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Antidepressant Treatment Algorithm

  1. Is patient currently taking any medication?

If YES

If NO

Symptoms improving but not resolved: Increase dose of current medication

If patient is on therapeutic dose (see table below) for 4 – 8 weeks that has not helped: Consider changing medication, and use the information below to select a course of treatment

Does patient have a history of taking an antidepressant that has helped?

If YES: Prescribe the same medication that helped the patient in the past, and use the information below to help with dosage

If NO: Use the information below to select a course of treatment

First Line Treatment

Other SSRI Options

Medication

sertraline (Zoloft)

fluoxetine (Prozac)

citalopram (Celexa)

escitalopram (Lexapro)

Starting dose

25 mg

10 mg

10 mg

5 mg

How to up

up to 50 mg after 4 days, up to 100 mg after 7 days, then up by 50 mg until symptoms remit

up to 20 mg after 4 days, then up by 10 mg until symptoms remit

up to 20 mg after 4 days, then up by 10 mg until symptoms remit

up to 10 mg after 4 days, then up by 10 mg up to 20 mg until symptoms remit

Therapeutic range

50 – 200 mg

20 – 60 mg

20 – 40 mg

10 – 20 mg

In general, if an antidepressant has helped, it is best to continue it during lactation

General Side Effects of Medications

Temporary

  • Nausea
  • Constipation/diarrhea
  • Lightheadedness
  • Headaches

Long-Term

  • Increased appetite/weight gain
  • Sexual side effects
  • Vivid dreams/insomnia

Recommend patients take medication with food to decrease side effects Tell women only to increase dose if tolerating; otherwise wait until side effects dissipate before increasing For effects on fetus/neonate, see Discussing Antidepressant Use with Perinatal Patients.

2. Repeat EPDS in 2 – 4 weeks and re-evaluate depression treatment plan via clinical assessment

If no/minimal clinical improvement after 4-8 weeks

If clinical improvement and no/minimal side effects

If patient has no or minimal side effects, increase dose If patient has side effects that are severe/intolerable, or that do not resolve after 1-2 weeks, switch to a different medication

Reevaluate every month and at postpartum visit

This resource has been adapted with permission from the MCPAP for Moms Pediatric Toolkit for Postpartum Depression.