What are the treatment options for patients with affective disorders?

Treatment Options for Affective Disorders

For patients with affective disorders, treatment should combine pharmacotherapy with psychotherapy, starting with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) alongside cognitive-behavioral therapy (CBT), with the specific combination tailored to symptom severity and functional impairment. 1

Pharmacological Treatment Options

First-Line Antidepressants

Second-generation antidepressants (SGAs) are the primary pharmacological option, including:

• SSRIs: Fluoxetine, sertraline, paroxetine, escitalopram, citalopram, and fluvoxamine 1, 2
• SNRIs: Venlafaxine 1, 3
• Other SGAs: Bupropion, nefazodone 1

Sertraline demonstrates lower sexual dysfunction rates than paroxetine but similar rates to fluoxetine, which should inform medication selection discussions 2. Treatment duration should be 4-6 months minimum after achieving response for first episodes, with acute treatment lasting 6-12 weeks followed by continuation for 4-9 months 2. Patients with recurrent depression require maintenance treatment of at least 1 year 4, 2.

Neuromodulators for Comorbid Conditions

When behavioral therapies alone are insufficient, particularly with comorbid depression, anxiety, or chronic pain, consider:

• Tricyclic antidepressants 1
• SSRIs or SNRIs as augmentation 1

Selective serotonin reuptake inhibitors are preferred over tricyclics in older patients due to fewer anticholinergic effects 1.

Monitoring Requirements

• Monitor closely for suicidal ideation, agitation, irritability, or unusual behavioral changes during the first 1-2 months, as suicide risk is highest during this period 4
• Evaluate therapeutic response and adverse effects within 1-2 weeks of starting treatment 4
• Use standardized tools like PHQ-9 or Hamilton Depression Rating Scale to quantify improvement (≥50% reduction in severity) 2
• If no adequate response within 6-8 weeks, modify treatment through dose escalation or switching antidepressants 4

Common Adverse Effects to Counsel Patients About

• Nausea, diarrhea, dry mouth, headache, insomnia, somnolence, dizziness, and sexual dysfunction 2, 5
• Bleeding risk increases with concomitant NSAIDs, aspirin, or anticoagulants 3, 5
• Weight changes and appetite alterations 3, 5
• Hyponatremia risk, particularly in elderly patients or those on diuretics 3, 5

Psychotherapeutic Treatment Options

Evidence-Based Psychotherapies

Cognitive-behavioral therapy (CBT) shows equivalent efficacy to antidepressants for major depressive disorder and should be offered as monotherapy or combined with medication 1.

Additional evidence-based options include:

• Interpersonal therapy 1
• Psychodynamic therapy 1
• Third-wave CBT approaches (acceptance-based therapies, mindfulness) 1
• Gut-directed hypnotherapy (for patients with comorbid GI symptoms) 1

Family and Psychoeducational Interventions

Family-focused therapy is particularly important for bipolar disorder, addressing:

• Treatment compliance and medication adherence 1
• Positive family relationships and reducing expressed emotion 1
• Problem-solving and communication skills 1
• Information about symptoms, course, treatment options, and heritability 1

Interpersonal and social rhythm therapy helps stabilize social routines and sleep patterns, reducing stress and vulnerability to relapse 1.

Treatment Sequencing Algorithm

For Patients with Severe Affective Symptoms

1. Start combination therapy immediately: SGA plus CBT or interpersonal therapy 1
2. Consider neuromodulators if comorbid depression/anxiety or chronic pain present 1
3. Add family-focused therapy for bipolar disorder 1

For Patients with Moderate Symptoms

1. Offer choice between monotherapy with SGA or psychotherapy 1
2. If no response in 6-8 weeks, switch to combination therapy 4
3. Address comorbid conditions in parallel with affective disorder treatment 1

For Patients with Mild Symptoms

1. Begin with psychotherapy alone (CBT, interpersonal therapy, or psychodynamic therapy) 1
2. Add medication only if insufficient response or patient preference 1

Critical Pitfalls to Avoid

Do not refer patients with severe comorbid Axis I disorders directly to specialized psychotherapy (e.g., GI-focused therapy) without first stabilizing the primary psychiatric condition, as brain-gut psychotherapies are less effective with pronounced comorbid psychopathology 1. Address severe depression or anxiety first through general psychological treatment or psychotropic medications before proceeding to specialized interventions 1.

For cancer patients with affective disorders, implement safety measures for suicidal risk in those with moderate-to-severe adjustment disorder, and refer to social work and chaplaincy services as adjuncts 1. Substance abuse during cancer treatment may indicate insufficient symptom control rather than true addiction, requiring improved symptom management before referral to substance abuse programs 1.

Second-Line Treatment Options

When First-Line Treatment Fails

Switching strategies show no clear superiority between different SGAs (bupropion vs. sertraline vs. venlafaxine) 1. Augmentation with bupropion decreases depression severity more than buspirone 1.

Switching to cognitive therapy shows equivalent outcomes to switching between SGAs 1. Augmenting with cognitive therapy shows similar efficacy to augmenting with another SGA 1.

Electroconvulsive Therapy (ECT)

ECT should be reserved for adolescents with well-characterized bipolar I disorder who have severe episodes and are nonresponsive to or unable to take standard medications 1. ECT is the treatment of choice for affective disorders during pregnancy, catatonia, neuroleptic malignant syndrome, or when medications are contraindicated 1.

Complementary and Alternative Options

Acupuncture shows no difference in treatment response compared to fluoxetine monotherapy 1. Exercise, relaxation/yoga, and massage are preferred by patients with mild-to-moderate distress 6.