Antidepressant regimens for major depression in adults and young people
If an antidepressant is indicated (see Principles of treating major depression), individualise the choice of antidepressant. Lower doses may be needed in older people; consult a source of drug information. Use:
1 citalopram 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression (adult) citalopram citalopram citalopram
OR
1 escitalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression (adult) escitalopram escitalopram escitalopram
OR
1 fluoxetine 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression (adult) fluoxetine fluoxetine fluoxetine
OR
1 fluvoxamine 50 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression (adult) fluvoxamine fluvoxamine fluvoxamine
OR
1 mirtazapine 15 mg orally, at night for a few days then increase to 30 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 15 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression mirtazapine mirtazapine mirtazapine
OR
1 paroxetine 20 mg orally, in the morning1. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 50 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression paroxetine paroxetine paroxetine
OR
1 sertraline 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression (adult) sertraline sertraline sertraline
OR
2 agomelatine 25 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 50 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression agomelatine agomelatine agomelatine
OR
2 desvenlafaxine 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression desvenlafaxine desvenlafaxine desvenlafaxine
OR
2 duloxetine 60 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 30 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 120 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression duloxetine duloxetine duloxetine
OR
2 venlafaxine 75 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 75 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 375 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression venlafaxine venlafaxine venlafaxine
OR
2 vortioxetine 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression vortioxetine vortioxetine vortioxetine
OR
3 reboxetine 4 mg orally, twice daily. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose to a maximum of 10 mg in divided doses. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing major depression reboxetine reboxetine reboxetine
OR
3 moclobemide 150 mg orally, twice daily. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 150 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 600 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing. major depression moclobemide moclobemide moclobemide