The Waco Guide

Any recent or
remote manic or
hypomanic
episode Avoid antidepressants,
which can precipitate mania
None
Anxiety
Chronic pain
(e.g.,
fibromyalgia)
Prominent
insomnia /
poor
appetiteAdequate response at
or before max dose
Adequate response at
or before max dose
Insufficient response at
max dose for 4-8 weeks
Partial response
at max dose
Partial response
Psychosis
Inadequate response
or not tolerable
Inadequate response
Depressive Disorders
Major Depression Bipolar Depression
See Bipolar
Decision Support
Mild-Moderate
Psychotherapy
Consider pharmacotherapy
alone or in combination
especially for patients with
history of recurrent
depression, patient
preference, or if they fail
psychotherapy
Evaluate for suicidality
Acutely suicidal
Emergent Hospitalization
Severe
Combination psychotherapy
and pharmacotherapy
First Trial Antidepressant (SOR A):
SSRI (e.g. sertraline, escitalopram)
SNRI (e.g. venlafaxine)
Atypical Antidepressant (e.g. bupropion, mirtazapine)
Special
considerations for
comorbid symptoms
SSRI, SNRI, or
Bupropion
SSRI or SNRI
SNRI
(e.g. duloxetine)
Mirtazapine
Evidence-based adjunctive pharmacotherapy
(consider in addition to primary therapy):
Omega-3
COX-2 inhibitor
SOR B
Consider
hospitalization
Antidepressant
+Antipsychotic:
-Aripiprazole
-Risperidone
-Lurasidone
-Olanzapine
(consider fluoxetine
combination pill)
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Maintenance:
-1st episode, 6-9 months
-Recurrent episode, at least 2 years
SOR A
Second Trial:
Switch to an antidepressant in
same OR different class
SOR B
Continue current
antidepressant and
augment
SOR B
First
Choice
Aripiprazole
Add antidepressant from alternate class
- If on SSRI/SNRI: Bupropion or Mirtazapine
- If Bupropion/Mirtazapine: Add SSRI or SNRI
Second
Choice
Consider Lithium for
chronic suicidality
For prominent residual anergia consider
using stimulants (e.g. methylphenidate)
Lurasidone
Follow up and titrate dose as
appropriate q 1-2 weeks for
active medication
management
Third Trial:
(select medication class which has not
been previously trialed)
SSRI
Inadequate Response Partial Response
SNRI
Bupropion
Mirtazapine
Other Options
Psychiatric
consultation
TCA (ECG
before initiation and at
each dose increase)
Nortriptyline Desipramine
Evidence-based psychotherapy
in primary care (SOR A):
-Cognitive behavioral therapy
-Interpersonal therapy
-Problem solving therapy
-Behavioral activation

What severity is the patient's depression?

Does the patient suffer from psychosis?