Psychiatric Association of Türkiye Mood Disorders Section Depression Treatment Guideline-III: Treatment Approach for Depression Subtypes and Special Groups, Psychotherapies, and Psychosocial Interventions

Abstract

This guideline article comprehensively examines pharmacological approaches and psychosocial interventions for depression subtypes and special patient groups in the treatment of major depressive disorder (MDD), along with their levels of evidence. Among depression subtypes, the approach with the highest level of evidence for psychotic depression is the combination of an antipsychotic with an antidepressant, whereas in atypical depression, despite a lack of new research, monoamine oxidase inhibitors (MAOI) have shown the most prominent efficacy compared to placebo. In melancholic depression, the response to selective serotonin reuptake inhibitors (SSRIs) has been found to be low. Tricyclic antidepressants (TCAs) and serotonin noradrenaline reuptake inhibitors (SNRI) stand out, and electroconvulsive therapy (ECT) plays a more important role in this population due to the low antidepressant response. For mild depression in children and adolescents, the first step is evidence-based psychotherapies (cognitive behavioral therapy [CBT], interpersonal psychotherapy [IPT]). When pharmacotherapy is necessary, the U. S. Food and Drug Administration (FDA)-approved SSRIs are recommended as the first-line agent for those aged 8 and above; however, close follow-up is essential during the first weeks of treatment due to the increased risk of suicidal ideation. In the elderly, antidepressant efficacy decreases after age 65. Cognitive behavioral therapy and life review therapy, along with ECT and transcranial magnetic stimulation (TMS), are important treatment options. For perinatal depression, psychotherapy (CBT) is recommended for mild to moderate depression during pregnancy or lactation, depending on the mother's preference. When deciding on pharmacotherapy, the risk-benefit balance of untreated depression and medications must be carefully considered. Comorbid conditions are another group of depression warranting attention regarding treatment options. In cases of comorbid anxiety disorders, SSRI/SNRIs and CBT stand out as the first choices. For comorbid alcohol/substance use disorder, SSRIs are recommended first-line in most cases. Concurrent psychosocial interventions such as CBT or motivational interviewing should be added to pharmacotherapy. For comorbid physical illnesses, medication selection is made according to the bodily system affected. Examining psychotherapy options, Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) are the approaches with the highest level of evidence in MDD treatment. Cognitive behavioral therapy is similar in efficacy to pharmacotherapy in the acute phase but is more protective in the long term. Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is recommended for chronic depression, and Mindfulness-Based CBT (MB-CBT) is suggested for recurrence prevention. Suicide is the most important issue in depression. The patient's suicide risk should be routinely assessed; antidepressants, proven to reduce suicidal behavior, must be used under close surveillance during the first weeks in young people due to the increased risk. Lifestyle adjustments also support existing treatment. Lifestyle modifications such as the Mediterranean diet, regular exercise, and sleep hygiene are fundamental components of depression treatment. Recently introduced telemedicine applications show similar efficacy to face-to-face treatments and improve access to care.