Section - Video Lectures

13. Major Depressive Disorder Algorithm Summary

Published on November 2, 2019 Expired on March 31, 2022

David Osser, M.D.

Associate Professor of Psychiatry - Harvard Medical School

Key Points

For inpatients with severe melancholic depression and acute safety concerns, ECT (or ketamine if ECT is refused or ineffective) may be first line.
For less-urgent melancholic inpatients, initial medication could be venlafaxine, mirtazapine, or a tricyclic. This may be augmented, if necessary, with lithium or triiodothyronine.
All other inpatients with depression and all outpatients may be offered first-line treatment with escitalopram, sertraline, or bupropion.
If there is no response, and if on reevaluation the diagnosis is confirmed (e.g., this is not bipolar depression), the prescriber and patient should decide together if they want to switch antidepressants or augment the first antidepressant. We offer 4 choices for switching and 4 for augmenting, all selected from among many possibilities based on our evaluation of data, safety, and cost. There is no clear preference based on evidence among these 8 options, so it is an individual collaborative decision.
If there is no response to the second medication trial, concerns should increase. All antidepressants generally work by the same mechanisms, so if a patient has failed a couple of good trials, the odds of responding decrease, and any improvement is likely to have a high risk of not maintaining (STAR*D data).
We suggest first determining whether there are any comorbidities that could be the primary cause of the problem, with the depression as the secondary cause. If there are none, determine whether the patient has an atypical depression, which would call for consideration of an MAOI or a combination of an SSRI and aripiprazole.
If no atypical depression is present, try another switch or augmentation. We add several more options to the original list at this point, including ECT.
If there is comorbidity with chronic pain, OCD, ADHD, or PTSD, we recommend trying to treat those problems with evidence-supported treatments.
Avoid unnecessary combinations.
Be mindful of placebo effects and high nonadherence rates.
Help patients make evidence-informed decisions whenever possible.
Following evidence-supported algorithms has produced superior and cost-effective outcomes with illnesses such as diabetes, pneumonia, and heart disease (Mullaney, 2005). The aggregate evidence on their use to improve depression outcomes seems comparable (Adli et al., 2006, 2017; Trivedi et al., 2004). See a review of these issues (Osser & Patterson, 2013) for more information.

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Slides and Transcript

Slide 1 of 8

This is video 13, the final video in the Algorithm for Major Depressive Disorder from the Harvard South Shore Psychopharmacology Algorithm Project. This summarizes the entire algorithm that we presented in the previous 12 videos with just a series of bullets of what the main points were.

Major Depressive Disorder Algorithm Summary Slide 1 of 8

Slide 2 of 8

So first, for inpatients with severe melancholic depression and acute safety concerns, ECT may be first line or ketamine if ECT is refused or ineffective. Second point, for the less urgent inpatients with severe melancholia, initial medication could be with venlafaxine, mirtazapine or tricyclic but not an SSRI. This may be augmented, if necessary, with lithium or triiodothyronine. They are two preferred augmenters for this subpopulation of severe depression that are inpatients.

Major Depressive Disorder Algorithm Summary Slide 2 of 8

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