Table 3.
Recommendations for the Pharmacotherapy of Major Depression from the 2001 US expert consensus guidelines (53) (50) (51)
| 2001 US Expert Consensus Guidelines | 2006 Canadian Guidelines | |
|---|---|---|
| Preferred treatment | An antidepressant (selective serotonin reuptake inhibitor [SSRI] or venlafaxine XR preferred) plus psychotherapy. | An antidepressant, psychotherapy, or a combination of both if the depression is of mild or moderate severity; a combination of an antidepressant and psychotherapy for severe depressions. |
| Specific antidepressant | Citalopram and sertraline are preferred with paroxetine as another first-line option. | Citalopram, sertraline, venlafaxine, bupropion or mirtazapine. |
| Starting dose | Begin with “somewhat lower doses” than in younger adults. | Half of the recommended dose for younger adults. |
| Increases in dose | Wait 2-4 weeks before increasing a low dose if there is little or no response and 3-5 weeks if there is a partial response. | Aim for “an average dose” within one month if the medication is well tolerated. In the absence of improvement after at least 2 weeks on “an average dose”, increase dose gradually (up to maximum recommended dose) until clinical improvement or, limiting side effects are observed. |
| When to change treatment | After 3-6 weeks at a “therapeutic” or the maximum tolerated dose” if there is little or no response and 4-7 weeks if there is a partial response. | After at least 4 weeks at the maximum tolerated or recommended dose if there is no or minimal response after 4-8 weeks if there is some partial response. |
| What to do in case of minimal or no response to initial antidepressant | Preferred option: switch to venlafaxine or bupropion. Alternative option: switch to nortriptyline, mirtazapine, or another SSRI | Consider “all reasonable treatment options” including ECT, combination of antidepressants or mood stabilizers, addition of psychotherapy |
| What to do in case of partial response to initial antidepressant | Combine or augment initial antidepressant with another agent | Switch to another antidepressant of the same or another class while considering the risk of losing the improvements made with the first treatment |
| Agents to consider for combination or augmentation | Bupropion, lithium, or nortriptyline | Mirtazapine, bupropion, or lithium |
SSRI: Selective serotonin reuptake inhibitor