Depression: Getting Treatment

Depression is a treatable mental illness that can usually be managed in primary care by a general practitioner, but may be the subject of care by a specialist - a psychiatrist for, example. There are three components to the management of depression:

• Support - ranging from discussing practical solutions to contributing stresses, to educating family members
• Psychotherapy - also known as talking therapies, such as cognitive behavioral therapy (CBT)
• Drug treatment - antidepressants.

Psychotherapy

Psychological or talking therapies for depression include cognitive-behavioral therapy (CBT), interpersonal psychotherapy and problem-solving treatment.

In mild cases of depression psychotherapies are the first-line option for treatment; in moderate and severe cases they may be an adjunctive therapy with other treatment.

CBT and interpersonal therapy are the two main types of psychotherapy used in depression. Both talking therapies are present-focused and encourage the regaining of control over mood and functioning:

• CBT helps to correct negative thought patterns
• Interpersonal therapy looks at the effect of relationships.

CBT may be delivered in individual sessions with a therapist, face-to-face or over the telephone, but it can also be completed via a computer or in groups. Computerized cognitive behavioral therapy is promising in reducing depression symptoms in young people. Sessions typically last one or two hours each week for two to four months.

We have a special page with more detailed information about cognitive behavioral therapy. Also see below for information about how cognitive therapy compares with antidepressant treatment.

Interpersonal therapy helps patients to identify emotional problems that affect relationships and communication, and how these in turn affect mood and can be changed.

Interpersonal therapy sessions - conducted over a limited number of weeks - will involve the therapist gaining trust before asking about symptoms and relationships, both through asking questions and providing questionnaires.

Antidepressant medications

Antidepressants are drugs available on prescription from a doctor, whether one providing primary care treatment, or a psychiatrist.

In mild cases of depression, antidepressants are not generally the first-line option for treatment - in which case, psychological therapy may be recommended first.

Drugs come into use for moderate to severe depression, but are not recommended for children, and will be prescribed only with caution for adolescents.

A choice of antidepressant medications is available - the individual selection is a matter of personal preference, previous success or failure, adverse side-effects, whether overdose is likely and could be a danger, and interaction with any other treatments being used.

A number of classes of medication are available in the treatment of depression:

• Selective serotonin reuptake inhibitors (SSRIs) - citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft)
• Monoamine oxidase inhibitors (MAOIs) - isocarboxzaid (Marplan), phenelzine (Nardil), selegiline (Emsam skin patch), tranylcypromine (Parnate), tranylcypromine (Phenelzine)
• Tricyclic antidepressants - amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil), trimipramine (Surmontil)
• Atypical Antidepressants - bupropion (Wellbutrin), maprotiline, mirtazapine (Remeron), nefazodone, trazodone
• Selective serotonin and norepinephrine reuptake inhibitors (SNRI) - desvenlafaxine (Pristiq), duloxetine(Cymbalta) venlafaxine (Effexor).

Each class of antidepressant acts on a different neurotransmitter - SSRIs, for example, increase the production of serotonin in the brain, while MAOIs block an enzyme that breaks down neurotransmitters. The exact way in which antidepressant medications work is not fully understood.

SSRIs are usually tried first, and one in the class can be switched for another that has not proven helpful. Other classes can also be switched in to find effect.

Antidepressant drugs need to be taken for some time before there is effect - typically 2 to 3 weeks - and continued for 6 to 12 months.

 The drugs should be continued as prescribed by the doctor, even after symptoms have improved, to prevent relapse.

A warning from the US Food and Drug Administration (FDA) says that "antidepressant medications may increase suicidal thoughts or actions in some children, teenagers, and young adults within the first few months of treatment."

Any concerns should always be raised with a doctor - including any intention to stop taking antidepressants.

Less severe adverse side-effects commonly experienced by people taking antidepressant medication include:

• Headache
• Night sweats
• Nausea
• Agitation
• Sexual problems
• Dry mouth
• Constipation.

St. John's wort, exercise and other therapies

St. John's wort is a herbal treatment (Hypericum perforatum) that may be effective for mild drepression although the evidence is mixed, and it should be noted that it can interact with other drugs, including antidepressants.

Aerobic exercise may help against mild depression since it raises endorphin levels and stimulates the neurotransmitter norepinephrine, related to mood.

Brain stimulation therapies - including electroconvulsive therapy detailed below - are also used in depression. Repetitive transcranial magnetic stimulation - that sends magnetic pulses to the brain - is one that may be effective in major depressive disorder.

Mind-body therapies recommended by complementary and alternative practitioners include:

• Acupuncture
• Relaxation techniques such as yoga or tai chi
• Meditation
• Guided imagery
• Massage therapy
• Music or art therapy
• Spirituality.

Electroconvulsive therapy

Severe cases of depression that have not responded to drug treatment may benefit from electroconvulsive therapy (ECT), which is particularly effective for psychotic depression. MNT has produced detailed information about the treatment on the page about electroconvulsive therapy.

Are talking therapies or antidepressants most effective for depression?

All medical treatments are prescribed against the individual suitability of the treatment for the person, and the same is true in depression.

For some patients it may be a simple matter of choice - perhaps antidepressants are more convenient for some than talking therapies. Another person, meanwhile, may prefer to avoid drug treatment.

If there is a question of choosing one or other option based on effectiveness alone, one study tested whether cognitive therapy had an enduring effect and compared this against continued antidepressant medication.

The conclusion of the 2005 report, published in the journal JAMA Psychiatry, was:

"Cognitive therapy has an enduring effect that extends beyond the end of treatment. It seems to be as effective as keeping patients on medication."

The study also cited evidence that CBT is associated with less relapse to depression after treatment than medication.

Another comparison looked at mindfulness-based cognitive therapy and found that it offered a level of protection similar to antidepressant drugs against relapses of depression.

The trial results were published in The Lancet in April 2015, as reported by MNT. The conclusion was:

"Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life."