Table 1

Summary of depression guidelines

US—APA guidelines (2010)UK—NICE guidelines (2009)Canada—CANMAT (2009)Taiwan—Taiwan Association Against Depression (2012)
First-line treatmentAntidepressant medications for patients with mild, moderate or severe MDD, especially patients with a history of prior positive response, moderate to severe symptoms, significant sleep or appetite disturbances, agitation, patient preference, etc.
Psychotherapy for patients with mild/moderate MDD, especially in the presence of significant psychosocial stressors, intrapsychic conflict, interpersonal difficulties, a co-occurring Axis II disorder, treatment availability or patient preference.
The combination of psychotherapy and antidepressant medication for patients with moderate to severe MDD, as well as in milder cases for patients with psychosocial or interpersonal problems, intrapsychic conflict, or co-occurring Axis II disorder.		For patients with persistent subthreshold depressive symptoms or mild to moderate depression, first-line treatment is low-intensity psychosocial interventions. Antidepressants should be considered only for patients with a past history of moderate or severe depression, initial presentation of symptoms that have been present for a long period (at least 2 years)or subthreshold depressive symptoms or mild depression that persists after other interventions.
For patients with persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, an antidepressant or a high-intensity psychological intervention should be considered.
For patients with moderate or severe depression, a combination of antidepressant medication and a high-intensity psychological intervention should be provided.		Second-generation antidepressants are first-line treatments for patients with a major depressive episode of moderate or greater severity.
First-line treatments for individuals with depression of mild severity include CBT and IPT.
Psychotherapy should be considered for patients with treatment-resistant depression.		Pharmacotherapy (preferred) or psychotherapy.
Pharmacotherapy first-line treatmentAntidepressant selection should be based on the tolerability, safety and cost of the medication, as well as patient preference and history of prior medication treatment.
SSRIs, SNRIs, mirtazapine and bupropion are optimal for most patients.
MAOIs are limited to patients who do not respond to other treatments.		Prescribed antidepressant should normally be an SSRI in a generic form.
When prescribing drugs other than SSRIs, the following should be considered:

  • The increased likelihood of the person stopping treatment because of side effects (and the consequent need to decrease the dose gradually) with venlafaxine, duloxetine and TCAs.

  • The specific cautions, contraindications and monitoring requirements for some drugs.

  • Non-reversible MAOIs, such as phenelzine, should normally be prescribed only by specialist mental health professionals.

  • Dosulepin should not be prescribed.

Choice of antidepressant should be based on patient factors (clinical features, patient preference, etc) and medication factors (drug–drug interactions, cost, availability, efficacy and tolerability).
First-line treatments include SSRIs, SNRIs, agomelatine, bupropion, mirtazapine, mianserin and vortioxetine.
Second-line treatments include TCAs, quetiapine and trazodone, moclobemide and selegiline, levomilnacipran and vilazodone.
Third-line treatments include MAOIs and reboxetine.		SSRIs, SNRIs or any one of the newer antidepressive agents except MAOIs.

  • APA, American Psychological Association; CANMAT, Canadian Network for Mood and Anxiety Treatments; CBT, cognitive behavioural therapy; IPT, interpersonal therapy; MAOIs, monoamine oxidase inhibitors; MDD, major depressive disorder; NICE, National Institute for Health and Care Excellence; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.