Antidepressant Selection and Management

Introduction to Antidepressant Treatment

The American Academy of Family Physicians recommends starting with an SSRI for treatment-naive patients with major depressive disorder due to their equivalent efficacy to other antidepressants but with superior safety and tolerability profiles 1, 2
The American Academy of Family Physicians suggests choosing an SSRI based on specific clinical features, such as fatigue, hypersomnia, or psychomotor retardation, for which fluoxetine may be selected 3

For older adults, the American Academy of Family Physicians prefers sertraline, citalopram, or escitalopram due to their safety profiles 1
Citalopram and escitalopram have the lowest drug-drug interaction potential among SSRIs, according to the Journal of the American Academy of Child and Adolescent Psychiatry 4
The American Academy of Family Physicians advises against using paroxetine as a first-line treatment due to its higher suicidal thinking risk and problematic discontinuation syndrome 4, 5

The American Academy of Family Physicians recommends continuing acute treatment for 8-12 weeks to assess efficacy 6, 1
For maintenance after the first episode, treatment should last a minimum of 4-12 months after remission, as suggested by the American Academy of Family Physicians 1

The American College of Neuropsychopharmacology suggests switching to an SNRI when SSRIs fail or when treating severe depression with prominent physical symptoms 7, 2
SNRIs show slightly higher response rates than SSRIs but with increased nausea and vomiting, according to Neuropsychopharmacology 8, 1

The American College of Internal Medicine reserves TCAs for treatment-resistant depression after SSRI and SNRI failure, or when a dual-action mechanism is specifically needed 2
Clomipramine and amitriptyline demonstrate superior efficacy to SSRIs in severe depression and hospitalized patients, as reported by Neuropsychopharmacology and Nature Reviews Disease Primers 7, 6

For adolescents with depression, the American Academy of Pediatrics recommends fluoxetine as the only FDA-approved and most evidence-supported SSRI 5
Combination therapy with fluoxetine and CBT is superior to either alone for adolescent depression, according to Pediatrics 5
The American Academy of Pediatrics advises against using duloxetine, venlafaxine, and paroxetine in adolescents due to poor tolerability 5

The Journal of the American Academy of Child and Adolescent Psychiatry warns of increased bleeding risk with SSRIs and anticoagulants/NSAIDs, recommending close monitoring 4