cognitive behavioral therapy (CBT) or a second-generation antidepressant (SSRI/SNRI), with combination therapy strongly preferred for severe presentations to maximize remission rates. 1, 2

Initial Assessment and Severity Classification

• Assess depression severity using validated instruments (PHQ-9 or HAM-D) to guide treatment selection, with scores determining mild, moderate, or severe classification 1, 2
• Screen for suicidality at every visit, particularly during initial treatment when risk is highest, and establish a safety plan including restricting lethal means and emergency contact mechanisms 1
• Evaluate for comorbid conditions including anxiety disorders (which worsen prognosis and increase suicidal ideation), substance use disorders, and bipolar disorder before initiating treatment 1, 2
• Assess functional impairment across school/work, home, and social domains to establish treatment goals 1

Treatment Selection by Severity

Mild Depression

• Do not initiate antidepressants for mild depressive episodes as first-line treatment 1
• Offer CBT, behavioral activation, or problem-solving therapy as monotherapy, which have medium to large effect sizes (SMD 0.50-0.73) over usual care 1, 3
• Consider relaxation training or structured physical activity as adjunctive interventions 1

Moderate Depression

• Offer either CBT or second-generation antidepressants as first-line treatment, as they demonstrate equivalent effectiveness (moderate-quality evidence) 1, 2
• Select SSRIs (fluoxetine, sertraline, escitalopram) or SNRIs based on side effect profile, cost, and patient preference, as no single agent shows superior efficacy 1, 2, 4
• Initiate fluoxetine 20 mg daily or sertraline 50 mg daily as typical starting doses for adults 5, 6
• If psychotherapy is chosen, options include CBT, interpersonal therapy (IPT), behavioral activation, or problem-solving therapy 1, 3

Severe Depression

• Strongly recommend combination therapy (psychotherapy plus antidepressant) over monotherapy, which nearly doubles remission rates (57.5% vs 31.0%, p<0.001) and substantially increases response rates (78.7% vs 45.2%, p<0.001) 2, 3
• Initiate SSRI/SNRI immediately along with concurrent (not sequential) CBT or IPT 2
• Consider SNRIs (venlafaxine) over SSRIs for slightly greater symptom improvement, though with higher nausea rates 2
• For severe depression with psychotic features, pharmacotherapy is essential and should be prioritized 1

Depression with Comorbid Anxiety

• Prioritize treatment of depressive symptoms when both depression and anxiety are present 1
• Alternatively, use a unified protocol combining CBT treatments for both conditions 1

Treatment Monitoring Protocol

• Assess treatment response at 4 weeks and 8 weeks using standardized instruments (PHQ-9, HAM-D) to evaluate symptom relief, side effects, and patient satisfaction 1, 2
• If minimal improvement after 8 weeks despite good adherence, adjust the regimen by switching medications, adding augmentation, or intensifying psychotherapy 1, 2
• Monitor for suicidality closely during the first 1-2 weeks and throughout initial treatment, as SSRIs increase risk for nonfatal suicide attempts 2, 4
• Evaluate adherence at each visit, as up to 50% of patients demonstrate non-adherence which can masquerade as treatment resistance 2

Treatment Duration

• Continue treatment for 9-12 months after recovery to prevent relapse, regardless of treatment modality 1, 7
• For first episodes, maintain treatment for minimum 4-9 months after satisfactory response 1, 2, 4
• For recurrent depression (≥2 episodes), extend treatment duration to ≥1 year or longer 2, 4
• Do not discontinue prematurely, as full therapeutic effects may require 4-6 weeks for medications and similar timeframes for psychotherapy 5, 3

Treatment-Resistant Depression

• Define as failure to respond to two or more adequate antidepressant trials (minimum 4 weeks at therapeutic dose with documented adherence) 2
• Add CBT to ongoing pharmacotherapy, which produces superior outcomes compared to medication adjustment alone 2
• Consider switching antidepressant class, adding a second antidepressant, or augmenting with atypical antipsychotics (approximately equal likelihood of success) 3

Critical Pitfalls to Avoid

• Inadequate dosing or duration: Ensure therapeutic doses are maintained for minimum 4-6 weeks before declaring treatment failure 5, 3
• Premature discontinuation: Do not stop treatment before 9-12 months after recovery, as this dramatically increases relapse risk 1, 7
• Using benzodiazepines: These are not indicated for depressive symptoms and should not be used for initial treatment 1
• Ignoring adherence issues: Verify medication adherence before escalating treatment, considering plasma level checks if uncertain 2
• Sequential rather than concurrent combination therapy: For severe depression, initiate psychotherapy and medication simultaneously, not sequentially 2
• Failing to establish safety plans: Always address suicidality and create emergency protocols, especially during initial treatment 1

Patient Education Requirements

• Provide culturally appropriate information about depression frequency, symptoms (psychological, behavioral, vegetative), signs of worsening, and when to contact the medical team 1
• Discuss treatment options through shared decision-making, considering availability, accessibility, patient preference, and cost 1
• Explain treatment timeline: Full effects may require 4-6 weeks, and continuation for 9-12 months is necessary to prevent relapse 5, 3