Choosing treatments for depression

Many effective treatments are available for depression. However, no single treatment is effective for everybody.[1] Important aspects in managing depression include eating a healthy diet, avoiding drinking excess alcohol, and getting enough sleep.

Most people with depression are treated by their primary care doctor, rather than a specialist - that is, a psychiatrist. Sometimes, it is advisable to see a psychiatrist; this may be because, for example, there is a coexistent medical condition that makes it difficult to choose a suitable antidepressant.[1]

As well as general practitioners and psychiatrists, other healthcare professionals who can help in the management of depression include psychologists, social workers, and psychiatric nurses.[3]

When developing a treatment plan with your doctor, you may find it helpful to involve your partner or members of your family.[2] The potential role of the family in helping a person who is depressed should not be underestimated. Family members can help with early recognition of depression, providing support and helping with treatment and recovery.[3]

Treatments for depression include:

Antidepressant medications

Some guidelines recommend against antidepressant medications for people who have only mild depression, reserving such medicines for people with moderate or severe depression.  However, some people with persistent mild depression, or experience of more severe depression in the past, may find these helpful.[4]

A number of drugs are available for the treatment of depression, and also for the prevention of relapse in the long term. Antidepressant medications should be continued long after the symptoms have resolved.[3]

Even in countries where antidepressant medications are affordable, many people who would benefit from their use do not take them. This may be because of a sense of hopelessness, or an unfounded belief that depression cannot be treated. Many people suffering from treatable depression have not been diagnosed.[3]

A range of medications are available. When choosing the best one, it is important to consider any possible side effects and any drug-drug interactions. Sometimes, different medications are tried before the one that is most effective and best tolerated is found. If a person has had a positive response to an antidepressant with a previous episode of depression, this would be a good choice. In many countries, cost is also an important consideration.[1,5]

People may begin by taking a low dose which is gradually increased to minimise any side effects. Lower doses are also taken by those who are elderly or have liverA large abdominal organ that has many important roles including the production of bile and clotting factors, detoxification, and the metabolism of proteins, carbohydrates and fats. or kidney problems.[1]

Newer classes of antidepressants include 'selective serotonin reuptake inhibitors' (SSRIs) and 'serotonin-norepinephrine reuptake inhibitors' (SNRIs). These tend to be safer and better tolerated than the older classes of antidepressants, 'tricyclic antidepressants' (TCAs) and 'monoamine oxidase inhibitors' (MAOIs).[6]

It is important to bear in mind that it usually takes a little while for antidepressants to have an effect. Symptoms do not usually start to resolve until a person with depression has been taking the medication for two to four weeks, and full remission of symptoms may take up to four months.[5]

After initial treatment is successful, preventative maintenance treatment is often taken to reduce the risks of recurrence.[2]

Psychological treatment

Psychological treatment can lead to an improvement in function and the symptoms of depression, and can help to prevent relapse in people with depression.[1]

Access to a psychotherapist can be difficult in some countries, however. Possible solutions to this problem include the administration of psychotherapy over the telephone, and computer programmes.[1,4]

Psychological treatment can range from discussion, counselling and simple problem solving, to more specialised treatments such as cognitive behavioural therapy which focuses on thought patterns and their associated behaviours.[2,7,8]

Other available treatments which have been shown to be effective include interpersonal therapy and training in problem solving.[2]

Electroconvulsive therapy

The mechanism of action of electroconvulsive therapy (ECT) is not well understood, although this treatment has been used since the 1930s. However, ECT is thought to be the most effective treatment for major depression; research suggests that between 60 and 80 percent of all people with depression who receive a course have an improvement in their symptoms.[5,9]

ECT is delivered by the attachment of electrodes to the head, which pass a brief electric current to the brain, causing a fit. This treatment is given under general anaestheticAny agent that reduces or abolishes sensation, affecting the whole body.. The most common side effect is memory loss, but this is not experienced by everybody.[9]

ECT is usually given in a course of six to 12 treatments, with two or three treatments delivered each week. An improvement in symptoms is usually noted after the fourth treatment.[5]

ECT is preferentially given to people who have psychotic features associated with their depression, those who have attempted suicide or are highly likely to, and people who have not responded to antidepressant therapy.[5]

Light therapy

Light therapy is helpful for people with major depression that is seasonal, that is, in which symptoms most frequently occur over the winter months. Light therapy is well established and has been shown to be very effective in people with seasonal depression, although it has not been established for people with non-seasonal depression.[5]

Light therapy is usually delivered for at least 30 minutes a day using a standard phototherapy device emitting full spectrum white light. It is best used throughout the autumn and winter period.[5]

St John's wort

Several European studies have shown St John's wort, a herb, to be an effective alternative treatment for depression. However, one North American study suggested that St John's wort was no more effective than placebo.[5,6]

Patients with mild symptoms of depression may receive benefit from taking this herb, and it is well tolerated.[5,6]

References

  1. RS DeJesus, KS Vickers, GJ Melin et al. A system-based approach to depression management in primary care using the patient health questionnaire-9. Mayo Clin Proc 2007; 82: 1395-402.
  2. Peveler R, Carson A and Rodin G. ABC of psychological medicine: Depression in medical patients. BMJ 2002; 325: 149-52.
  3. http://www.searo.who.int/EN/Section1174/Section1199/Section1567/Section1826_8103.htmLast accessed January 6, 2010.
  4. Lester H and Howe A. Depression in primary care: three key challenges. Postgrad Med J 2008; 84: 545-8.
  5. Remick RA. Diagnosis and management of depression in primary care: A clinical update and review. CMAJ 2002; 167: 1253-60.
  6. Adams SM, Miller KE, and Zylstra RG. Pharmacologic management of adult depression. Am Fam Physician. 2008; 77: 785-92.
  7. Fulcher CD, Badger T, Gunter AK et al. Putting evidence into practice: Interventions for depression.  Clinical Journal of Oncology Nursing 2008; 12: 131-40.
  8. de Graaf LE, Gerhards SAH, Arntz A et al. Clinical effectiveness of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial. The British Journal of Psychiatry 2009; 195: 73-80.
  9. http://www.nice.org.uk/nicemedia/live/11494/32599/32599.pdf Last accessed April 22, 2010.