14th February 2025

Management of depressive disorders

Management of an acute depressive episode

First line for an acute mild-to-moderate depressive episode is a low-intensity psychological intervention, e.g. CBT.

If the response is inadequate, the symptoms have been mild but long lasting, or the episode is moderate to severe, NICE recommends high-intensity psychological interventions and antidepressant treatment.

Usually, an SSRI (e.g. sertraline) is first line. If ineffective, another SSRI (e.g. fluoxetine) may be trialled, then another class, such as an SNRI (e.g. venlafaxine). Switching antidepressants should be done cautiously and under specialist guidance due to the risk of serotonin syndrome.

In the initial period of antidepressant treatment suicide risk may increase due to improved energy and motivation.

For treatment-resistant depressive episodes, NICE recommends combination therapy with either two antidepressants (commonly mirtazapine and venlafaxine) or an antidepressant with lithium or an antipsychotic. The choice of agent is usually determined by the symptoms and what the patient has responded to in the past; for example, with psychotic symptoms, one might preferentially use an antipsychotic for augmentation.

For depressive disorders which are highly treatment-resistant and/or posing a threat to life (e.g. through poor oral intake), ECT is an important and effective management option.

Maintenance therapy for depressive disorders

NICE recommends at least 6 months of antidepressant treatment on recovery to reduce the risk of relapse or 2 years if there is a higher risk. Cessation of therapy should be gradual due to the risk of discontinuation syndromes. Lifelong treatment may be considered, especially if the episode was severe and/or this is the patient’s preference.

ECT is only recommended by NICE as treatment of acute depressive episodes, not as maintenance therapy.