Treatment Plan

First-line:

• Wellness/wellbeing interventions
• Exercise
• Self-help courses
• Helplines
• CBT/Counselling

Medication:

• First-line: SSRIs (sertraline/citalopram preferred in multiple comorbidities)
• Continue 6 months post-remission
• Alternative options: SNRIs, TCAs (avoid high suicide risk)

Follow-up:

• 2-4 weeks after starting medication
• A week’s review of 18-25yr old (as they are high suicide risk
• 6-12 monthly thereafter

Medication switching:

• Cross-tapering is generally required in most cases. However, a direct switch is possible in some cases
• Mirtazapine & Trazadone require cross-tapering cautiously

Chronic/resistant cases:

• Combined CBT + medication
• Specialist referral for alternative treatments
  • Consider adding mirtazapine/trazodone to an SSRI
  • Bipolar history: consider antipsychotic combinations alongside antidepressant
  • Consider switching to or from MAOI’s (selegiline & rasagiline)