What follows is a summary of stage one of the treatment stages for depression using the Texas Medication Algorithm Project Guidelines for Depression. See Texas Medication Algorithm Project Procedural Manual: Major Depressive Disorder Algorithm.
In the TMAP scheme, this is when the patient presents for assessment and when the doctor and patient make the diagnosis of depression and discuss the next steps. At this step the doctor discusses the use of psychotherapy for depression, either by itself or with antidepressant medicine. It is also important to emphasize healthy living habits, daily exercise, and good nutrition.
At this step we begin an antidepressant medicine. There are five classes or groups of antidepressants and TMAP recommends that the initial choice in persons who have not been previously treated should be a selective serotonin reuptake inhibitor (SSRIs) (fluoxetine, paroxetine, sertraline, citolapram and escitolopram) or a sertonergic noradrenergic reuptake inhibitors (SNRIs) (venlafaxine and duloxetine)
or a member of the others class (bupropion and mirtazapine).
Each of these medicines is equally effective in patients who have never been treated before. So the choice is made on the basis of the patient’s other medical problems and on the basis of possible side effects.
Two classes that are not recommended for Step 1 are the tricyclic antidepressants (TCAs), the monoamine oxidase inhibitors (MAOIs), and a medicine from the others class (nefazadone). These medicines’ safety profiles and side effects profiles are less favorable than the recommended step one medicines.
Stage One A (augmentation):
In this stage your medicine has helped your depression, but you’re symptoms aren’t gone. You aren’t back to where you were (and remember, the goal of modern depression treatment is remission of symptoms not just better).
You’re on the recommended maximum dose (for you) and you’ve been taking it for a long enough time.
So in this step, you stay on the medicine that is helping, but you and your doctor add another medicine with a different mechanism of action. If you are currently taking an SSRI or SNRI, the recommendation is to bupropion, mirtazapine, lithium, liothyronine (T3, a specific thyroid hormone), or buspirone.
If you are taking bupropion or mirtazpine, then you augment (add) an SSRI or SNRI.
And you and your doctor gradually increase the dose of the second agent, watching for side effects and for improvement.
In the next post, I’ll talk about Stage Two TMAP recommendations.