Most patients starting depression treatment are given a brief explanation of two or three medication options and then asked which one they prefer. That is not how the decision is actually made by experienced psychiatrists, and the gap between the brief patient-facing explanation and the underlying clinical reasoning matters because it changes outcomes. For anyone starting treatment for depression, here is the more honest version of how a good clinician chooses the first treatment, when they change course, and what the year ahead usually looks like. What to know •  First-line medication choices for depression are based on a structured weighing of symptom profile, prior personal and family medication history,…