First Line Treatments
- Cognitive-behavioral therapy consists of a variety of interventions designed to help the depressed person think and behave in more adaptive ways. Some specific components of cognitive-behavioral therapy include behavioral activation, which involves increasing the depressed person’s engagement in potentially rewarding activities, and cognitive therapy, which involves helping the person to challenge inaccurate beliefs that they may hold (such as “I’ll never feel better” or “I’m not a worthwhile person”).
- Interpersonal therapy is a type of psychotherapy in which the person addresses social issues that might be contributing to the depression.
- Problem solving therapy teaches the person strategies to solve problems more effectively, including brainstorming solutions, identifying the best possible solution, implementing it, and then assessing its effectiveness.
- Antidepressant medications are thought to help by improving the balance of certain neurotransmitters in the brain. No specific antidepressant medication has been found to be more effective than others for reducing depression, although selective serotonin reuptake inhibitors (SSRIs) are usually considered the first-line treatment because of their efficacy and relatively modest side effect profile. Specific first-line medications for MDD include:
- Citalopram
- Escitalopram
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Buproprion
- Mirtazapine
- Combined treatment with cognitive-behavioral therapy and pharmacotherapy
For more information about drug prescribing in MDD, click here.
Second Line Treatments
In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:
- Alternative psychotherapeutic strategies such as social skills training and psychodynamic psychotherapy.
- Alternative antidepressant medications such as tricyclic antidepressants (such as amitriptyline, imipramine, and desipramine) or monoamine oxidase inhibitors (such as phenelzine, isocarboxazid, and moclobemide)
- Augmentation of first-line medication with an additional antidepressant, atypical antipsychotic, lithium, busprione, or thyroid hormone T3.
Third Line Treatments
When patients do not respond adequately to the first- and second-line treatments described above, other strategies might include:
- Electroconvulsive therapy (ECT)
- Repetitive transcranial magnetic stimulation (rTMS)
- Vagus nerve stimulation
- An alternative therapy called cognitive-behavioral analysis system of psychotherapy (CBASP), which was designed to treat chronic, treatment-refractory major depressive disorder
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered.
- Aerobic exercise
- Acceptance- and mindfulness-based treatments, such as Acceptance and Commitment Therapy
- Augmentation of a first-line antidepressant with omega-3, an anticonvulsant, or a psychostimulant
- Herbal therapies including St. John’s wort or S-adenosyl methionine (SAMe)
- Bright-light therapy in patients whose depression follows a seasonal course
