Treatment of Depression Across Three Age Cohorts

1 Types included: minor depression, major depression, persistent depressive disorder (formerly called “dysthymia”), intermittent depression, or having depression symptoms at or above a prespecified level based on a validated measure of depression severity. The Zhou et al. (2015) review excluded patients with psychotic depression.
2 Throughout the table, interventions are listed alphabetically.

Recommendations for the Adolescent Population

For initial treatment of adolescent patients with depressive disorders 3 the panel recommends that clinicians offer one of the following psychotherapies/interventions 4 :

3 Types included: minor depression, major depression, persistent depressive disorder (formerly called “dysthymia”), intermittent depression, or having depression symptoms at or above a prespecified level based on a validated measure of depression severity. The Zhou et al. (2015) review excluded patients with psychotic depression.
4 Throughout the table, interventions are listed alphabetically.

The panel recommends fluoxetine as a firstline medication compared to other medications for adolescent patients with major depressive disorder, specifically when considering medication options. ( Recommendation )

There was insufficient evidence to recommend either treatment (psychotherapy or fluoxetine) over the other for major depressive disorder. ( Insufficient evidence )

If neither recommended psychotherapy is available or neither is acceptable to the patient and their parent/guardian, the panel suggests considering an alternative model. However, at this time, while the following interventions have been evaluated in adolescents, there is insufficient evidence to recommend for or against clinicians offering any one of the following psychotherapies/interventions over the others:

• Behavioral therapy
• Cognitive therapy
• Family therapy
• Problem-solving therapy
• Psychodynamic therapy
• Supportive therapy

Information is lacking regarding other medication options for adolescents. Thus, if fluoxetine is not a treatment option or is not acceptable, the panel recommends shared decision-making regarding medication options with a child psychiatrist in addition to the clinician, patient, and their parents/guardians or family members actively involved in their care. ( Conditional recommendation )

In general, the panel recommends against using the following medications for adolescent patients with major depressive disorder. However, when other options are not available, effective, and or acceptable to the patient, the panel recommends shared decisionmaking between the patient and clinician.

• paroxetine over clomipramine when both are being considered.
• paroxetine over imipramine when both are being considered.
• There was no information available for other comparisons between the listed medications.

Recommendations for the General Adult Population

Psychotherapy and Pharmacotherapy

• When selecting between treatments, the panel recommends considering the following options:
  • Second-generation antidepressants
  • The panel found that effectiveness studies demonstrated similar effects across psychotherapy. Thus, the panel is not able to recommend specific monotherapies for initial treatment. General models that appear to have comparable effects include:
    • Behavioral therapy
    • Cognitive, cognitive-behavioral (CBT), and mindfulness-based cognitive-therapy (MBCT)
    • Interpersonal psychotherapy (IPT)
    • Psychodynamic therapies
    • Supportive therapy

    2) If considering combined treatment, the panel recommends cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) plus a second-generation antidepressant.

    ( Recommendation )

    5 The depression recommendations refer to the full range of depression diagnoses identified by the panel for inclusion unless a recommendation specifies otherwise. Note that recommendations do not pertain to psychotic depression.
    6 Throughout the recommendations, both the terms “antidepressant medication” and “second-generation antidepressant” are used. Note that “second-generation antidepressants” refers specifically to selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) while the term “antidepressant medication” could include second-generation antidepressants as well as other antidepressants.

    For adult patients with depression who are also experiencing relationship distress, if a recommended treatment is not acceptable or available, the panel suggests that clinicians offer problem-focused couples’ therapy.
    When selecting between treatments the panel suggests considering the following options:

    • Suggest behavioral therapy rather than antidepressant medication alone.
    • If considering combined treatment, the panel suggests cognitive therapy plus antidepressant medication to improve likelihood of full recovery in treatment.

    ( Conditional recommendation )

    For adult patients with depression, there is insufficient evidence to recommend for or against clinicians offering:

    • Cognitive-behavioral analysis system of psychotherapy (CBASP)
    • Brief problem-solving therapy (10 or fewer sessions) vs. treatment as usual.